Child Behavior Incident Report Form
Document and report behavior incidents involving children accurately and thoroughly.
Child/Student Full Name
*
First Name
Last Name
Class/Grade
*
Date and Time of Incident
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Incident Location
*
Please Select
Classroom
Playground
Cafeteria
Hallway
Restroom
Gym
Other
Type of Incident
*
Physical aggression
Verbal aggression
Non-compliance
Disruption
Bullying
Property damage
Other
Description of Incident (What happened?)
*
People Involved or Witnesses (List names and roles)
Possible Triggering Factors
Peer conflict
Transition/time of day
Academic frustration
Sensory overload
Unstructured time
Unknown
Other
Immediate Actions Taken
*
Were there any injuries or property damage?
*
No
Yes, injury
Yes, property damage
Yes, both
If yes, describe injuries or property damage
Staff/Member Reporting the Incident
*
Is follow-up needed?
*
Yes
No
Parent/Guardian Notification Method
*
Phone call
Email
In-person
Written note
Not notified
Parent/Guardian Notification Details (Name, time, summary)
Submit Report
Should be Empty: