East Fannin Elementary School 1 Elementary Circle

Morganton GA 30512

http://efes.fannin.k12.ga.us/

Mathew Price, Principal

PBISPositive Behavior Intervention Support

Policies & Procedures Handbook

2019-2020

Table of Contents

School Wide Behavior Support

Wildcat Pledge

Expectation Chart

EFES Rules by Setting Matrix

PBIS Team Member Roles

Categorizing Behaviors

Office Managed Behaviors

Teacher Managed Behaviors

Crisis Behavior

EFES Rules

Bus Rules

Play Ground Rules

Hallway Rules

Lunchroom Rules

Restroom Rules

Discipline

EFES Discipline Flow Chart

EFES Behavior Flow Chart

Reflection Zone- Description

Stop and Think Sheet – K-1st Grades

Reflection Zone Sheet – 2nd – 3rd Grades

Reflection Zone Sheet- 4th & 5th Grade

EFES 10 Minute Chill Pass

EFES Student Rewards

PBIS Wildcat Cash Program

Wildcat Cash Reward Store

EFES Rewards Survey

EFES Peer Mediation Program Procedures

What is Peer Mediation

Parent Guardian Permission Form

Teacher Recommendation Form

Peer Mediation Referral Process

Student Peer Mediation Request Form

Check In Check Out (CICO) Program

Daily Card Flip Tracking Form

Daily Check In Check Out Form 1st- 5th

Daily Bus Check In Check Out Form

Daily Check In Check Out Form (Variation)

School Behavior Contract

School Bus Behavior Contract

Behavior Intervention Chart Grades K-3

Behavior Intervention Chart Grades 4-5

On-site PBIS Walkthrough Form

What is Positive Behavioral Intervention &

Support?

The East Fannin Elementary Positive Behavioral Support (PBIS) plan was developed by a team of teachers and

the school administration. The team of teachers consisted of a grade level representative from each grade, a

special education teacher and the school counselor. The purpose of the PBIS plan was to develop a school-wide

code of conduct:

At East Fannin Elementary we are the BEST WE CAN BE by being Respectful, Responsible and Ready to

Learn.

The PBIS team also developed expected student and teacher behaviors for a variety of settings. Students are

rewarded at the end of each school day for modeling appropriate behaviors. At the end of 20 school day

students are recognized by choosing an incentive from a list.

At the start of every school year our students are reminded and re-taught the appropriate school-wide

expectations. We start the year by having the grade level transitions from one setting to another. Positive and

negative behaviors are modeled by staff members.

Schoolwide Positive Behavior Support

East Fannin Elementary has implemented a system of teaching all students school wide procedures and

rewarding them with incentives known as Positive Behavior Intervention Support (PBIS).

PBIS is a broad range of systemic and individualized strategies for achieving important social and

learning outcomes while preventing problem behavior with all students.

Students who behave appropriately and abide by the school rules will receive Wildcat Cash, which can

be used to “purchase” rewards and privileges.

Students will be introduced to the Schoolwide Expectations (Wildcat Pledge) on the first day of school

and will recite them each morning during morning announcements. The school wide expectations are as

follows:

Wildcat Pledge

As an East Fannin Elementary School Wildcat,

I pledge to

Be Respectful

Be Responsible

Be Ready to Learn

EXPECTATIONS Be Respectful

Follow directions, take turns, share with others, be a

team player, problem solver, be a good listener, treat

others the way you want to be treated, allow others to

be different, and acknowledge other’s ideas

Be Responsible Take care of self, allow others to resolve their own

problems, do your job,

accept outcomes of your behavior, and be honest.

Be Ready to Learn Bring materials/homework to class, listen attentively,

have agenda/folder, participate in class, and ask

questions

May 2019

EFES Rules by Setting Matrix Student Expectations - Schoolwide Procedures

Settings and Expected Behaviors

Expectations Cafeteria

Rules

Hall

Rules

Commons/

Playgroun

d

Rules

Restroom

Rules

Bus Area

Rules

BE

Respectful

Respect

Other’s

Space

Use a Low

Voice

Respect

Other’s

Space

Use a Low

Voice

Respect the

Rights and

Space of

Others

Follow

Safety

Rules

Keep

Bathroom

Clean

Respect the

Privacy of

Others

Use a Low

Voice

Use

Appropriate

Language

BE Responsible

Stand

Quietly

and

Appropriat

ely in Line

Clean Up

Your

Space

Keep

Hallway

Clean

(Keep

Lockers

Organized

& Close

Them

Quietly- 4th

& 5th)

Report

Concerns

and Unsafe

Behavior to

Playground

Supervisors

Report

Problems to

Adults

Use Time

Wisely

Report

Problems to

the Driver

Keep the

Aisle Clear

BE Ready to

Learn

Use Good

Table

Manners

Obey

Adults

Walk in a

Straight

Line Facing

the Front

Obey

Adults

Share

Equipment

Keep

Hands,

Feet, and

Objects to

Yourself

(no

throwing

rocks…)

