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Student Name:
Grade:
Directions: Please answer the following questions while you are in time out.
1. Why do you think you are in time out?
2. Is there anything you could have done differently so you wouldn't be in time out right now?
3. If you broke a rule which one was it?
4. Will you try to do better from now on?
______ YES ______ NO 5. Explain what you are going to do in the future to avoid being in time out. 6. Sign Your Name _______________________________________
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