Date:____________________________
To:_____________________________
STUDENT:_________________________

             I hereby request that the action indicated below be taken regarding the student named above.   This action is taken pursuant to Board Policy FO, FO Local, and Chapter 37.002  of the Texas Education Code. I request the following action be taken:

______ A conference be held with the student's parent(s) to discuss the student's behavior.  I am asking that you or another member of the administration be present at the conference.
______That the student named above be TEMPORARILY removed pursuant to Board Policy FO and Chapter 37.002 (a) of the Texas Education Code because it appears that the student appears to be:

          _____highly agitated;
          _____suffering from a condition that temporarily threatens the student's
                      welfare, other individuals' welfare, or the efficient operation
                      of the school
          _____under the influence of alcohol or drugs

I realize that this is only a temporary removal and that the student will return to class once the office has taken action.
______ That the student named above be PERMANENTLY removed from my classroom pursuant to Board Policy FO and Chapter 37.002 of the Texas Education Code.  I am asking for this removal because the student continues to interfere with my ability to teach.  It is my understanding that under Section 37.002 of the Texas Education Code, a teacher may remove from the classroom a student:
------who has been documented by the teacher to repeatedly interfere with the teacher's ability to communicate effectively with the students in the class or with the ability of the classmates to learn.  I have followed the discipline management plan and will provide you with documentation upon your request or the request of the Placement Review Committee.
______ whose behavior the teacher determines is so unruly, disruptive, or abusive that it seriously interferes with the teacher's ability to communicate effectively with the students in the class or with the ability of the student's classmates to learn.
______That the student named above be PERMANENTLY removed from my classroom because:

It is my understanding that upon a request for removal under Chapter 37.002 of the Texas Code, the principal may not require that the student be returned to the classroom without the teacher's approval, unless the Placement Review Committee determines that such placement is the best or only alternative available.  The principal may place the student in another appropriate classroom, in-school suspension, or an alternative education setting.
Respectfully submitted by,


Name______________________________________________________ Date______/_____/_____