Incident Report
Student
*
First Name
Last Name
Staff
*
First Name
Last Name
Date
*
/
Month
/
Day
Year
Date Picker Icon
Time
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
:
Hour
00
10
20
30
40
50
Minutes
Classroom
*
105
106
107
010
Observer #1
Observer #2
Observer #3
Location where incident occurred
*
Classroom
Recess
Bus
Hallway
Office
Bathroom
Gym
Computer
Engineering
Drama
Speech
Occupational Therapy
Responders
Option 1
Option 2
Option 3
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
Self-injurious behavior
Left School w/out permission
Bullying
Primary reason for cooldown
*
Verbal Agression
Physical agression
Classroom Distraction
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
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:
Submit
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