Wash

Hands with

Soap &

Water; Dry

hands

Keep

Hands,

Feet, and

Objects to

Yourself

Stay Seated

Keep

Hands,

Feet, and

Objects to

Yourself

5

PBS TEAM ROLES AND RESPONSIBILTIES

Role Responsibilities

Team Leader Starts and chairs the meeting

Develop agenda

Reviews purpose of the meeting

Facilitate meeting by taking the team through the agenda

PBIS Coach/

School Level School Based Team Member

Primary contact for District Coordinator

Updates the action plan

Maintains the product book

Recorder Keep minutes

Distribute minutes to team members

Notify/remind team members of meeting time and location

Data Specialist/

Administrator Summarize data from previous month

Present update on standard data (e.g. office referrals, etc…)

Supports and facilitates PBIS team activities and

recommendations

Communication

Coordinator Notify/remind team members of meeting time and location

Coordinates communication between students, parents,

community, staff and team regarding PBIS and behavior

Time Keeper Monitor agenda times and topics

Keep the group focused and moving

Monitor start and end times

Table the subject or make a decision

Team Cheerleader/

Snack Masters Monthly booster notes supporting PBIS implementation

Treats for staff members

Behavior Specialist Competent with behavioral principles and interventions

Assists in analyzing data

Categorizing Behaviors Office-Managed Incidents- Major Infraction

Behavior Definition

Harassment/bullying Student delivers disrespectful messages (verbal or gestural) to

another person that includes threats and intimidation, obscene

gestures, pictures, or written notes.

Disrespectful messages include negative comments based on race,

religion, gender, age, and/or national origin; sustained or intense

verbal attacks based on ethnic origin, disabilities or other personal

matters.

Fighting/physical aggression Actions involving serious physical contact where injury may occur

(e.g., hitting, punching, hitting with an object, kicking, hair pulling,

scratching, etc.).

Property damage/vandalism Student participates in an activity that results in destruction of

disfigurement of property.

Abusive language/profanity/

inappropriate language

Verbal messages that include swearing, name calling or use of

words in an inappropriate way.

Forgery/theft

Student is in possession of, having passed on, or being responsible

for removing someone else's property or has signed a persons name

without that person’s permission.

Inappropriate physical contact/sexual

Skip class/truancy

Student leaves class/ school without permission or stays out of class/

school without permission.

Disruption Behavior causing an interruption in a class or activity. Disruption

includes sustained loud talk, yelling, or screaming; noise with

materials; horseplay or roughhousing; and/or sustained out-of-seat

behavior.

Other Behavior

Problem behavior causing this referral is not listed above. Staff

using this area will specify the problem behavior observed.

Internet Violation Student attempts to access inappropriate material or website

Categorizing Behaviors Teacher-Managed Incidents- Minor Infractions

Behavior Definition

Lying/cheating Student delivers message that is untrue and/or deliberately violates

rules.

Defiance/disrespect/insubordination/

non-compliance

Refusal to follow directions, talking back and/or socially rude

interactions.

Dress code violation Student wears clothing that does not fit within the dress code

guidelines practiced by the school/district.

Technology Student engages in inappropriate (as defined by school) use of cell

phone, pager, music/video players, camera, and/or computer.

Inappropriate display of affection Student engages in inappropriate (as defined by school) verbal

and/or physical gestures/ contact, of a sexual nature to another

student/adult, either consensual or non-consensual.

Physical contact Student engages in non-serious, but inappropriate physical contact.

Defiance/ disrespect/ non-compliance

Student engages in brief or low-intensity failure to respond to adult

requests.

Disruption

Student engages in low-intensity, but inappropriate disruption.

Property misuse

Student engages in low-intensity misuse of property.

Other

Student engages in any other minor problem behaviors that do not

fall within the above categories.

Categorizing Behaviors “Crisis” Incidents

Behavior Definition

Alcohol Student is in possession of or is using alcohol.

Weapons Student is in possession of knives or guns (real or look alike), or

other objects readily capable of causing bodily harm.

Combustibles Student is in possession of substances/objects readily capable of

causing bodily harm and/ or property damage (matches, lighters,

firecrackers, gasoline, lighter fluid).

Drugs Student is in possession of or is using illegal drugs/substances or

imitations.

Arson

Student plans and/or participates in malicious burning of property.

Bomb threats/ False Alarm Student delivers a message of possible explosive materials being on-

campus, near campus, and/or pending explosion.

Inappropriate location/out of bounds

Student is in an area that is outside of school boundaries (as defined

by school).

Tobacco Student is in possession of or is using tobacco.

Bus Rules

1. Hands, Feet, and Objects to

Yourself

2. Use Appropriate Language

3. Use a Low Voice

4. Stay Seated

5. Keep the Aisle Clear

6. Report Problems to the Driver

Playground Rules

1. Report Concerns and Unsafe

Behavior to Playground

Supervisors

2. Follow Safety Rules

3. Respect the Rights and Space

of Others

4. Share Equipment

5. Hands, Feet, and Objects to

Yourself

Hallway Rules

1. Walk in a Straight Line

Facing the Front

2. Keep the Hallway Clean

3. Use a Low Voice

4. Obey Adults in Charge

5. Respect Others’ Space

Lunchroom Rules 1. Stand quietly and appropriately

in line

2. Use a low voice

3. Obey adults in charge

4. Respect others’ space

5. Use good table manners

6. Clean up your space

Restroom Rules

1. Hands, Feet, and Objects to

Yourself

2. Respect the Privacy Others

3. Wash with Soap & Water/ Dry

Hands

4. Use Time Wisely

5. Keep Bathroom Clean

6. Report Problems to Adults

EAST FANNIN ELEMENTARY SCHOOL

BEHAVIOR FLOW CHART

Consistently Teach and Re-Teach School-Wide Rules/Expectations

1st Step- Redirect student behavior

No consequence

Conference with student

Communicate with parent as needed

Referring teacher completes

referral- (electronically) and

contacts parents to make them

aware

2nd

Step- (same behavior)

