I use this form in my classroom when students (grades 3, 4, or 5) are not following directions after multiple reminders have been given. After a 5 minute "break" (or however long student needs to be compliant) the student and teacher complete the form. Initially, teacher and student complete the form together, but students can also complete them individually and the teacher will fill out their portion at convenient time in the day.
This is a good way of keeping lines of communication open with parents about a student's behaviors while at school. Additionally, this form is a good way to track behavioral citations with students and to thoroughly document what happened and how it was dealt with.
This form can be sent home to the parents, or could even be sent to principal depending on severity/frequency of the behavior.
The class rules are currently set to my school's rules, but I can change the document to show your school name and rules before sending it to you. To do this, please post a question under the "Ask a Question" tab and include your email, school/class name & the 3 rules you would like listed.