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Community Restitution Form

Thank you for serving as a Referral Supervisor for the student conduct process. Please complete this form as soon as possible after the assigned deadline or when the hours have been completed, whichever is sooner. Please contact Brittanie Jones (bsj3g@uvawise.edu or 276-376-4502) if you have any questions.

Referral Supervisor Information

Supervisor Name *

Supervisor Email *

Supervisor Phone *

Sanction Referral Information

Student Name *

Sanction Deadline *

Actual Completion Date *

Sanction(s) *

Community Restitution

Additional Community Restitution/Fine Conversion

Counseling Session

Health & Safety Inspection

Other

Please check all that apply. List any specifics (number of hours, sessions, etc.) in the NOTES section at the bottom of the form.

Sanction Hours/Sessions/Projects *

All assigned sanctioned hours/sessions/projects have been completed as of the deadline.

A portion of the assigned sanctioned hours/sessions/projects have been completed as of the deadline.

None of the assigned sanctioned hours/sessions/projects have been completed as of the deadline.

Sanction Hours/Sessions/Items Completed *

Please list the number of completed hours, sessions, items here.

Referral Experience *

The assigned student worked diligently to complete assignment.

The assigned student put forth minimal effort to complete assignment.

I was contacted to coordinate a work schedule, but the assigned student did not follow-up after that time.

I was never contacted by the assigned student to coordinate a work schedule.

Notes

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Community Restitution Form