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Student Discipline Report

Jackson Middle School Student Discipline Report


Student’s Name:                               Grade:                  Race:                           Sex:


Parent’s Name:                                                              Address:


Home Phone:                                    Work Phone:                                             Cell Phone:


Name of Staff Member:                                                                                      Date of Incident:


Time of Incident:


The purpose of this report is to inform you of a disciplinary incident involving your child and the action taken. You are urged to counsel your child concerning his/her behavior in order to lessen the possibility of continued misbehavior resulting in further disciplinary action.


Details of Violation ( To be completed by staff member )






Action Taken by Teacher:

_____ Issued corrective instructions/ warning

_____ Referred to Administrator

_____ Paddled student ( # of licks ____ )

_____ Held Conference with parent

_____ Telephoned Parent

_____ Consulted Counselor


Administrative Actions:

_____ Counseled & Warned

_____ Alternative School ( # of days ____ )

_____ Paddled ( # of licks ____ )

____ Suspension from bus ( # of days ___ )

_____ Telephoned Parent

_____ Suspension from school ( # of days ___ )

_____ Held conference with parent Date to return to school or report to

____ Detention ( # of days ____ ) located @ Alternative School



Principal’s Office

Principal’s Comments:






_______________________                                   _________________________

Parent’s Signature                                                        Administrator’s Signature

Notice To Parents

Parent’s must accompany child to Alternative School when assigned Alternative Days ( not Detention Days ). Under Clarke County Board of Education Policy suspended students and those to Alternative School may not attend or participate in school functions or enter school property for any reason day or night. Students assigned to Alternative School must be accompanied on the 1st day by parent or guardian for a conference and must be transported daily.