Redirect student

Re-teach behavior

(Verbal Warning)

Communicate with parent as needed

3rd

Step- (same behavior)

Assign Consequence

Contact Parent

Re-teach behavior

Is the behavior teacher or office

managed?

Did the behavior

change?

Administrator follows up with

teacher/ staff member and parent

Administrative consequence

recommended

Administrative behavior &

consequence recorded in IC

Yes No

Notice and reward correct behaviors

Consider further support through PBIS, MTSS

or SPED, after multiple referrals for same

behavior patterns.

Observe & identify problem

behavior

1st Step- Consequence

Re-state Expectation/Rule

Manage with class behavior system

Remind student of appropriate behavior in this situation and potential

+/- consequences

Referral- Referring teacher completes referral-

(electronically)

Escort student to office (if needed)

Classroom Managed: Minor Incidents

1. Lying/ cheating 2. Defiance/ disrespect/ insubordination/ non-

compliance 3. Dress code violation 4. Technology 5. Inappropriate display of affection 6. Physical contact 7. Disruption 8. Property misuse 9. Other- not listed above

Managed in Classroom or Office?

Office Managed: Major Incidents

1. Harassment/ Bullying 2. Fighting/ Physical Aggression 3. Property damage/ vandalism 4. Abusive language/ profanity/

inappropriate language 5. Forgery/ theft 6. Inappropriate physical contact/ sexual 7. Skip class/ truancy 8. Disruption 9. Other behavior- not listed above 10. Internet Violation

3rd Step- Parent/Guardian Contact (Same behavior)

(after a minimum of 1 verbal reminder)

Contact parent/guardian through phone call or email

Determine consequence and request additional assistance if needed

(such as school counselor referral)

4th

Step- Office Referral for Repeat Minor Incidents

(after a minimum of 1 parent contact (Step 3)

Follow Major Incident Procedure (see right)

For repeat students seek suggestions from MTSS/ PBIS Team

Members

Administrator

Conferences with student & investigates further if

needed

Considers teacher input, discipline history, &

student age

Determines action/consequence

Notifies parent/guardian

Distributes copies to classroom teacher, referring

staff member, parent/guardian, and office

Considers need for further intervention whether

through school counselor, MTSS/ PBIS/ SPED or

community services

Verbal Warning

Re-state Expectation/Rule

Manage with class behavior system

Redirect student behavior:

No consequence

2nd Step- Consequence (Same behavior)

Re-state Expectation/Rule

Manage with class behavior system

Agenda/ DOJO/ Parent note completed in classroom sent home for

signature to record behavior

Menu of Classroom Consequences

Here is an example of what a menu of

consequences can look like.

1st Offense: Verbal warning

2nd

Offense: lose recess minutes

3rd

Offense: time out in another classroom

4th

Offense: Parent phone call

5th

Offense: Office referral

** Use to reinforce their classroom rules and

expectations

Reflection Zone

How I should do it:

Teachers will set up an extra work area to be used as a reflection space by their

teammates and students that need to use it when behavior becomes disruptive. This is not

meant as a timeout work station where work can be made up etc… This is a space for the

student to self-reflect on current behavior to figure out what is not working and change

the behavior. The student is to be placed their without any disagreement or argument on

his behalf. Once student has successfully filled out the reflection sheet and it is reviewed

by the team teacher, he may return to his original class. The student will not be allowed

to be disruptive or argumentative when in the reflection zone classroom. Excessive

disruptions, arguments, or reflection zone placements will result in an office referral, note

home or parent contact.

Why should I do it:

We learn from reflecting on experiences, good and bad. A Reflection Sheet is a very

effective tool to use when a student is displaying unacceptable behaviors and can be used

in conjunction with the Class Rules. The sheets can be used to help correct undesired

behaviors.

When should I do it:

When students are exhibiting unacceptable behaviors.

When students are not following school/class rules.

How do I do it:

The student is told to go to the reflection zone.

The teacher explains briefly to the student why they are being sent and what behaviors or

rules they were breaking.

The student is withdrawn to reflect on his/her behavior and completes the Reflection

Sheet, discussing it with the Teacher after it is completed.

A timer may be used.

Alternatives to writing may be drawing pictures, talking into a microphone and recording

responses, or typing responses into computer.

A desk set apart from the other students in the reflection zone will be best to limit

disruptions.

Stop and Think

Today we are learning how to make good choices. Today _________________________

NAME

had some trouble making the best choice for his/her learning. He/she has talked with me, and

we filled out this form together.

Please discuss it with your child. Thank you!

