Name ______________________
Date _______________________
Time of Incident ______________
This is the classroom rule I chose not to follow:
________________________________________________________________________________________________________________________________
This is what happened:
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
This is why I did it:
________________________________________________________________________________________________________________________________________________________________________________________________
This is what I could have done:
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Teacher’s Comments:
________________________________________________________________________________________________________________________________________________________________________________________________
Other Comments:
________________________________________________________________________________________________________________________________________________________________________________________________
Student Signature ____________________________ Date ________________
Teacher Signature ____________________________ Date ________________