Incident Report 2020-2021
Student
*
First Name
Last Name
Staff
*
First Name
Last Name
Grade Level
*
Please Select
7th
8th
9th
10th
11th
12th
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
Location where incident occurred
*
Classroom
Recess
Bus
Hallway
Office
Restroom
Gym
Student Activity
Cafeteria
Library
Other
Student Witnesses
Adult Witnesses
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
Cell phone
Bullying
Sleeping in class
Tobacco/Smoking
Academic Dishonesty
Other
Consequence
*
Law Enforcement called by school
Phone call home
Counseling Center
Out of school suspension
In-school suspension
Bus suspension
Cool Down Room
Conference with student
Conference with parent
Other
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
Other
Describe the incident with as much detail as possible
*
Parent Communication
*
Phone Call
Meeting/Conference
Report Sent Home
Text
Other
Signature:
Submit
Should be Empty: