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Run: 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 off...

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Submission Notice and Data Use

I understand this referral will be used for PBIS data review and follow-up by authorized school staff. (required)

Yes No N/A

Submitted by (required)

Role (required)

Student and Incident Information

Student name (required)

Student ID

Date of incident (required)

Time of incident (required)

Location (required)

If other, specify location

Behavior Description

Problem behavior (required)

If other, describe the behavior

What happened? (required)

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 (required)

If other, describe the intervention

Was the student removed from instruction? (required)

Follow-up needed

Follow-up notes

Safety, Injury, and Escalation

Did anyone get injured? (required)

Injury details

Was there a threat, weapon concern, or immediate safety risk? (required)

Safety actions taken

Get your results

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Email (required)

Your name (optional)

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