Within the framework of Louisiana's educational system, the School Behavior Report Form "B," as dictated by R. S. 17:416(A), serves a critical function in maintaining a conducive learning environment by promptly informing parents or guardians about behavioral incidents involving their children. This comprehensive form details the student's name, the supervising teacher or staff, and the principal's name, alongside the specific date, time, and location of the incident. It meticulously categorizes the incident by various codes covering the time and location of the incident, the underlying motivation for the behavior, and any influences such as drugs, alcohol, or gang association that might have played a role. The form goes further to specify the nature of the behavior by detailing whether there was serious bodily injury or the need for medical treatment for either the perpetrator or the victim. A wide range of behaviors, from the possession of controlled substances and weapons to bullying, sexual harassment, and other serious offenses, are meticulously accounted for. Additionally, the form records the actions taken by teachers or other school employees in response to the incident, recommendations for further action, and any subsequent actions taken by school administrators, ranging from counseling referrals to suspension or expulsion. Parental or guardian contact is an integral part of the process, with spaces allocated for their signatures, recommendations, and any comments they wish to add, ensuring a collaborative effort between the school and home to address and remedy the student's behavior.
| Question | Answer |
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| Form Name | Louisiana School Behavior Report Form |
| Form Length | 2 pages |
| Fillable? | Yes |
| Fillable fields | 142 |
| Avg. time to fill out | 28 min 58 sec |
| Other names | 5th, louisiana department of education school behavior report, OTC, SBLC |
LouiSiAnA dEPARtMEnt of EducAtion ScHooL BEHAvioR REPoRt
foRM “B”
In accordance with R. S. 17:416(A) the purpose of this report is to inform parents/guardians of a behavior incident on the school campus, in the classroom, cafeteria, gymnasium, auditorium, elsewhere at the school or during
Name of Student ____________________________________________________________ |
Phone ____________________________ Grade/Section ____________________________ |
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Name of Teacher/Staff _________________________________________________________________________ |
Room #/Location _____________________________________________ |
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Name of Principal____________________________________________________________ |
School ______________________________________________________________________ |
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Check One: |
Regular Education |
504 |
Special Education |
Date of Incident________________ |
Time ________________ Location ______________________________ |
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Time Code:____________ |
01 |
Before School on Grounds, 02 During Class, 03 Between Classes, 04 After Normal School Hours & Supervised, 05 To / From School, 06 At Bus Stop or Transfer Station, |
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07 |
During School Extracurricular / Assembly Event, 08 Recess, Club, Free Time, 09 Homeroom, 10 Breakfast /Lunch, 99 Outside of School Hours or Supervision |
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Location Code:_________ |
01 |
Classroom, 02 Restroom, 03 Lunchroom, 04 Hallway, 05 Playground, 07 Bus Stop, 08 Parking Lot, 09 Locker Room, 10 Cell Phone, 11 Internet, 12 To or From |
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School, 13 School Sponsored Event, 14 Home, 98 Offsite Program, 99 Other_______________________ |
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Motivation Code: _______ |
1 Avoid Adult, 2 Avoid Peers, 3 Avoid Task / Activity, 4 Obtain Adult Attention, 5 Obtain Items / Activities, 6 Obtain Peer Attention, 7 Other____________, 8 Don’t Know |
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Related Influences: |
Drugs, Alcohol, Gang, Bias (Bias Motivation Codes: 01 Appearance, 02 Gender, 03 Religion, 04 Disability, 05 Race / Ethnicity, |
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(Check all that apply) |
Don’t Know____________, 06 Sexual Orientation, 07 Home Circumstances, 08 Medical Condition, 09 Poverty, 99 Other________________) |
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Circle Yes or No |
Perpetrator: Serious Bodily Injury Y N |
Medical Treatment Y N |
victim: Serious Bodily Injury Y N |
Medical Treatment Y N |
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07. Uses or possesses any controlled dangerous substances governed by the Uniform Controlled Dangerous Substances Law, in any form
13. Possesses weapon (s) as defined in Section 921 of Title 18 of the U.S. Code. *Use of code 13 requires additional submission of the Weapon Type code.
14. Possesses firearms (not prohibited by federal law), knives, or other implements, which may be used as weapons, the careless use of which might inflict harm or injury (Excludes pocket knives with a blade length < 2 ½“ - refer to code 31).
15. Throws missiles liable to injure others
Primary incident / Reason codes. check all that apply.
