This form can be used for ANY class at ANY grade level to address ANY behavior issues. It is a simple form that students fill out to evaluate and improve their own class behavior. It is designed to go home, get signed by a parent, and then be returned.
When I use it, students must fill it out after school and have the form returned the next day. If not, they get another form and write it all again. After filling it out a second day, they are always returned. For first/lesser offenses, I sometimes just keep the form on file without getting it signed.