This is a form that was used at one of the middle schools I have worked in; it assists the student in thinking critically about their poor behavior and how it may have affected the classroom. While there will always be students who will respond that they did not do anything, this form can be implemented successfully with quite a few students. Typically I would send this (and also a worksheet) with a student who needs to be sent out of the room.
About Lady Fair
Lady is a musician with a bachelor's degree in music education. She plays multiple instruments and has participated in numerous musical ensembles, giving her a wide variety of experiences and knowledge to use in her teaching career. Of her ensemble participation, she has fifteen years of band experience, nine years choral, and four years in orchestra. Éowyn's primary instrument is clarinet, with voice and piano being close secondary instruments. Throughout her musical education career she studied voice and clarinet simultaneously. In addition to clarinet, piano, and voice, she has also studied violin and oboe at the college level, and also plays recorder, tin whistle, and other instruments in the woodwind family.
If you ask her, she will say, "I chose to major in music education because I have a desire to use my knowledge and experience in music to share its beauty and foster a love of music in the hearts of my students. I hope to encourage my students to try their hardest, feel like they have accomplished something, and give them a life long passion for music."
Lady currently teaches private lessons on clarinet, sax, flute, oboe, piano, and voice, and recently gained a position teaching orchestra and chorus at a local middle school. She is also a member of the Once Upon a Dream woodwind ensembles.