Reset Refocus Reflection Sheet
Reset & Refocus Plan
Student Incident Reflection & Restorative Agreement
Reset Room Record
Student Name:
Date:
Period / Time In:
Sending Teacher:
Class / Subject:
Time Out:
My mindset upon arrival:
Frustrated Overwhelmed Distracted Ready to Reset
1 Why was I sent to the Reset Room?
What happened in class that led to being sent out?
2 My Perspective on What Happened
My point of view
What is my perspective on what happened that sent me to the Reset Room? What was going on from my point of view?
3 Agreed Next Steps & Action Plan
Agreed between Student & Staff
What specific steps did we agree I will take when I return to class to avoid having to come back to the Reset Room?
"By signing below, we agree that we have discussed what occurred, shared perspectives, and agreed upon the next steps above to support a successful return to class."
Student Signature: Date: ____________
Staff Signature: Date: ____________
Re-entry Status: Cleared to Return Further Follow-Up Needed
Authorized Departure Time: ________ Staff Initials: ______