I use Character Counts in my classroom and I wanted students to be able to reflect on each of the six character traits when they got in trouble. (Trustworthiness, Respect, Responsibility, Fairness, Caring and Citizenship.) Every time students make wrong choices, they have to write about it. I created this form to help students reflect on the character trait they failed to follow. Students explain things they can do to improve the character trait they didn't follow.
It has worked very well with my students. It works better with upper grade students. I first started using it with 6th graders. I use it with 5th graders now and it also works great! Parents love to be able to see how their children take responsibility for their actions. At the end of the year, we work on putting portfolios together, and I give students their reflections. They put them as part of their portfolio to keep with them.