PBIS Office Discipline Referral (ODR) Form
This PBIS Office Discipline Referral (ODR) Form captures who was involved, what happened, where it occurred, and what response was taken. Use it to route office-managed incidents into a consistent record for PBIS review and follow-up.
Trusted by frontline teams 15 years of frontline software AI customization in seconds
Built for: K 12 Education · School Administration · Student Support Services
Overview
The PBIS Office Discipline Referral (ODR) Form is a structured workplace form for schools to document behavior incidents that move beyond classroom management and into office review. It captures the submission acknowledgement, submitter identity, student and incident details, behavior description, antecedent and consequence, immediate intervention, whether the student was removed from instruction, and any safety or injury concerns.
Use this template when you need a consistent record for PBIS data review, behavior pattern tracking, and follow-up decisions. It works well for referrals from teachers, aides, bus staff, and supervisors because the fields are specific enough to compare incidents across locations and time periods. The form is also useful when a school wants a clear handoff from the staff member who observed the incident to the office team responsible for next steps.
Do not use this form for every minor correction or routine classroom redirection. It is not a substitute for informal classroom documentation, and it should not be overloaded with unrelated student records. If your school needs to collect highly sensitive details, use the minimum necessary information and keep optional fields hidden until they apply. The best version of this template is short, factual, and easy to complete right after the incident, while the details are still accurate.
Standards & compliance context
- Use data minimization under GDPR Article 5 by collecting only the student and incident details needed for discipline review and follow-up.
- Apply WCAG 2.1 AA practices such as clear labels, logical field order, and keyboard-accessible controls so staff can complete the form efficiently.
- If the form may capture disability-related or accommodation-related context, keep the language neutral and route sensitive details through authorized staff only.
- When injury or threat concerns are recorded, limit access to staff with a legitimate need to know and preserve the audit trail for incident review.
- Use anonymous submission only if your school’s policy allows it and the workflow still supports safe follow-up and accountability.
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 used and who is submitting it, which supports accountability and appropriate data handling.
- 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
These fields identify the student and anchor the referral to a specific date, time, and place so the incident can be reviewed and trended accurately.
- Student name
- Student ID
- Date of incident
- Time of incident
- Location
- If other, specify location
Behavior Description
This section captures what happened in observable terms, along with the antecedent and consequence needed for PBIS analysis.
- 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
These fields document what staff did immediately and what action is still needed so the referral leads to a clear next step.
- Immediate intervention used
- If other, describe the intervention
- Was the student removed from instruction?
- Follow-up needed
- Follow-up notes
Safety, Injury, and Escalation
This section flags higher-risk incidents and records the actions taken when injury or threat concerns are present.
- Did anyone get injured?
- Injury details
- Was there a threat, weapon concern, or immediate safety risk?
- Safety actions taken
How to use this template
- Add the submission notice, student identifiers, incident fields, response fields, and safety fields to your form, then mark only the truly required fields as required.
- Set up dropdowns or multi-select fields for problem behavior, location, immediate intervention, and follow-up needed so staff do not type inconsistent labels.
- Assign the form to the staff member who witnessed the incident or handled the first response, and use the submitter fields to preserve accountability and audit trail context.
- Complete the referral immediately after the incident by entering the date, time, location, observed behavior, antecedent, consequence, and any removal from instruction.
- Review the submission in the office or PBIS team workflow, then assign follow-up actions such as parent contact, behavior support, or safety escalation.
- Close the loop by documenting what happened after submission so the referral becomes usable for trend review instead of a one-time note.
Best practices
- Use controlled lists for behavior, location, and intervention fields so PBIS reports stay consistent across staff members.
- Keep the behavior_description field factual and observable, and avoid labels that mix interpretation with evidence.
- Use conditional logic to show location_other, behavior_other, intervention_other, and injury_details only when the selected answer requires it.
- Mark the submitter and incident fields clearly so staff can complete the form in one pass without searching for missing context.
- Include a clear what happens after I submit line so staff know who reviews the referral and what follow-up to expect.
