Burnet Hill Incident Report

Reporting Staff Member: ___________________________________ Date: ____________________

Name of Student(s): _______________________________________________________________________________

Grade: ___________ Date of Incident: ______________________ Time of Incident: ________________

Others Involved: __________________________________________________________________________________

Location:
q Classroom q Office
q Hallway q Restroom
q Recess q Assembly/Field Trip
q Cafeteria q Bus/ Bus Area
q Specials q Other: _______________________________
Incident:
q Inappropriate Language/Gestures q Property Damage/Vandalism
q Fighting/Physical Aggression q Theft
q Defiance/Non-compliance q Lying/Cheating
q Disrespectful q Harm to other(s)
q Disruptive Behavior q Threats/Taunting
q Refusal to Work q Other: _______________________________
Short Description of Incident:

Teacher Actions Prior to Referral:

q Re-direction/Warning q Parent Conference
q Reinforced positive behavior q Developed behavior management plan
q Conference with student q Support Person/Team called
q Use of quiet area q Removal from classroom
q Loss of privilege q Other: ___________________________________
q Parent Communication (email/note/call)

Administrative Action (to be filled out by administrator ONLY):

q Conference with student q Referral to school counselor
q Warning q Behavior Support Plan
q Restitution/Apology q Problem Solving/Conflict Resolution
q Supervised Recess q Loss of Privilege
q Parent Contact q Suspension
q Parent Conference q Other: __________________________________

Parent/Guarding Contact: Comment and/or Follow-Up:

q Email
q Call
q Letter
q Conference
q Other: _________________________________