21. Commits any other serious offense
22. Murder
23. Assault and/or Battery
24. Rape and/or Sexual Battery
25. Kidnapping
26. Arson
27. Criminal Damage to Property
28. Burglary
29. Misappropriation with violence to the person
30. Discharge or use of weapon (s) prohibited by federal law
31. Possesses pocket knife or blade cutter with a blade length < 2 ½”
32. Serious Bodily Injury
33. Use of OTC medication in a manner other than prescribed or authorized
34. Possession of Body Armor
37. False Alarm / Bomb Threat
40. Public Indecency
41. Obscene behavior or Possession of Obscene/ Pornographic Material
45. Trespassing Violation
48. Sexual Harassment
REMARKS/DESCRIPTION OF INCIDENT: _________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________
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Action(S) tAKEn BY tEAcHER oR otHER ScHooL EMPLoYEE |
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The student named above is hereby reported for inappropriate behavior as indicated in this report. This is the student’s 1st |
2nd 3rd 4th 5th |
(circle one) or other ____ cumulative |
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behavioral referral(s). I have taken the following action(s): |
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011 |
Referred to Office |
012 |
Referred to Counselor |
013 |
Referred to Social Worker |
014 |
Referred to SBLC |
018 Secondary Referral (PBIS) |
019 |
Tertiary Referral (PBIS) |
022 |
Therapeutic Removal |
025 |
Intervention Room |
080 |
Assigned Remedial Work |
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120 |
Student Conference |
140 |
Student Reprimand |
160 |
Loss of Privileges |
030 |
Restorative Practices Implemented |
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173 |
Conference with Parents or Guardians |
175 |
Conference with Principal |
999 |
Other Action__________________________________________ |
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Y n Contact Parent/Guardian Date: ________________ Time:_____________________ Phone Call |
Letter |
Conference Date: ______________ Time:_____________ |
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REcoMMEndAtion(S) BY tEAcHER oR otHER ScHooL EMPLoYEE _________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________
Signature of School Employee: ____________________________________________________________________________________________________ |
Date: ___________________ |
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Action(S) tAKEn BY ScHooL AdMiniStRAtoR |
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The student named above is hereby reported for inappropriate behavior as indicated in this report. This is the student’s 1st |
2nd |
3rd 4th 5th (circle one) or other ____ cumulative |
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behavioral referral(s). I have taken the following action (s): |
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000 |
No Action– only use if no reportable action was taken |
160 |
Loss of Privileges |
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020 |
TOR (Time Out Room) |
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012 |
Referred to Counselor |
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014 |
Referred to SBLC |
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040 |
In School Detention from _____ to _____ |
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043 After School Detention from _____ to _____ |
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045 Weekend Detention from _____ to _____ |
002 |
Suspension Out Of School from ______to _____ |
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004 Suspension In School from _____ to _____ |
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006 Suspension Alternative Site from _____ to _____ |
001 |
Expulsion Recommendation |
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017 |
Enforcement Referral (Arrest Resulted Y N) |
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016 |
Court Referral Date ______________ |
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013 |
Referral to Social Worker |
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080 Assigned Remedial Work |
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999 Other Action (s): ________________ |
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030 |
Restorative Practices Implemented |
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140 |
Student Reprimand |
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120 |
Student Conference Date: __________ |
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173 Conference w/ Parents or Guardians on:___________ |
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175 |
Conference w/ Principal on: _______________ |
180 |
Corporal Punishment (if |
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Y n Contact Parent/Guardian Date: ________________ |
Time:_____________________ Phone Call |
Letter |
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Conference Date: ______________ Time:_____________ |
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SIS Primary Infraction/Reason Code Entered: ______ |
Signature of Principal: _____________________________________________________________ |
Date: ___________________ |
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coMMEntS BY StudEnt And/oR PAREnt/GuARdiAn: ___________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________
Signature of Student: ________________________________________ |
Signature of Parent/Guardian: ________________________________________ |
Current Date: _________________ |
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Check appropriate blocks as copies of the document are supplied: |
Parent/Guardian |
School’s Pupil File |
Employee Filing this Report |
Principal |
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*notE: the principal shall return a completed copy of this form to the staff member who initiated the referral within 48 hours (excluding
**Attachments: Provide a copy of the classroom minor tracking form, behavior intervention plan and data, or other applicable intervention information.