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: ________