UES Student Log Entry Form

Upi Elementary School

Student Log Entry Form
School Year*
Student's Initials*
(Ex. JK)
Classroom Teacher's Name*
Incident Date & Time*

MonthDayYear
Date
Hour MinutesAM/PM Option
Incident Location*

BusBus_Stop/Loading AreaBathroomCafeteriaClassroomGymHallwayLibraryMain/Admin OfficePlaygroundParking LotAssembly/Special Event/FieldtripOther
Do you think the student was trying to:

Obtain Peer AttentionObtain Adult AttentionObtain Item/ActivityAvoid Adult(s)Avoid Peer(s)Other
School Category Incident Type*

DisrespectDefianceInapp LanguageDistruptionPhy Cont/AggressionOther
Describe what happened.*
Note: Please be brief and specific.
Was the parent contacted?*

YesNo
Name of person contacted and relation to the student.
(Ex. Julie Salas / Principal)
Action Taken/Intervention*
Reported By*
Date Reported*

MonthDayYear
Date
Email*
example@example.com
Should be Empty:

Upi Elementary School