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FORM “A”
DISCIPLINARY ACTION FORM
In accordance with R. S. 17:416(A) the purpose of this report is to inform parents/guardians of a behavior incident on the school campus, in the classroom, cafeteria, gymnasium, auditorium,
elsewhere at the school or during school-related activities, and of subsequent disciplinary action taken by school officials. Because this or other incidents may jeopardize the safety, wellbeing or education of other students, parents are urged to discuss the incident and possible implications with the student to prevent further occurrences.
Name of Student
Name of Teacher/Staf
Name of Principal
Check One:  Regular Education

504

Special Education

Phone
Teacher/Staf/Location
School
_ Date of Incident
Time

Grade/Section

Location

Time Code:____________

01 Before School on Grounds, 02 During Class, 03 Between Classes, 04 After Normal School Hours & Supervised, 05 To / From School, 06 At Bus Stop or Transfer
Station, 07 During School Extracurricular/Assembly