Incident Report
Student
First Name
Last Name
Staff
First Name
Last Name
Incident Date & Time
 /
Month
 /
Day
Year
Date Picker Icon
Hour Minutes
AM
PM
AM/PM Option
Classroom
105
106
107
108
Observer #1
First Name
Last Name
Observer #2
First Name
Last Name
Observer #3
First Name
Last Name
Observer #4
First Name
Last Name
Location where incident occurred
Classroom
Recess
Bus
Hallway
Office
Bathroom
Gym
Computer
Engineering
Drama
Speech
Occupational Therapy
Other
Problem Behavior
Theft
Fighting
Harassment
Left classroom w/out permission
Aggression to staff
Aggression to student
Possession of missing property
Property destruction
Suicidal Ideation
Threatening Behavior
Inappropriate Language
Inappropriate Behavior
SelfÂ-injurious behavior
Left School w/out permission
Bullying
Other
Primary reason for cooldown
Verbal Agression
Physical agression
Classroom Distraction
Other
Consequence
School Police Called
Phone call home
Counseling Center
School suspension
In-school suspension
Bus suspension
Ladder Drop
Cool Down Room
Walked out- noted
Processed with Staff
Possible Motivation
Obtain peer attention
Obtain adult attention
Obtain preferred item
Avoid peers
Avoid task
Avoid adult
Sensory seeking
Outside school issue
Student didn't understand expectations
Unknown
Other
Describe the incident with as much detail as possible
Transport Needed
Yes
No
Restraint Needed
Yes
No
Parent Communication
Phone Call
Meeting
Report Sent Home
Plan to Prevent Recurrence of Incident
Length of Cooldown
Please Select
5 Minutes
10 Minutes
15 Minutes
20 Minutes
25 Minutes
30 Minutes
40 Minutes
50 Minutes
1 Hour
1+ Hour(s)
Coordinator Signature
Date of Signature
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
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