Here’s what happened:

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

Next time, this would be a better choice:

______________________________________________________________

______________________________________________________________

______________________________________________________________

Parent Comments and Signature:

________________________________________________________________________

X_____________________________

Reflection Zone Think Sheet

What did you do?

Why was that a bad thing to do?

Do you need to apologize to anyone? Did I apologize?

_____ Yes _____ No _____Yes _____ No

To whom?__________________________________

__________________ ______ ____________ _______________________ Student’s Signature Teacher’s Signature Parent/Guardian’s Signature

EAST FANNIN ELEMENTARY SCHOOL REFLECTION ZONE

Name:______________________________________ Date:__________

1. What expectation did I not meet? _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

2. Why was my behavior a problem? (Continue on back if needed.) _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

3. What could I have done instead? (Continue on back if needed.) _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

4. Do you need to apologize to anyone? Did I apologize?

_____ Yes _____ No _____Yes _____ No

To whom?__________________________________

__________________ ______ ____________ _______________________ Student’s Signature Teacher’s Signature Parent/Guardian’s Signature

EFES

10 minute chill pass Please answer the following questions: 1. What were you doing? __________________________

2. What were you supposed to be doing? ______________

____________________________________________

3. What are you going to do about it now? ____________

____________________________________________

EFES

10 minute chill pass Please answer the following questions: 1. What were you doing? __________________________

2. What were you supposed to be doing? ______________

____________________________________________

3. 4. What are you going to do about it now? ____________

____________________________________________

Send Student On Errand

Why should I do it:

Provides student time away from situation

Provides student exercise and a release of tension

Allows student to feel needed and important

Can help students to “reset” and return to a task fresh

Takes student’s mind off what may be hindering them

Helps break up monotonous tasks, assignments, activities, etc

When should I do it:

When a student gets off task

When you are aware of an ADD/ADHD diagnosis

When student seems fidgety, moves a lot, cannot sit still

When student is becoming frustrated or agitated with the task at hand

When two or more students are engaged in conflict, argument, or are just getting annoyed

with one another

When a student seems to be getting bored, sleepy, or their eyes are glazing over

When a student’s emotions and/or behaviors need to be deescalated

When a student has poor self-esteem and poor self concept

When student is seeking adult approval

How do I do it:

When a student(s) displays any of the characteristics above or similar characteristics,

send the student on an errand

Errands can just be random or part of a more formal classroom system whereby when a

student is called on to run an errand, they choose from a list of errands that need to be

done

Examples of errands include erasing the board, taking out the garbage, helping in the

office or lunch room, writing on the board, cleaning, organizing, assisting, helping, taking

a note to another teacher, walking somewhere to retrieve or drop something off, opening

the windows, making or reading announcements, etc

PBIS Wildcat cash Program

Parent Introduction

PBIS Mission Statement: Establish a positive, supportive and safe learning environment

PBIS is based on the three R’s:

1. Be Respectful – Listen to all adults, your teacher, and

other students in the classroom. Do as you are asked. Keep your hands and feet

to yourself. Take care of your locker, desks, computers, and other equipment at

East Fannin Elementary School.

2. Be Responsible – Follow the three R’s wherever you

are on school grounds. Follow directions. Start work right away and stay on

task. Turn in your assignments on time.

3. Be Ready to Learn - Be on time. Have your materials-agenda, books, paper,

pen/pencil. Have your assignments ready to turn in.

Why? EFES has chosen to use the PBIS Wildcat Cash program to

acknowledge students for positive behavior and for providing support to students

who have difficulty with positive behavior.

How we will use the Wildcat Cash program:

There will be 3 school wide expectations for all students, staff, & settings

There will be direct instruction of expected behaviors

We will regularly acknowledge expected behavior

We will respond to problem behavior with consistent consequences that are

focused on re-teaching the expected behaviors

There will be targeted and intensive intervention for students that need

more support to be successful

Wildcat Cash Reward Store

East Fannin Elementary is proud to support our PBIS Reward Store. PBIS

(Positive Behavioral Interventions and Supports) is a way for EFES faculty and

staff to encourage and reward positive behavior. Students earn Wildcat Cash for

being in the right place, doing the right thing, at the right time with the right

people. They can redeem the passes at the Wildcat Store for a variety of fun

stuff. But to make the store a success, we need:

Volunteers to work in the Reward Store Want to have some fun while helping

the school? Come work in the Wildcat Store! It's a great opportunity to meet

other parents, see the students, and help implement EFES’s Positive Behavior

reward program.

Donations of money or gift cards. You may now support EFES’s popular

Wildcat Store program by making a monetary donation toward it. 100% of

monies received will go directly to restocking the Reward Store with popular

items our students have asked for or need, such as school supplies, gloves, sports

equipment, small gifts for family, and more. Send cash or check made payable to

EFES to the office. Please note on the envelope that this is a donation to the

Wildcat store and your student's name; you will get a receipt.

Donations of a variety of school supplies, small games, candy, and other

trinkets (no gum). The Wildcat Store stocks a wide assortment of cool and fun

items. At the beginning of the school year, school supplies and locker "swag" are

most popular. As we approach the winter holidays, many students request items

they can "buy" as gifts for a parent or other family member.

