USD 286 JR-SR High School Incident Report 2020-2021

Incident Report 2020-2021
Student*

First NameLast Name
Staff*

First NameLast Name
Grade Level*
Date*

MonthDayYear
Time*

:HourMinutes
Location where incident occurred*

ClassroomRecessBusHallwayOfficeRestroomGymStudent ActivityCafeteriaLibraryOther
Student Witnesses
Adult Witnesses
Problem Behavior*

TheftFightingHarassmentLeft classroom w/out permissionAggression to staffAggression to studentPossession of missing propertyProperty destructionSuicidal IdeationThreatening BehaviorInappropriate LanguageInappropriate BehaviorSelf-injurious behaviorCell phoneBullyingSleeping in classTobacco/SmokingAcademic DishonestyOther
Consequence*

Law Enforcement called by schoolPhone call homeCounseling CenterOut of school suspensionIn-school suspensionBus suspensionCool Down RoomConference with studentConference with parentOther
Possible Motivation*

Obtain peer attentionObtain adult attentionObtain preferred itemAvoid peersAvoid taskAvoid adultSensory SeekingOutside school issueStudent didn't understand expectationsUnknownOther
Describe the incident with as much detail as possible*
Parent Communication*

Phone CallMeeting/ConferenceReport Sent HomeTextOther
Signature:
Should be Empty: