Classroom Behaviour Reflection Form

School Vision
We are called to provide an exemplary Catholic Education
Discipleship: With Christ as our light we aspire to nurture the whole person in a community centred on gospel
values.
Learning: We are committed to providing an education that empowers all to become life-long learners.

School Code of Conduct: Students, staff and parents strive for excellence for ourselves, others and the community
by following Christs example in the Gospels.
Compassion Honesty Respect Inclusivity Self Control

Dear Parent
Your child displayed negative behaviour today during class and was asked to complete the following reflection
form. Please take the time to discuss the behaviour with your child, sign at the bottom and return it
tomorrow.
As you are aware, our school Code of Conduct outlines the following consequences for negative classroom
behaviour by students:
Step 1 Verbal warning
Step 2 Verbal warning and reminder of rules
Step 3 Time Out
Step 4 Time Out to complete Classroom Behaviour Reflection Form
Step 5 Sent to a buddy class to complete work and teacher to arrange meeting with parents to discuss
behaviour.
Step 6 or any serious negative behaviour that causes danger to self or others Sent to Leadership Member and
parents are called.
Please make an appointment to see me to discuss your childs behaviour YES / NO (teacher to circle).
Kind Regards
________________________
Class Teacher
Name: ________________________________ Date: ________________________
Which school Code of Conduct value/s did I not follow?
_______________________________________________________________________
Why?
_______________________________________________________________________
_______________________________________________________________________

Right now I feel ___________________________ because ________________________

_______________________________________________________________________

What should I have been doing instead?

_______________________________________________________________________
_______________________________________________________________________

What do I need to do to change my behavior?

_______________________________________________________________________
_______________________________________________________________________

My Action Plan: I will ______________________________________________________

_______________________________________________________________________
Parent Comment: __________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Signed: _____________________________ Date: _______________________________

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