Westgate Elementary School Problem Solving Form Grade 4-6

1. What did you do that caused the problem? __________________________________________________________

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If you broke a school expectation, white one(s)?
[ ] We are Courteous - consider the rights of others, use good manners
[ ] We are Cooperative - work together as a team, follow directions
[ ] We are Caring - consider other's feelings as well as your own
[ ] We use Common Sense - think before you act
[ ] We demonstrate a Commitment to Learning - put forth your best effort.

3. What problems did this cause for others and yourself? _________________________________________________

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4. What can you now do to take responsibility for what you did? ____________________________________________

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5. What could you choose to do differently next time so that you won't create a problem for yourself or others? __________

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School Consequence: ____________________________________________________________________________

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