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Incident Form - Student Behaviour1

This document is an incident form submitted to the principal describing a behavior issue with a student. It provides information on the date and time of incident, location in the classroom, initial problem behavior of throwing objects, possible motivation of avoiding an assigned task, action taken of giving the student a timeout in a quiet place, and follow up action requiring the student to complete the assigned work while others had free time.

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1K views2 pages

Incident Form - Student Behaviour1

This document is an incident form submitted to the principal describing a behavior issue with a student. It provides information on the date and time of incident, location in the classroom, initial problem behavior of throwing objects, possible motivation of avoiding an assigned task, action taken of giving the student a timeout in a quiet place, and follow up action requiring the student to complete the assigned work while others had free time.

Uploaded by

api-170071552
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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INCIDENT FORM - STUDENT BEHAVIOUR

- Submit to Principal as soon as possible Date of incident: __________________________________ Time: ______________________________________


Student (initiator only): ____________________________

Other student/s involved (initials): ______________

Reported by: _____________________________________ Class teacher informed? Yes / No

LOCATION
COLA
Pool
Bus
Sandpit
Bus (travelling on)
Bus area (am/pm)
Corridor
Playground
Toilet / change-room
Classroom
Excursion
Rainbow room
Other ____________

INITIAL PROBLEM
BEHAVIOUR
Defiance
Inappropriate language
Property misuse
Disobeying instructions
Inappropriate sexual
Throwing things
Bullying / harassment
Disruption
Off-task
Unsafe play
Dangerous behaviour
Fighting / physical aggression
Physical contact
Other ____________________

POSSIBLE
MOTIVATION
Avoid - peer/s
Avoid - adult/s
Revenge
Attention - adult/s
Attention - peer/s
Avoid - task / activity
Sensory
Obtain - item / activities
Transition / change
Power
Dont know
Other ______________

BY

ACTION TAKEN
REPORTING STAFF

Walked with teacher


Time out - own class
Time out - quiet place
Time out - sandpit
Time out - Principal
Loss of privileges
Restitution / apology
Back up call
Other ____________

FOLLOW-UP ACTION TAKEN


BY EXECUTIVE / PRINCIPAL
Parent contact
Conference with parent
Interview request
Suspension - warning
Suspension - in-school
Suspension - short
Suspension - long
Other _______________

ADDITIONAL INFORMATION:

_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

SIGNED REPORTING STAFF: ________________________ DATE: ________

SIGNED PRINCIPAL / EXECUTIVE: ________________________ DATE: ________

EXAMPLE INCIDENT FORM - STUDENT BEHAVIOUR


- Submit to Principal as soon as possible Date of incident: __________________________________ Time: ______________________________________
Student (initiator only): ____________________________

Other student/s involved (initials): ______________

Reported by: _____________________________________ Class teacher informed? Yes / No

LOCATION
COLA
Pool
Bus
Sandpit
Bus (travelling on)
Bus area (am/pm)
Corridor
Playground
Toilet / change-room
Classroom
Excursion
Rainbow room
Other ____________

INITIAL PROBLEM
BEHAVIOUR

POSSIBLE
MOTIVATION

Defiance
Inappropriate language
Property misuse
Disobeying instructions
Inappropriate sexual
Throwing things
Bullying / harassment
Disruption
Off-task
Unsafe play
Dangerous behaviour
Fighting / physical aggression
Physical contact
Other ____________________

Avoid - peer/s
Avoid - adult/s
Revenge
Attention - adult/s
Attention - peer/s
Avoid - task / activity
Sensory
Obtain - item / activities
Transition / change
Power
Dont know
to avoid sitting down at
desk to complete a work task

BY

ACTION TAKEN
REPORTING STAFF

Walked with teacher


Time out - own class
Time out - quiet place
Time out - sandpit
Time out - Principal
Loss of privileges
Restitution / apology
Back up call
Other ____________

FOLLOW-UP ACTION TAKEN


BY EXECUTIVE / PRINCIPAL
Parent contact
Conference with parent
Interview request
Suspension - warning
Suspension - in-school
Suspension - short
Suspension - long
the student had to
complete the work task while
other students were having
free time

ADDITIONAL INFORMATION:
THE TEACHER DIRECTED THE STUDENT TO SIT DOWN FOR INDIVIDUAL WORK TIME. THE STUDENT WALKED OVER TO THEIR CHAIR, PICKED IT UP
CLASSROOM.

SIGNED REPORTING STAFF: ________________________ DATE: ________

AND THREW IT ACROSS THE

SIGNED PRINCIPAL / EXECUTIVE: ________________________ DATE: ________

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