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PBIS Office Discipline Referral (ODR) Form

PBIS Office Discipline Referral (ODR) Form for documenting student behavior incidents, immediate response, and follow-up in one consistent record. Use it to support tiered PBIS review, parent contact, and clearer behavior data.

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Overview

This PBIS Office Discipline Referral (ODR) Form is a structured school behavior referral template for documenting a specific incident, the setting where it happened, the response taken, and the follow-up action. It is built for schools using PBIS or similar behavior support systems that need consistent data for review, not just narrative notes.

Use this template when a behavior needs office-level documentation, when a pattern is emerging, or when the school wants a clean record for team review, parent contact, and intervention planning. The form captures the referral date and time, student and staff details, incident location and timing, the problem behavior, impact, immediate response, and follow-up. That structure helps reduce vague entries and makes it easier to compare referrals across students, settings, and time periods.

Do not use this form as a catch-all for every minor classroom issue. For low-level classroom management, a teacher log or brief note may be more appropriate. It is also not the right place to collect unrelated personal details, medical history, or broad disciplinary commentary. Keep the record focused on what happened, what was observed, what action was taken, and what happens next. If your school uses conditional logic, show injury or property damage details only when those fields apply.

Standards & compliance context

  • Keep the form aligned with GDPR data minimization principles by collecting only the student and incident details needed for behavior review and follow-up.
  • If the form is used in a public-facing or shared workflow, include clear consent or data-use language for any PII collected.
  • For school accessibility, design labels, validation messages, and navigation to support WCAG 2.1 AA so staff can complete the form reliably.
  • If the form is part of an HR-style intake for staff conduct or accommodation concerns, include ADA-aware prompts only where relevant and avoid unnecessary sensitive questions.

General regulatory context for orientation only — verify current requirements with counsel or the relevant agency before relying on this template for compliance.

What's inside this template

Submission Notice and Data Use

This section sets expectations for how the referral will be reviewed and who can access the information.

  • I understand this referral will be used for school behavior tracking and PBIS decision-making. (required)
  • Data use and privacy notice

    Provide only observable behavior details and minimum necessary information. Avoid sensitive personal details unless directly relevant to the incident.

Student and Referral Details

These fields identify the student, the incident, and the staff member submitting the referral so the record is traceable.

  • Date of referral (required)
  • Time of referral (required)
  • Student name (required)
  • Student ID
  • Referring staff member (required)
  • Staff role (required)

Incident Location and Timing

This section captures when and where the behavior occurred, which is essential for spotting patterns and supervision gaps.

  • Date of incident (required)
  • Time of incident (required)
  • Location (required)
  • Location details
  • Activity or setting at the time

Problem Behavior

These fields define what happened in observable terms so the referral can support consistent PBIS review.

  • Problem behavior category (required)
  • What happened? (required)

    Describe observable actions, words, and sequence of events. Avoid opinions or diagnoses.

  • Severity level (required)
  • Was this behavior repeated during the incident? (required)
  • Number of times behavior occurred

Impact and Immediate Response

This section records who was affected, whether harm occurred, and how staff responded right away.

  • Who was affected? (required)
  • Did anyone sustain an injury? (required)
  • Injury details
  • Was property damaged? (required)
  • Property damage details
  • Immediate intervention used (required)

Follow-Up and Review

These fields document parent contact, next actions, and the final submitter confirmation so the referral is complete.

  • Was a parent or guardian contacted? (required)
  • Recommended follow-up action (required)
  • Follow-up notes
  • Submitter signature

How to use this template

  1. 1. Set the required fields, field types, and conditional logic so staff can enter dates, times, counts, and follow-up details without extra free-text clutter.
  2. 2. Assign the form to the staff member who observed the incident or handled the referral, and make the submission notice clear about how the data will be used.
  3. 3. Record the student, date, time, location, behavior category, and a short behavior description immediately after the incident while the facts are still fresh.
  4. 4. Add impact details such as others affected, injury, property damage, and the immediate intervention only when those fields apply to the event.
  5. 5. Complete the follow-up section with parent contact, next action, and notes, then route the submission to the PBIS team or administrator for review.
  6. 6. Review referral patterns regularly and use the data to adjust supports, expectations, supervision, or intervention plans.