East Fannin Elementary Student Reward Survey

The PBIS committee is working on a program that will acknowledge students for

behaving in a positive manner. We would like to know what students would like

to earn as part of this program. The rewards need to be things that do not cost

money. We have listed a few ideas that you can check off if you would like to

earn that reward. Please add your own ideas also!

_____ Lunch with favorite teacher

_____ Play outside during study hall

_____ Free Time on Computer

_____My idea is: _____________________________________________

_____My idea is: _____________________________________________

East Fannin Elementary Student Reward Survey

The PBIS committee is working on a program that will acknowledge students for

behaving in a positive manner. We would like to know what students would like

to earn as part of this program. The rewards need to be things that do not cost

money. We have listed a few ideas that you can check off if you would like to

earn that reward and please add your own ideas!

_____ Lunch with favorite teacher

_____ Play outside during study hall

_____ Free Time on Computer

_____My idea is: _____________________________________________

_____My idea is: _____________________________________________

Peer Mediation Application Procedures

Instructions for the student applicant:

Please follow the steps below in completing your peer mediation application

packet:

1. Complete the application. (Respond in complete sentences. Neatness

does count.)

2. Have a teacher complete a student recommendation form.

3. Take home the parental permission letter and have a parent/guardian

sign.

4. When you have completed your application and turn it in to Mr. Miller.

What is Peer Mediation?

Conflict is a normal and positive force that can be a part of personal growth and social change.

To deal effectively with a conflict, a trained peer mediator manages a process of communication

and problem solving that leads to a resolution. Peer mediation is a “chance to sit face to face

and talk, uninterrupted, so each side of the dispute is heard. After the problem is defined,

solutions are created and then evaluated. When an agreement is reached, it is written and

signed.”

What qualities should a peer mediator possess?

Peer mediators should be students who are:

Trustworthy and willing to keep

confidence

Dependable

Respectful Courteous

Academically successful Well-behaved

A team player Attentive

Good listeners Responsible

Sample Interview Questions Please take some time prior to the interview to ponder

these questions. You may want to practice answering the questions with a parent or peer.

Thoughtful and thorough responses to each question are appreciated.

1. What do you know about Peer Mediation Programs?

2. Why do you want to become a Peer Mediator?

3. What do you think it takes to become a successful Peer Mediator?

4. What motivates you?

5. What qualifications do you have that you believe will make you a successful Peer Mediator?

Parent/Guardian Permission Form

Date: ____________________

Dear Parent/Guardian:

Your child has taken a bold step in advancing his/her progress as a contributing member in our

society. Peer mediation is a program that allows students to help their peers with specific

academic and social issues before they are referred to school administrators. A successful Peer

Mediation Program positively affects the school by assisting students in solving minor conflicts

thus decreasing the number of students who are issued consequences such as detention and

suspension.

Your support of this desire is extremely important. As a part of our peer mediation training,

there will be special training sessions to prepare your child for this experience.

If you wish for your child to be considered for the program, please review the application packet

and sign below. Thank you for your support.

For the children,

East Fannin Elementary School Counseling Department

I, (Parent Name)___________________________ give my child__________________________

permission to apply for entrance/ participation in the peer mediation program. I understand that

it is my child’s responsibility to complete assignments that are missed during peer mediation

training sessions, activities, and field trips.

Parent/Guardian Signature:________________________________________________________

Teacher Recommendation Form

For Teachers Only!

Student Name:___________________________________ Date:________________

Please rate this student by comparison to other students in terms of the following:

Below

Average

Average Good Very

Good

Excellent No basis

for

judgment

Motivation

Independence, initiative

Intellectual promise

Academic Achievement

Written Work

Class participation

Disciplined work habits

Sense of humor

Interpersonal relations

Ability to work with a team

Communication with peers

Communication with adults

Listening Skills

Honesty and Integrity

We are interested in your comments concerning the above named student’s academic

performance, intellectual ability, and personal character. In particular, we would appreciate your

appraisal of the candidate’s potential for intellectual growth, honesty, integrity, and emotional

stability. Does this child have the characteristics of an effective peer mediator?

Please use the following space or attach your written evaluation.

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Overall Recommendation

Not

recommended

Without

enthusiasm

Fairly

strongly

Strongly Enthusiastically

For

academic

promise

For

personal

character

Teacher’s Signature_______________________________________ Date: ________________

Peer Mediation Referral Process

The procedure for referring students to peer mediation once both

students agree to mediation is as follows:

o E-mail or send the Peer Mediation Referral Form to Mr.

Miller

If the situation needs IMMEDIATE ATTENTION,

please send the form with a student who is not involved

in the conflict along with one of the disputants to Mr.

Miller.

If the situation does NOT require immediate attention,

please send the form to Mr. Miller, and the mediation

will be conducted within 1 week during the students’

activity or recess block.

o Once the referral is sent, Mr. Miller will determine if the

conflict is suitable for Peer Mediation and which mediators to

use.

o Upon completion of the mediation, the mediators will turn in

their mediation contract, and both mediators and disputants

will be debriefed by Mr. Miller

o The mediators will escort the students to class separately.

o Mr. Miller will e-mail the appropriate staff members the

outcome of the peer mediation.