- Limit free-text fields to the details that cannot be captured in structured fields, especially when the note may include PII.
- Review referral patterns by location and time regularly so repeated incidents can be addressed with targeted supports rather than one-off responses.
What this template typically catches
Issues teams running this template most often surface in practice:
Common use cases
Frequently asked questions
What incidents should be documented with this ODR form?
Use this form for office-managed behavior incidents that need administrative review, not every minor classroom correction. It is suited to repeated disruption, aggression, defiance, unsafe conduct, or any event that requires a formal follow-up. If the issue can be handled with a classroom intervention and no office record is needed, this template may be more than you need.
Who should complete the referral form?
Typically the staff member who witnessed the incident or first responded to it completes the form. The submitter fields make it clear who entered the referral and in what role, which helps with follow-up and audit trail review. Schools can customize the workflow so teachers, paraprofessionals, bus staff, or supervisors submit it based on local practice.
How often should this form be used?
Complete it each time an office-managed incident occurs so the PBIS team has a consistent record for pattern review. Ad hoc notes and verbal handoffs are easy to lose, while a structured form supports trend analysis by location, time, behavior type, and response. If your school uses tiered behavior supports, this form can also help identify when repeated incidents warrant a team review.
Does this form collect more information than necessary?
It should not. The template is designed around data minimization: only collect the fields needed to describe the incident, document the response, and support follow-up. Avoid adding sensitive details unless they are relevant to the school’s process, and use conditional logic so optional fields appear only when applicable.
How should schools handle student privacy and consent?
Limit access to staff who need the information for discipline, safety, or support planning. If the form is shared beyond the immediate response team, make sure the school’s privacy rules and consent practices are followed, especially when notes include health, disability-related, or family-sensitive information. Keep the language factual and avoid unnecessary PII in free-text fields.
What are common mistakes when using an ODR form?
Common problems include vague behavior descriptions, missing location or time details, and overusing free-text when a controlled list would be clearer. Another frequent issue is skipping the follow-up section, which makes the referral useful for filing but not for action. Schools also sometimes mark too many fields required, which reduces completion quality and slows reporting.
Can this template be customized for different grade levels or settings?
Yes. You can tailor the behavior list, location options, and intervention choices for elementary, middle, high school, bus, cafeteria, hallway, or playground settings. Conditional logic can also hide fields that do not apply, such as location_other or intervention_other, so the form stays short and easier to complete.
How does this compare with informal incident notes or email referrals?
Informal notes and email threads are hard to standardize, search, and review across staff members. This template creates a consistent field structure that supports PBIS data review, follow-up tracking, and clearer handoffs. It also reduces ambiguity by prompting the submitter to record the behavior, antecedent, consequence, and immediate intervention in the same format each time.
Related templates
Go deeper on the topic
-
A standard operating procedure (SOP) is a documented, step-by-step procedure for a repeatable task — the written version of "how we do this here." Good SOPs...
-
Workforce management (WFM) is the operational discipline of getting the right employees, with the right skills, in the right place, at the right time — and...
-
A daily huddle is a brief (10–15 minute) standing meeting held at the start of a shift or workday to align the team on priorities, surface issues, and...
-
A deskless worker is any employee whose job happens without a desk, a company laptop, or a fixed workstation. They're roughly 80% of the global workforce —...
-
When scheduling tools lack leave and budget data, costly errors follow. See how integrated workforce management closes the context gap.
-
Integrated digital workplace task management tips to keep work moving, reduce stalls, and turn conversations into accountable action.
-
MangoApps is named a Leader in the IDC MarketScape for Content Management in Authenticated Digital Workspaces. See what sets our intranet platform apart.
-
Compare the top internal communications platforms of 2026—MangoApps, Staffbase, Simpplr, and more—by workforce fit, features, and frontline reach.
Ready to use this template?
Get started with MangoApps and use PBIS Office Discipline Referral (ODR) Form with your team — pricing built for small business.
