This is a form that I use to correct and document inappropriate behavior in my classroom. It is most effective when the student has repeatedly ignored directions to get to work or stop an inappropriate behavior, and has been (calmly) asked to step outside in the hallway for a teacher conference. When the student has left the room, I give them a copy of this form, and ask them to begin filling it in as I finish up with the rest of my class and can come to a place where I can step out for a minute to talk with the student. This also gives the student time to calm down and reflect on their behavior. In ten years of education, I have only had 2 students refuse to fill out the form and return to class. It also serves an excellent documentation that can be attached to any future referrals that may occur with this student. Administrators love to see that you have attempted to correct the issue in class and have contacted parents BEFORE immediately contacting them.