Incident Report
Student
*
First Name
Last Name
Reporting Information
*
Staff Reporting
Student's Teacher
Other witnesses?
Date
*
/
Month
/
Day
Year
Date Picker Icon
Time of Incident
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01
02
03
04
05
06
07
08
09
10
11
12
13
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15
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17
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:
Hour
00
10
20
30
40
50
Minutes
Reason for Submission
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Major Referral
Minor Referral
Documentation
Request for Support
ABC Data Tracking
Family Follow-Up
Notify Administrator
Other
Location where incident occurred
*
Classroom
Library
PE
Music
Office
Hallway
Bathroom
Cafeteria
Playground
Bus/Bus-Line
On Microsoft Teams
Via Email
Off-Campus
School Bus
Social Media
Other
Problem Behavior
*
Avoidance
Bullying
Bus Referral
Cheating/Plagiarism
Class Disruption (Minor)
Class Disruption (Major)
Computer Misuse
Defiance
Dress Code
Elopement
False Information/Report
Fighting
Inappropriate Chat Use
Inappropriate Language/Obscene Comments
Inappropriate/Sexual Behavior
Inappropriate Use of School Property
Left Class without Permission
Needed a Regulation Break/Reset
Physical Aggression
Possession of Prohibited Items
Profanity
Property Damage/Destruction
Repeated/Severe Defiance
Repeated/Abusive Language
Requested a Break
Restorative Circle/Conflict Resolution Held
Severe Disrespect to Adult/Staff
Severe Disruption
Student Escalated/Reset Needed
Student Reported
Teasing/Taunting
Theft
Threat/Harassment/Intimidation
Unsafe Behavior
Response/Action Taken
Community Service
Conflict Resolution/Apology
Detention
Helped Facilitate a Break for Student
Helped Transition Back to Class
Intervention Curriculum Used
Major Referral Issued
Oops Slip Issued
Phone Call Home
Parent Conference Request
Re-Teach Expectations
Reset Offered/Utilized
Think Time/What Happened Sheet Used
Restitution/Restoration Held
Reported Incident Documented
Time Spent in Buddy Room
Time Spent in Office
Verbal Warning Given
Possible Motivating Factors
*
Obtain Peer Attention
Obtain Adult Attention
Obtain Preferred Item
Avoid Peers
Avoid Task
Avoid Adult
Sensory Seeking
Outside of School Issue
Student Did Not Understand Expectations
Unknown
Describe the incident with as much detail as possible
*
Parent Communication (by you prior to this submission)
Phone Call (spoke on phone)
Phone Call Made/Left Message
Family Meeting Held
Family Meeting Scheduled
Oops Slip Sent Home
Referral Sent Home
Email Communication
Other: ________________
Parent Not Contacted
Recommend Follow-Up with Parent
Family Contact Not Necessary
Would you like someone to communicate about this incident, and it's response?
*
Yes, please communicate home about the incident or behavior.
Yes, please communicate this with Principal.
Please communicate with the EA.
Please communicate this with School Counselor.
Please communicate this with the specialists that support the student (LAP, IE, etc.)
No, I have already communicated home. Please document only.
Family Contact Not Necessary
Other
Next steps, request for support, or any other additional information you would like to add!
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