Incident Report
Student*
First Name Last Name
Staff*
First Name Last Name
Date*
Month Day Year
Time
: Hour 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
Coordinator Signature:
Should be Empty: