This was used between me and another teacher. We were frustrated with sending students out into the hall unsupervised, or sending them down to the office wondering if they actually made it or the Vice Principal had time to see them. We wanted something a little more immediate and definite.

If a student needed to be sent out, they went to my "partner teacher's classroom". It just happened they were the classroom next to mine. Student was sent to the partner teacher with the form. Each of us had a designated spot where students who were sent out were supposed to sit. The student filled out the form, the partner teacher signed when the student was sent back to my class, and then the student and I had a conversation after school about their responses on the form after school. If the student did not show up after school, or their answers were not acceptable, they were referred to the Vice Principal for discipline.

I hope that makes sense. It's very easy to use. It gives the student and me a break from each other rather than yelling or causing more disruption to the classroom. The "heart-to-heart" conversations with the student afterwards always proved fruitful and while it always didn't ultimately change behavior, it proved to be very effective with most students.