Peer Mediation Request Form

Date _________________________

Names of students involved in the conflict:

Name _________________________ Teacher/Grade __________________

Name _________________________ Teacher/Grade __________________

Name _________________________ Teacher/Grade __________________

Where did the conflict occur: (circle all that apply)

Classroom

Hallway

Cafeteria

Outside

Other (specify) _________________________

Briefly describe the conflict: ___________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

_______________________________________

Mediation requested by: (circle one)

Student

Teacher

Principal

Counselor

Other (specify) _________________________

“I PROMISE TO TELL THE TRUTH, NOT INTERRUPT, NOT CALL NAMES,

AND AGREE TO WORK ON THE PROBLEM. I AGREE TO “STAY COOL”

UNTIL MEDIATION.”

Student signature________________________

Check In Check Out (CICO) Program

CICO is a Tier II, check-in, check-out program for students who are starting to engage in

problem behavior. The goal of the CICO Program is to help students monitor their own behavior

and to prevent students who are acting out from escalation, providing them with more frequent

feedback on their behavior. Students will use a universal point sheet and will be given points

periodically for following EFES three school rules: Be Safe, Be Respectful, and Be Ready to

Learn. Below are answers to some frequently asked questions about the CICO Program.

Which students do well on CICO?

Students who you are concerned about and/or who are starting to act out but are NOT

currently engaging in dangerous (ex: extreme aggression, property destruction) or severely

disruptive behavior (ex: extreme noncompliance/defiance) would be good candidates for CICO.

Students who have problem behavior across the day and in different settings are good candidates

for the program versus students who have trouble only at recess or at math. CICO is NOT a

program designed to monitor homework completion.

How do students get selected for CICO?

The teacher should contact the counselor in person or via email to request that a student

be added to CICO. The counselor will set up a time to meet with the teacher to determine

whether the CICO Program is appropriate or whether another intervention would be more

appropriate. The counselor will make every effort to start CICO within one week from the

referral. If a teacher does not refer a student and the PBIS team notices that a child has three or

more disciplinary referrals, the PBIS team may suggest implementation of CICO.

How do teachers participate in the CICO Program?

Teachers participate by providing both verbal and written feedback to students at pre-

determined times throughout the day. The feedback is quick and instructional. The student

should give their point sheet to the teacher at the beginning of the time period. If the student

forgets, the teacher may need to remind him/her. Here are some suggestions:

Be cheerful and positive with the student

Acknowledge the student for being responsible by giving you his/her point sheet. You

might say, “Thanks for giving me your point sheet – you’re off to a great start!”

Avoid negative comments to the student. Negative comments will focus the student’s

attention on what not to do and you want to focus on the appropriate, expected behavior.

Let them know you will be watching for them following expectations and appropriate

behavior.

Who is responsible for checking students in and out?

The counselor is responsible for checking students in and out on a daily basis. Another

staff member(s) will be trained to provide back up assistance should the counselor be absent.

The counselor will also make sure all staff that work with the child understand the CICO process

and know when a student will begin CICO.

What is the student’s role?

The student is responsible for checking in with the counselor before 8:00 each morning.

He/she is also responsible for checking out with the counselor at 2:45 each day. The student will

bring the point sheet home each day and is encouraged to return it with a parent/guardian

signature. The student should give his/her point sheet to the teacher at the beginning of each

time period and pick it up at the end. The counselor will work with the student prior to starting

the program to practice desired behavior and procedures for the program. Younger students may

need more teacher assistance than older students.

What is the family’s role?

A parent or guardian is contacted by the counselor either in person or by phone. The

parent/guardian will be given a CICO brochure along with a sample copy of the point sheet prior

to their son/daughter starting the CICO program. A copy of the student’s point sheet goes home

daily with the student once he/she starts the program. The student is encouraged to show the

report to a parent/guardian and get a signature to return to school during the next day at check in.

The signed point sheets will go into a weekly drawing. Families are encouraged to acknowledge

their child’s efforts and successes and to refrain from punishment when their child temporarily

slips up.

How long are students on CICO?

The purpose of CICO is to help students learn to manage their behavior on their own,

without using a point sheet. The goal is to fade students off the program once they demonstrate

that they have learned the necessary skills to be successful without the additional support.

Generally speaking, students are expected to get 80% of the possible points when they start the

program. When that goal is met consistently, the goal will be moved up to 90%. Once a child is

successful reaching a goal of 90%, then he/she will start monitoring him/herself and comparing

his/her scores to the teachers’ scores. After a few weeks of successful self-monitoring, the

student will check in and out with the counselor for a week without a point sheet. The last step is

graduation from the program!

How is student progress monitored?

Student data will be recorded in SWIS daily and will be reviewed by the counselor

weekly. The counselor uses the data to determine if the program should stay the same, be

adjusted, or be terminated. General data decision rules use an 80% figure to determine whether

things are working or need to be revised. If a student is getting 80% or more of the daily

possible points, they are being successful. If a student is not getting 80% of the possible points,

the counselor will look to see if there is a pattern to the data, if progress is decreasing or

stagnant. The counselor will report to the IPBS team monthly to brainstorm and discuss students

who are not meeting their goals.

What incentives will students earn?

