1. Incident Referral Forms Office of Family Services

2. Incident Referral Form The MPS Incident Referral Form was revised in the summer of 2009 as a result of the Positive Behavioral Interventions and Supports (PBIS) initiative. – Administrators, Principals, Teachers, Assistants, Support Staff, and MTEA all had input on the revisions 2 Office of Family Services

3. Incident Referral Form Revisions The MPS Incident Referral Form was revised to do the following: – Align with the Code of School/Classroom Conduct and Discipline Chart in the Parent/Student Handbook on Rights, Responsibilities, and Discipline – Save time using check boxes instead of writing everything out – Align with the data entry process on the incident screen – Improve data collection for problem solving school- wide/systems issues 3 Office of Family Services

4. Types of Data From Referrals The PBIS Big 5 Reports: – Average Referrals per Day per Month – Referrals by Time – Referrals by Location – Referrals by Behavior – Referrals by Student These reports are used by the Tier 1/Universal Team to problem solve – When a report has Unknown, that means data was not entered in that field 4 Office of Family Services

5. Average Referrals per Day per Month 5 Office of Family Services

6. Referrals by Time 6 Office of Family Services

7. Referrals by Location 7 Office of Family Services

8. Referrals by Behavior 8 Office of Family Services

9. Referrals by Student 9 Office of Family Services Student ID

10. Incident Referral Form Revisions In addition to the revisions to the Incident Referral Form, the various offenses in eSIS were aligned to the Code of School/Classroom Conduct and Discipline Chart (pages 22-24 in the Parent/Student Handbook on Rights, Responsibilities and Discipline). – Previously there were over 140 types of offense choices available on eSIS which made discipline data less useful for schools to problem solve with 10 Office of Family Services

11. The following are simple guidelines all schools should utilize: No student should be removed from an instructional setting without an incident referral. Incident referrals that result in a student being removed from an instructional setting should be recorded on the Incident Screen in eSIS. 11 Office of Family Services

12. Guidelines continued: No student should be suspended from school without an incident referral being recorded on the Incident Screen in eSIS. Incident referrals that are being written for a documentation purpose only and the student is not removed from the instructional setting should be recorded in eSIS Notes. 12 Office of Family Services

13. Guidelines continued: Bus referrals that are written by the bus driver that result in disciplinary action by an administrator should be transferred to an incident referral. The incident referral should be recorded on the incident screen in eSIS with the incident site identified as Transportation – Yellow. – These are incidents that result in the student being assigned a detention, bus suspension, or suspension from school. Bus referrals written by a bus driver that do not result in disciplinary actions should be retained at the school for one year after the student leaves the district. – These are incidents that do not result in anything more than parent contact or counseling by an administrator. 13 Office of Family Services

14. Guidelines continued: Only one offense may be recorded in the incident screen in eSIS. If multiple offenses are checked on the incident referral, the administrator should select the most severe offense that is the main cause for disciplinary action. The additional offenses may be noted in the narrative. Multiple Administrative Actions may be recorded on the Incident Screen in eSIS, i.e., parent contact (14) and suspension (33). 14 Office of Family Services

15. Blank Incident Referral Form: Front It is important to complete all of the fields on the Incident Referral Form. 15 Office of Family Services

16. Incident Referral Form: Back Directions for completing the Incident Referral Form 16 Office of Family Services

17. Sample Incident Referral Form Possible Motivation: Why you think the student did what they did. Use your professional judgment. If you dont know, select Unclear/Dont Know Administrators may also complete the Possible Motivation field by asking the student: Why did you do it? 17

18. Possible Motivation The Possible Motivation field is important when teams start implementing Tier 2 interventions. If the student is avoiding tasks/ activities, it may be for academic reasons not behavioral reasons. – The student does not understand how to complete the equations, so he/she acts out instead to avoid the work 18 Office of Family Services

19. T-Charts PBIS recommends the school staff members collaborate with the school administration for developing the T-Chart. The T-Chart identifies behaviors that are classroom managed and the behaviors that are office managed and must have an Incident Referral Form completed. 19 Office of Family Services

20. 20 Classroom ManagedOffice Managed (Minor)(Major) No Supplies No Homework Talking Gum Tardy Fighting Weapon Illegal Substances Sample T-Chart Office of Family Services

21. Additional Information Keep in mind that Incident Referral Forms may be used as a legal document in some instances. – Statements should be professional at all times i.e. legible, clear, good grammar and spelling – Statements should simply relay the facts of the incident, not personal feelings or opinions. i.e. The student is a jerk! is an example of inappropriate information included on an Incident Referral Form 21 Office of Family Services