PBIS Office Discipline Referral (ODR) Form

Structured referral form for documenting office-managed behavior incidents, including the behavior, location, time, intervention, and follow-up needed for PBIS data review and decision-making.

Submission Notice and Data Use

• I understand this referral will be used for PBIS data review and follow-up by authorized school staff.
• Submitted by
• Role

Student and Incident Information

• Student name
• Student ID
• Date of incident
• Time of incident
• Location
• If other, specify location

Behavior Description

• Problem behavior
• If other, describe the behavior
• What happened?
  Describe only observable facts. Avoid opinions or diagnoses.
• What happened right before the behavior?
• What happened immediately after the behavior?

Response and Follow-Up

• Immediate intervention used
• If other, describe the intervention
• Was the student removed from instruction?
• Follow-up needed
• Follow-up notes

Safety, Injury, and Escalation

• Did anyone get injured?
• Injury details
• Was there a threat, weapon concern, or immediate safety risk?
• Safety actions taken