Students can earn prizes for “made days”, which means that they met their daily goal

(80%-90% depending on where the child is in the program). Students’ names will be listed on a

chart and they will color in a square each day that they have a “made day”. They may choose

prizes from a labeled cart, from one “made day” to five “made days”. The prizes increase in

value each day and there’s a wide range of prizes (see Incentive sheet). As students cash in their

“made days”, a mark will be put on the chart and they will start working towards a new

incentive.

What are the goals for the first five days of CICO implementation?

The student understands the use of the point sheet and reward system.

The student uses the point sheet daily to receive positive feedback. He/she will receive a

daily incentive for checking out with the point sheet regardless of points earned for behavior.

Teachers and staff who are involved with the student are supportive, encouraging, and

positive with the student.

Parents know how students are doing each day when they receive the point sheet.

Menu of Incentives

80% of Points Earned “Made Day”

Student Earns a Wildcat Cash

100% Points Earned “Made Day”

Student Earns Two Wildcat Cash and Candy

5 “Made Days”

15-20 minutes of play time in counselor’s office

Or

Another prize incentive identified by teacher or selected by student

Name __________________________ Date:___________________________

Great Day !!! Card flip to YELLOW Card flip to RED

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

______________________________________________

___________________________________________________

Name __________________________ Date:___________________________

Great Day !!! Card flip to YELLOW Card flip to RED

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

______________________________________________

Name:

Date: 2 = Great Be Respectful

Be Responsible Be Ready To Learn

Comments 1 = OK

0 = Difficult Time

Morning Check In 2 1 0

NBI 2 1 0 Block 1 2 1 0

Activity 2 1 0 Block 2 2 1 0

Block 3 2 1 0

Afternoon Check Out 2 1 0

Today’s Goal = 80%

Today’s Total Points:

Parent/ Guardian Signature: ___________________________________

------------------------------------------------------------------------------------------------------------------------------------------

Name: Date:

2 = Great Be Respectful Be Responsible Be Ready To Learn

1 = OK 0 = Difficult Time

Morning Check In 2 1 0 NBI 2 1 0

Block 1 2 1 0

Activity 2 1 0 Block 2 2 1 0

Block 3 2 1 0 Afternoon Check Out 2 1 0

Today’s Goal= 80%

Today’s Total Points:

Parent/ Guardian Signature: ___________________________________

Name:

Date: 2 = Great Be Respectful

Be Responsible Be Ready to Learn

Comments 1 = OK

0 = Difficult Time

Morning Bus Behavior 2 1 0

Afternoon Bus Behavior 2 1 0

Today’s Goal

Today’s Total Points:

Parent/ Guardian Signature: ___________________________________

------------------------------------------------------------------------------------------------------------------------------------------

Name:

Date: 2 = Great Be Respectful

Be Responsible Be Ready to Learn

Comments 1 = OK

0 = Difficult Time

Morning Check In 2 1 0 Afternoon Check Out 2 1 0

Today’s Goal

Today’s Total Points:

Parent/ Guardian Signature: ___________________________________

----------------------------------------------------------------------------------------------------------------------------------------

Name:

Date:

2 = Great Be Respectful Be Responsible Be Ready to Learn

Comments 1 = OK

0 = Difficult Time

Morning Check In 2 1 0 Afternoon Check Out 2 1 0

Today’s Goal

Today’s Total Points:

Parent/ Guardian Signature: ___________________________________

Check in check out Point Sheet Points Possible _____

Points Received _____ %of Points _____ Goal Met ______

2 – Great Job!

1 – So, so

0 – Doesn’t meet goal Name: ______________________________

Date: ____/_____/____

GOALS:

Target

Behaviors

Math Social

Studies

Specials Recess Language

Arts

Science

Respectful

2 1 0

2 1 0

2 1 0

2 1 0

2 1 0

2 1 0

Responsible

2 1 0

2 1 0

2 1 0

2 1 0

2 1 0

2 1 0

Safe

2 1 0

2 1 0

2 1 0

2 1 0

2 1 0

2 1 0

Parent Signature:

School Behavior Contract

Agreement between the Parents, Students and School

Name: ________________________________

Date: _________________________________

_________________________will demonstrate appropriate effort each day.

_________________________ is expected to follow directions the first time asked

to do something. ____________________ is expected to do so promptly and with a

good attitude. Each time that _____________________ does not meet these

expectations, ________________ will receive a tally mark for the day on the

tracking sheet. These tally marks will determine the rewards and consequences that

_______________________ receives, as shown below.

Zero tallies in one day = A chance to roll the die for one of the rewards listed

below

One tally in one day = Does not get a chance to roll the die that day

Two or more tallies in one day = Loss of a privilege the next day and/or other

consequences as determined

(number rolled on a die)

1.

2.

3.

4.

5.

6.

We agree to the terms of this behavior contract as set forth above.

