Maybe reword a little more positively, but great for quickly letting parents know about a tough day. Maybe "something I did well today" and have checkboxes and then "what I had trouble with today:" and a student section for writing in explanation?
This is a good way to use non-verbal prompts with your students. You can hand them the card without disrupting the entire class. Giving them 5 minutes to calm down and think about their behavior will help them take responsibility for their actions. I