Prince George’s County Public Schools

Upper Marlboro, Maryland 20772

RESET
STUDENT Discipline Referral
SCHOOL ___________________________
Crossland High School STUDENT _______________________________
Jaiden Tracey

English 11
r Yes
Special Education: ✔ r No
TEACHER______________________
Braddock SUBJECT_____________________ GRADE _______
504: ✔ No
r Yes r
2:20 pm
TIME REFERRED _________________PERIOD ___________
3/4 January 24, 2024
DATE/YEAR______________ ESOL: r Yes r
✔ No

CHECK CONDUCT OF STUDENT BELOW

Academic Dishonesty Dress Code/Student Uniform Policy Possession, use or distribution of of Explosives

RD
Alcohol Drugs/Controlled Substances Possession or use of weapons
Arson Failure to come to class prepared Sexual misconduct
Attack (Physical) Failure to wear Identification badge Shakedown

CO
Attendance Related Offense False Alarm Theft
Bomb Threat Fighting Threat

RE
Bullying/Harassment Forgery Trespassing
Disruption Gambling Tobacco, e-cigarette use
Destruction of Property Group Fight Unauthorized use of Electronic and/or Portable Electronic Devices

T
Disrespect Internet/Computer Misuse Non compliance of Face coverings/Masks

EN
Describe student’s conduct:
During specific administrative instructions to remain in the classroom during a school emergency, Jaiden walked out. This is the

AN
second time today he has done so. I stopped him earlier in the hallway because he had walked out of the office when instructed to
remain by administration.
RM
PE

INDICATE PRIOR ACTION TAKEN BY TEACHER TO RESOLVE STUDENT’S PROBLEMS

S

(Send to office with student)

T’
EN

Teacher/Student Conference Teacher/Parent Conference Parent Notification: E-mail Phone

School Counseling Intervention

UD

Other Disciplinary Action Taken by Teacher: Timeout Lunch Detention Other_____________________________________

FBA / BIP      504 Plan     IEP Meeting     Warning

ST

Teacher’s Signature______________________________________________
OF

Teacher-student conference
Teacher-parent conference or contact \ CHECK ACTION TAKEN BY ADMINISTRATOR
Teacher-counselor conference Other Disciplinary Action Taken:
RT

Counselor-student conference
Counselor-parent conference
Administrator-student conference
PA

Administrator-parent conference
Student Program adjustment
Referral to Student Services
ES

Student Services-student/parent contact

Detention Hall/In-School Intervention Conference held with teacher ________________________________________
M

Behavioral Probation
Date Student returned to teacher _____________________________________
CO

Temporary removal from class

Short-term suspension
____________________________________________ Administrator’s Signature
Long-term suspension
Send all copies to office with student
BE

Referral to Security Counselor

WHITE COPY – Administrator    COPY – Returned to Teacher    COPY – Cumulative Folder    COPY – Other
PS-74 (4/21) PGIN 7540-3074 (See Reverse Side for Instructions)
 Student Discipline Referral Form (PS-74)
Purpose and Direction for Use

This form is designed to facilitate and standardize record keeping with respect to problems of student conduct
and the actions taken pursuant thereto by teachers and administrators. It should be used in all instances in which
student conduct problems are formally brought to the attention of appropriate school administrators for action, in line
with the Code of Student Conduct or local school regulations consistent with that Code.

It is recognized that there may be instances in which teachers and others wish to informally bring to the attention
of the principal or his/her designee concerns relative the conduct of a student, as a matter of information and/or for
informal advice as to how to deal with the student. This form is not mandated for use in such circumstances, nor is it
intended to impede such a flow of informal consultation among teachers and administrators. The Student Discipline
Referral should be used when these conditions exist:
a) The conduct in question has reached the level of gravity of those examples outlined in the Code of Student
Conduct, and
b) the teacher or other referring individual has decided that they are unable to appropriately deal with the conduct
and are seeking the formal involvement of the principal or his/her designee.

Directions:
1. The referring individual (teacher, counselor, other instructional or administrative personnel) having knowledge
of the student conduct in question completes the first three sections of the form at the time the student is to be
referred to the principal or his/her designee.
● Identifying data – Complete those items in the section as are appropriate to the level of the student in the
system, and to the circumstances in question.
● Description of Conduct – Classify the conduct by checking the appropriate item(s) at the left of this section.
Definitions of these items are found in the Code of Student Conduct. Add in the space provided (attaching
addenda as needed) a clear and concise description of the circumstances of the conduct.
● Prior action by Teacher (or others) – Indicate steps taken by referring personnel to resolve the immediate
problem, or to deal with recent similar problems involving the student.

2. The principal or his/her designee completes the final section of the form as action is taken in response to the
referral.
● Description of Action – Classify the action taken in response to this referral by checking the appropriate
item(s) at the left of this section. Check only those items taken in this instance – to not indicate here
prior action for previous referrals. Elaborate on the action taken, as appropriate, by commenting in the space
provided.
● Distribute copies of the form as indicated. The white copy is for administrative records. The canary copy
should be returned to the teacher or other referring personnel. The pink copy is forwarded to the guidance
counselor for inclusion in the Cumulative Folder. The goldenrod copy (marked other) may, at the discretion
of the principal or his/her designee, be forwarded to the parent/guardian.

Special Note:
It is understood that in certain circumstances it may be impractical for the teacher or other referring personnel to
complete this form at the time the student must be brought to the attention of the principal or his/her designee.
In such cases the form should be completed as soon thereafter as reasonably possible.

Filing Instructions:
– File the appropriate copy of this form in the Cumulative Folder with the student’s other school records. A copy
may be maintained in a separate disciplinary file by the principal or his/her designee.
– Discipline Records must be maintained until the student graduates or completes his/her education program or
the student becomes 21 years of age.

Prince George’s County Public Schools • 14201 School Lane • Upper Marlboro, MD 20772 • www.pgcps.org