___________________ _____________________

[Parent Signature] [Child’s Signature]

School Bus Behavior Contract Agreement between the Parents, Students and School

Bus drivers, students, parents, and the school all share the responsibility for bus safety, following all bus rules, and behaving in a responsible manner while riding the bus. Riding the school bus is a privilege. If you behave appropriately, you will be allowed to ride the bus. This agreement is designed to ensure that all students riding the bus are picked-up and dropped-off in a safe and orderly manner. Below, you will find the terms and conditions that must be agreed upon in order for your child to ride the school bus. Please initial each bulleted category to note that you have read and agree with the information. Initials Below ___________I agree to ride the bus safely. Stay seated (with your back to the back of the seat, facing forward) Talking softly; especially at bus stops Give the bus driver my name when asked Stay away from the bus until it comes to a complete stop __________I agree to follow all bus rules. Keep hands and feet to myself Respect bus property Respect personal property at bus stops and on bus ___________I agree to treat the bus, the driver, and all the passengers with respect Obey to directions from my bus driver Talk kindly to others No inappropriate language No inappropriate conversations ___________I have read and understand the bus rules. If I choose not to follow this contract, I understand the following consequences may occur, or in the event of a serious offense I may be suspended from the bus immediately:

1. My parent(s)/guardian will be notified by an administrator from my school and I will be warned about the consequences of not following the school bus rules. I understand that other disciplinary measures may be taken if I violate the school bus rules.

2. Administrator will notify my parent(s)/guardian and I may lose all bus privileges for 3 to 5 days of school.

3. A school administrator will contact my parent(s)/guardian, and I may lose all my bus privileges for 10 school days.

4. Severe cases: students may be suspended immediately from the bus for severe infractions for a period of time to be determined by a school administrator. A serious infraction, such as a weapon, drug or physical violence, may result in bus privileges being suspended immediately. Note: I know and understand, if bus privileges are suspended, I must arrange my own transportation to and from school. Students must continue to attend school. Additional referrals (regarding behavior on the bus) may result in removal from the bus for the remainder of the school year.

Please print legibly. Signatures indicate that you have discussed, understand, and agree to the above statements.

Student’s name_________________________________ Grade________________ Homeroom teacher_______________________

Student’s signature_____________________________ Parent(s)/Guardian signature_________________________________ Contact info (1)_______-_________-_____________ Contact info(2)_________-__________-______________

Behavior Intervention Chart Grades K-3

Teachers must indicate which color a student ends their day on in the child’s take-home

folder or planner daily.

Teachers must keep track of all students’ daily data. Use your own discretion on which

format to use (examples will be provided).

Each student that ends their day on GREEN is allowed to color in a block on their

incentive chart.

Once a student earns 20 blocks on their incentive chart, they select a reward.

Color Consequences

Green

Great Job-keep it up! Student is

respecting themselves AND others. They

are following directions, working hard,

and being the best they can be.

Yellow

Verbal Warning

Red

“Cool Down” Card

(Student completes “Cool Down” card

regarding behavior and parent must sign

and return. Teacher may call or write a

note to send with card if needed.)

Behavior Intervention Chart Grades 4-5

Teachers must indicate which level (number) a student ends their day on in the child’s planner.

Teachers must keep track of all students’ daily data. Use your own discretion on which format

to use (examples will be provided).

Each student that ends their day on a level “0” is allowed to color in a block or write in the

appropriate number.

Once a student earns 20 blocks on their incentive chart, they select a reward

Level Consequences

0

Great Job-keep it up! Student is

respecting themselves AND others. They

are following directions, working hard,

and being the best they can be.

1

First Intervention

Friendly Reminder

Proximity Control

Nonverbal/ Verbal Cues

Other Surface Management Strategies

2

Second Intervention

Last to leave room

Verbal Warning

Seating Change

Parent phone call

Reflection Zone/ Problem Solving Sheet

10 Minute Chill Pass

3

Third Intervention

Parent Phone Call

Time out/ Walking @ recess

10 Minute Chill Pass w/ parent phone call

Lunch/ After School Detention

Reflection Zone/ Problem Solving Sheet

4 Fourth Intervention

10 Minute Chill Pass w/ parent phone call

Administrative Office Referral

On-site PBIS Walkthrough

Purpose: This tool is meant for use as a quick glance when visiting a school to see if School-

Wide PBIS is evident. It will allow the observer to provide feedback to the PBS team and

administration.

Observer: School: Date:

Product Book Review: Complete ____ Incomplete ____

Comments (what element(s) was missing): __________________________________________

Using SWIS: Yes No

School Expectations:

I. Visibility

Circle the following locations where Expectation Posters were visible:

Hallways Main Office Classrooms Cafeteria

Media Center Gym/Playground Computer Lab Other

Circle the following locations where Rules Posters were visible:

Hallways Main Office Classrooms Cafeteria

Media Center Gym/Playground Computer Lab Other

II. Student Awareness (Ask 5 students from a variety of classes/grades)

Ask 5 students if they know the Expectations. (Circle how many students were able to tell you

the expectations). 1 2 3 4 5

III. Staff Awareness (Ask 5 staff members the following questions)

Do you have a school wide team to address behavior/discipline across campus? (Circle how

many staff knew about the team). 1 2 3 4 5

Can you name the School-wide Expectations? (Circle how many staff could tell you the

expectations). 1 2 3 4 5

Have you taught the School-wide Expectations? (Circle how many staff has taught the

expectations). 1 2 3 4 5

Have you seen the schools discipline data this year? (Circle how many staff has seen the data).

1 2 3 4 5

IV. Behavior Lesson Plan- (Observer was able to see a written School-wide behavioral lesson

plan to teach an expectation/ rule from the matrix). Yes ____ No ____

Additional Comments/ Suggestions: