This is a sheet that can be used when you do not want to write a referral on a student, but they need to be out of your room for a little bit so that you both can think on things. It works well and it's great evidence for parent teacher conferences. I bring these to conferences and students can not deny that they have been given every opportunity to get themselves under control.
It's also great if classroom management is part of your professional development plan. You can use this as evidence that you are doing things to help keep discipline under control within your classroom instead of calling on an administrator whenever something small goes wrong.
My students actually fill them out completely and come up with ways to help themselves. It's a great tool for student self reflection.