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*

Responders

Option 1 Option 2 Option 3

Problem Behavior*

Primary reason for cooldown*

Verbal Agression Physical agression Classroom Distraction

Consequence*

Possible Motivation*

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: