This form allows students to take responsibility for their own actions!
To discipline in my classroom I remain as consistent as possible. Action one is a warning, Action 2 is a warning slip, Action 3 is this Disciplinary Form, Action 4 is a trip the office with a phone call home.
The best thing to do is protect instructional time! So when I reach step 3 I will remove the student to a "Safety Zone" which is a secluded area of my classroom. Students will sit their and reflect on their behavior while filling out the form above. I will continue on with my lesson.
During a down time or the end of class I will go over the form with the student. This allows them to be responsible and reflect on their behavior rather then me telling them what they did wrong.