Behavior Report

Behavior Report
Name:
Date:

MonthDayYear
Date
Time:
Grade:
Referring Staff Member:
Please check all that apply. This form should be emailed to Amanda at shultzabergera@avoneagles.org
Problem Behavior

Please select the behavior below.
Inappropriate languagePhysical ContactDefiance/Non-complianceDisruptive BehaviorProperty Misuse
Other
Abusive languageFighting/AggressionOvert DefianceHarrassment/BullyingLying/Stealing
Other
Loss of privilegeTime out with SupervisorParent ContactSuspension from programTime out
Other
NonePeersStaff MemberOther
1st offense2nd offense3rd offense (Meeting is requested)
Please describe the behavior
To the parent: Please sign and return to the Site Supervisor. After three Behavior Reports, your child may be asked to leave the program.
Parent Signature:

Clear
Site Supervisor Signature:

Clear
Should be Empty: