Preview Student Behaviour Student

Observed Student Behavior (OSB) Report

This form is used to document a recurring behavior incident. The student has been given a warning

and re-taught the expectation and specific rule concerning the infraction prior to recording on this

form.

This is not a referral. However, continuation of this behavior will result in an office discipline referral.

Student:

Teacher:

Grade:

Gender:

INCIDENT TYPE (Check One):

Respect

 Disruption

 Disrespect/Non-Compliance

 Inappropriate language

Acting Responsibly

 Lying/ Forgery on class

assignments

 Dress code

 Tardy

Care for Others/Safety

 Property damage

 Physical aggression

(minor)/Horseplay

Everyone Matters

 Harassment/ teasing/

bullying

 Other:_____________

Discuss and conference on the expectation and write in the student’s planner. Date: _________

I will cooperate with these interventions to improve my behavior

Student Signature:_____________________

Observation of Behavior Date:______________ Time of Incident:_______

INTERVENTION (Check One):

POSSIBLE MOTIVATION

(Check One):

OTHERS INVOLVED

(Check One):

 Seating change

 Commitment Group

 Time out in Alternate

Classroom

 Working lunch with an

adult

 Student contract with a reward

 Use of timer during activities

 Controlled movement during

passing time

 Loss of privilege

 Other:

 Avoid Adult

 Avoid Peer(s)

 Avoid Task/Activities

 Don’t Know

 Obtain Adult Attention

 Obtain Items/Activities

 Obtain Peer Attention

 Other: ______________

 None

 Peers

 Staff

 Teacher

 Substitute

 Unknown

 Other:

____________

Parent Call:___________________________ Comments: ______________________________

Incident Date:______________ Time of Incident:_______

INTERVENTION (Check One):

Please use different interventions.

POSSIBLE MOTIVATION

(Check One):

OTHERS INVOLVED

(Check One):

 Seating change

 Commitment Group

 Time out in Alternate

Classroom

 Working lunch with an

adult

 Student contract with a reward

 Use of timer during activities

 Controlled movement during

passing time

 Planner signed daily

 Loss of privilege

 Team After School Detention

 Avoid Adult

 Avoid Peer(s)

 Avoid Task/Activities

 Don’t Know

 Obtain Adult Attention

 Obtain Items/Activities

 Obtain Peer Attention

 Other: ______________

 None

 Peers

 Staff

 Teacher

 Substitute

 Unknown

 Other:

____________

Parent Call: _________________________________________ Date: _________ Time: ____________________

Comments: __________________________________________________________________________________

An OSB form must be started anew if more than 30 days occurs between incidents.

Next Offense

Office Discipline Referral, please attach this OSB form and place in the AP’s box, DO NOT

SEND THE STUDENT, if class can continue.

Turn in copies to the front office in the following order

Gold--1

offense Pink--2

offense Canary--3

Offense White—staple to referral

Dr. David L. Anderson Middle School

Rev. 6/10

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