Richland One Hearing Office Referral Form

Male
Female
Pre-K
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Yes
No
A - Autism
DB - Deaf/Blindness
DD - Developmentally Disabled
ED/SC - Emotionally Disabled/Self-Contained
ED/RR - Emotionally Disabled/Resource Room
LD - Learning Disabiled
LD/SC - Learning Disabled/Self-Contained
LD/RR - Learning Disabled/Resource Room
O - Other/Different
OHI - Other Health Impairment
SDI - Specific Learning Disability
SLI - Speech Language Impairment
VI - Visual Impairment
N - None
Possession
Transfer
Distribution
Procurement
Use or Sale of Drugs
Consumption of Drugs at School
Attending School Under the Influence
Switchblade Knife
Box Cutter
Metallic Knuckles
Tear Gas Gun
BB Gun
Stun Gun
Paintball Gun
Pellet Gun
Chemical Weapon
Mace
Pepper Spray
Replicas
Knife under 2 inches
Knife over 2 inches
3.02 - Alcohol
3.03 - Arson
3.04 - Assault/Battery
3.05 - Aggravated Assault/Battery
3.06 - Theft
3.07 - Illegal School Entry
3.08 - Vandalism
3.09 - Firearms
3.11 - Bomb Threat
3.12 - Explosives/Ammunition
3.13 - Sexual Assault
3.14 - Sexting
3.15 - Gang Affiliation
3.16 - Trespassing
3.17 - Major Disruption of the Educational Environment
3.18 - Unjustified Activation of a Fire Alarm or Fire Extinguisher System
3.19 - The UNAPPROVED use of Electronic Devices during School Hours
3.20 - Improper Use or Sabotage of a Computer or Computer System or any other Communications System
3.21 - Repeated Defiant or Disruptive Behavior
3.22 - Threats to a District Employee (Administrator Check This Box)
3.23 - Aggravating Bullying, Threat, Harassment or Intimidation
3.24 - Gambling
3.25 - Interference with school personnel in the performance of their duties in a unsafe situation.
3.26 - Any other offense that the principal (or designee) may deem to fall within this category

* Required