EXHIBIT
STUDENT DISCIPLINE
NOTICE TO PRINCIPAL OF
REFUSAL TO READMIT STUDENT
(Must be submitted by next business day following
temporary removal)
Teacher __________________________ Student ____________________
School ___________________________ Class ____________ Period ___
Under the provisions of A.R.S. 15-841, I am refusing to readmit the above-named student to the identified class. The temporary removal was made under the following condition (one [1] of the two [2] conditions must be selected and substantiated):
◻ 1. The pupil has repeatedly interfered with my ability to communicate effectively with the other pupils in the classroom or with the ability of the other pupils to learn.
◻ 2. The pupil's behavior is so unruly, disruptive, or abusive that it seriously interferes with my ability to communicate effectively with the other pupils in the classroom or with the ability of the other pupils to learn.
Instructions: Describe the incidents that have prompted the decision to remove the student from the class. It is important that complete and detailed information is provided, as it will be used 1) by the principal in determining the appropriate discipline management techniques, consistent with Governing Board rules, to be applied to this case, and 2) by the placement review committee to determine whether the student should be placed back in the class if the teacher and principal cannot reach consensus that acceptable corrective measures have been accomplished to effect the student's return to class.
To the extent possible, report literal disruptive remarks made by the student, and list contributing factors such as the student's facial or bodily expressions, gestures, sounds, and so forth. Explain how the student attempted to divert the attention of other students, to encourage their participation in the misbehaviors, and to otherwise interfere with the classroom management, teaching, and learning processes. State the techniques, both successful and unsuccessful, that have been attempted to restrain the student's misconduct, gain the student's cooperation, or otherwise control the situation. List the dates of and summarize the communications and conferences with the student's parent(s) or other responsible adult(s) to elicit their assistance in resolving the difficulties with the student.
If the space on this form is inadequate, check the box on the following page and indicate the number of supplemental sheet(s) you are attaching to this notice.
Date of misbehavior: Description of incident:
Techniques attempted:
Parental conference held? ◻ Yes ◻ No If yes, date held and summary of outcome.
Date of misbehavior: Description of incident:
Techniques attempted:
Parental conference held? ◻ Yes ◻ No If yes, date held and summary of outcome.
Date of misbehavior: Description of incident:
Techniques attempted:
Parental conference held? ◻ Yes ◻ No If yes, date held and summary of outcome.
◻ Additional space is needed. ______ supplemental sheets are attached to this notice.
Express your opinion of the action(s) that will be most effective with the student and state your expectation for the outcome of your decision to remove the student from your class.
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________________________________________________________________
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______________________________ _______________________________
Teacher's Signature Date notice submitted to
principal
SUPPLEMENT TO
NOTICE TO PRINCIPAL OF REFUSAL TO READMIT STUDENT
Teacher ____________________ Student _______________ Date ________
School _____________________ Class ________________ Period ______
Date of misbehavior: Description of incident:
Techniques attempted:
Parental conference held? ◻ Yes ◻ No If yes, date held and summary of outcome.
Date of misbehavior: Description of incident:
Techniques attempted:
Parental conference held? ◻ Yes ◻ No If yes, date held and summary of outcome.
______ of ______ Supplemental Sheets