Best practices

  • Use a controlled behavior category list so staff classify incidents consistently across classrooms and grade levels.
  • Keep the incident description factual and observable, and avoid labels or conclusions that are not supported by what was seen.
  • Use conditional logic to reveal injury, property damage, or repeat-count fields only when they are relevant to the referral.
  • Mark only the fields that are truly required, because overrequired forms slow completion and reduce data quality.
  • Choose field types that match the data, such as date pickers for dates, time fields for times, and numeric inputs for repeat counts.
  • Include a clear submission notice that explains who can view the referral and what happens after the form is submitted.
  • Capture the immediate intervention in specific terms so the PBIS team can see whether the response matched the behavior and setting.
  • Review referrals for location and time patterns, since hallway, cafeteria, bus, and transition incidents often need different supports.

What this template typically catches

Issues teams running this template most often surface in practice:

The behavior description is too vague to support a useful review.
The location field is broad, which makes pattern analysis harder.
Repeat behavior is noted in text but the repeat count is left blank.
Immediate intervention is missing, so the school cannot tell how the incident was handled.
Parent contact is assumed but not recorded in the follow-up section.
Injury or property damage details are entered even when no such impact occurred.
The form collects extra personal details that are not needed for the referral.

Common use cases

Elementary classroom referral
A teacher documents repeated disruption, notes the classroom setting, records the immediate redirection used, and sends the referral for PBIS review. The form helps the team see whether the behavior is isolated or part of a pattern.
Middle school hallway incident
An administrator records a hallway conflict during passing time, including location details, others affected, and any injury or property damage. The structured fields make it easier to compare incidents across transitions and supervision points.
High school cafeteria behavior review
A staff member submits a referral after a cafeteria incident and uses the follow-up section to document parent contact and next steps. The record supports later review of lunch-period supervision and intervention planning.
PBIS team pattern analysis
A school behavior team reviews multiple referrals to identify repeated locations, times, and behavior categories. The form's consistent structure supports decisions about schedule changes, targeted supports, or additional supervision.

Frequently asked questions

What is this PBIS Office Discipline Referral form used for?

This form is used to document a student behavior incident in a consistent, reviewable format. It captures who was involved, when and where it happened, what behavior occurred, what immediate intervention was used, and what follow-up is needed. That makes it easier for PBIS teams to review patterns and decide on next steps.

Who should complete the ODR form?

The referring staff member should complete it as soon as practical after the incident, while details are still accurate. In most schools, this is a teacher, paraprofessional, administrator, or support staff member who directly observed the event or handled the response. The submitter signature field helps confirm accountability and traceability.

How often should an office discipline referral be submitted?

Submit one form for each distinct incident that requires office-level review or a formal behavior record. If the same student has multiple incidents on different days, each event should be logged separately so the data stays usable for trend analysis. For repeated behavior in the same incident, use the repeat behavior and repeat count fields rather than creating duplicate entries.

Does this form support PBIS tiered decision-making?

Yes, the form is designed to produce structured data that PBIS teams can review by behavior category, location, time, and response. Those fields help identify patterns that may point to Tier 1 classroom supports, targeted Tier 2 interventions, or more individualized Tier 3 planning. The follow-up section also helps track whether the referral led to a parent contact or other action.

What should schools avoid collecting on this form?

Only collect the minimum information needed to document the incident and support school response. Avoid adding unnecessary sensitive details, free-text notes that include unrelated personal information, or medical information beyond what is needed to describe an injury. If your school uses the form for public-facing or shared workflows, keep the consent and data-use language clear.

Can this form be customized for different grade levels or behavior systems?

Yes, the behavior category list, intervention options, and follow-up actions can be tailored to elementary, middle, or high school use. You can also add conditional logic so injury or property damage details only appear when relevant, which reduces clutter and improves completion speed. Keep required fields limited to the minimum needed for a usable record.

How does this compare with ad hoc email or paper notes?

Ad hoc notes are harder to compare across staff, locations, and time periods because they often use different wording and missing fields. This template standardizes the key data points so the same incident type is recorded the same way each time. That makes review faster and reduces the chance that important details, like location or immediate intervention, are left out.

What integrations are useful with this form?

Schools often connect ODR forms to student information systems, behavior dashboards, or case management tools so referrals can be reviewed in context. If your workflow supports it, routing the submission to administrators, counselors, or PBIS team members can speed follow-up. An audit trail is also helpful when the form is used for formal behavior documentation.

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