Form – Incident and Disciplinary Referral

Student(s) being Referred:
Student #1 Name*
First Last
Add 2nd Student?*
- Yes
- No
Student #2 Name*
First Last
Add 3rd Student?*
- Yes
- No
Student #3 Name*
First Last
Date of Incident*
Date Format: MM slash DD slash YYYY
Time of Incident*

: HH

MM
Where did the Incident occur?*
Select the location
Reason for Referral:

Please Read through the complete list and Check ALL that apply to this referral:
Student behavior / actions described as:*
- Academic issues ( Cheating on Test, Not doing their own work, Refusal to do work, Sleeping in Class, etc)
- Alcohol, drugs and/or tobacco
- Arguing/Fighting/Threatening/Pushing another student/Conflict/Physical Altercation
- Behavioral Issue (skipping class, ongoing lateness, excessive absences, acting out, etc)
- Bullying/Teasing/Name calling/Offensive hand gestures
- Cell phone violations / computer misuse
- Disrespectful towards teacher/staff in actions, words, gestures, lying, inappropriate language
- Dorm issue (Not abiding by curfew, Leaving without permission, In Dorm without permission, roommate issues, etc.)
- Dress Code violations (Student was previously given dress code warnings by this staff member)
- Off Campus Behavior Unacceptable (athletic games, school trips, weekend activities, etc)
- Sexual Harassment
- Theft or destruction of school property
- Weapons
- Unauthorized departure from campus
- Other
Please describe the incident below. Please include how you responded and any actions you have taken in this matter:
Please indicate any Knox Core Value that may apply to this referral:*
- Student demonstrated Lack of Integrity (Acted without honesty in word or deed, trustworthiness, sincerity, or principals of truth)
- Student demonstrated Lack of Kindness (Acted without consideration, compassion, or empathy for others)
- Student demonstrated Lack of Respect (Acted without courtesy, timeliness, fairness, or sensitivity to individuals or community)
- Student demonstrated Lack of Responsibility (Did not Act in accordance with what is right or being accountable for one's own behavior)
- Student demonstrated Lack of Scholarship (Acted in manner which impedes the building of a foundation of knowledge and skills that allows for development of the intellect through openness of thought and freedom of inquiry.)
Thank you for taking the time in completing this referral. Please forward this form to the Dean of Students and the School Social Worker by clicking the "Submit" button below.

Incident and Disciplinary Referral Form

Student(s) being Referred:

Reason for Referral:

Please Read through the complete list and Check ALL that apply to this referral:

Thank you for taking the time in completing this referral. Please forward this form to the Dean of Students and the School Social Worker by clicking the "Submit" button below.