We use this in our first grade class to help students understand the consequences of their actions. They "Stop and Reflect" in order to make a better choice the next time.
*I have recently updated the document to include a middle grade version for 3-5 with more grade appropriate wording and formatting!
After it is completed, fold in half to keep private. The student signs it, the teacher signs it, then it goes home for the parent to sign.
It has helped our parent communication immensely to have a sheet in the student's own words about the choices made at school!