I created this form for my own classroom use. Personally, I run off several on colored (yellow) paper and keep them on a clipboard near my door. Sometimes a student fails to heed nonverbal cues ("the look") or verbal warnings. However, I am not prepared to issue silent lunch. (Resulting in giving up my own lunchtime, too, where I am often helping other students, etc.) That's where this self-reflection comes in.
I've already explained the procedure to the whole class early in the year. After several warnings (to stop talking, or whatever behavior) the student takes the clipboard into the hallway or a colleague's classroom room. The completed form is his/her ticket back into class. I sign it in the corner (if it's acceptable, send them back if not). I keep completed reflections on file.
Besides dealing with repeat offenders, this is also very effective to separate a student who is acting out distracting others. I am able to get everyone back on task while s/he is gone, and have him/her better focused upon returning.
One occasional form does not result in any further actions. However, having recurring issues written in the student's own handwriting is very powerful during parent conferences, and can even be attached to discipline referrals for my assistant principal if needed.