Littleton Public Schools Exhibit

Policy Code    JKBA-E Policy Name Disciplinary Removal From                                  Classroom                                  January 25, 2001

If this is revised, also revise b\eforms\JKBA-E.

Behavior Plan to Prevent Further Formal Classroom Removal

□ First Removal                                                                       Date

□    Second Removal

Student Name

Teacher Name       School

Name of Class or Grade Level       Class Period

Special Education    _____ Yes      _____ No                          504 Plan    _____ Yes       _____ No

1. What behaviors must be changed?

2. What will the student do to change his/her behavior?

3. What will others do to help the student maintain proper behavior?

Parent

Teacher

Student’s Signature                                                         Parent’s Signature

Teacher’s Signature                                                        Administrator’s Signature