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N SEX RACE PUPIL I.D. NUMBER GRADE 2 Hispanic 3 Amer Indian/Alaskan Native 4 Asian/Pacific Islander 5 Other REASON FOR REFERRAL (Check all that apply) Failure to follow classroom rules/disruption/disrespect for authority Rule 1A Dress code violation Rule 1B Failure to carry hall-pass/appropriate ID Rule 1C Failure to participate in class/unpreparedness Rule 1D Truancy/excessive tardiness/cutting class Rule 2 Possession of beepers, pagers or cell phones, and othe.

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