Westgate Elementary School Problem Solving Form Grade K-3
| Name ______________________________ Date _______________ | ||
Retelling______________________________________________________ |
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|
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| My behavior level was a : |
4
|
3
|
2
|
1
|
because I: _______________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
How did my behavior make me feel? ________________________________________________________________
_______________________________________________________________________________________________
How did my behavior make others feel? ______________________________________________________________
_______________________________________________________________________________________________
School Consequence: ____________________________________________________________________________
_____________________________________________________________________________________________
My plan: Next time I will..._________________________________________________________________________
_______________________________________________________________________________________________
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_______________________________________________________________________________________________
| Student __________________________________ | Parent ____________________________________ |
| Principal __________________________________ | Teacher ______________________________________ |
| COPIES TO: | Principal | Teacher | Parent |
| (white) | (yellow) | (pink) |