Behavior Incident Report
Child:____________________________________________________________
Date: _____________________________Classroom:______________________
Teacher:__________________________________________________________
Problem Behavior: (See definitions on backside of sheet)
 Physical Aggression
 Self-Injury
 Disruption/Tantrums
 Bullying classmates
 Making inappropriate
gestures
 Biting
Location of Incident:
 Assigned classroom
 Outside(Front or Back
yard
 Hallway (1st or 2nd floor)
Activity Time:
 Arrival
 Large group activity
 Small group activity
 Self-care (Bathroom)
 Departure
Others Involved:
 Teacher
 Assistant teacher
 Peers
Possible motivation:
 Obtain desired item
 Obtain desired activity
 Gain peer attention
Strategy/Consequence:
 Verbal reminder
 Redirection
 Removal of Item
 Loss of privilege
 Family contact
Effect on behavior:
 Stopped
 Escalated
 Moving out of assigned
area / Running Away
 Inappropriate language
 Excessive and
inappropriate attention-
seeking behaviors
 Bathroom
 Field Trip
 Other classroom
___________________
 Meals
 Quiet Time/Nap
 Outdoor play
 Special activity
__________________
 Family member
 Admin staff/substitute
 Gain adult attention
 Avoid task
 Avoid peers
 Time with other adult in
different classroom
 Removal from class
 Ignore the behavior
 No effect
 Diminished but still
present
 Property damage
 Refusing to follow directions
 Unsafe behavior
 Other_______________
 Property damage
 Unsafe behavior
 Stairwell
 Other_______________
 Transition from
____________________ to
______________________
 Individual activity
 Other_______________
 None
 Other_______________
 Avoid adults
 Not known
 Other________________
 Move within group
 Remove from activity
 Other________________
 Other_________________
 Parent action:

 Has observed specified
behavior in classroom
 Behavior has occurred at
home / Does occur at
home
 Enroll in Counseling by:  Have child seen by primary
___________________ care physician
 Enroll in Early Mental
Health Consultant
Program

Action to be taken:

 Verbal Warning  Suspension ______day(s)  Other_____________

 Written Warning  Dismissal from program
effective _____________
Additional comments:

_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

Signature of Director/ Assistant Director ___________________________

Signature of Teacher ___________________________________________

Signature of Parent____________________________________________

 (Parent refused to sign form)

Date:____________________________ Staff person who witnessed the Incident___________________

Behavior Definition
Physical Aggression Making physical contact with an adult or peer where injury may occur.
Self-Injury Physically abusing self.
Disruption/Tantrum Causing an interruption in class or activity or activity.
Bullying classmates Verbally abusing another child.
Making inappropriate Use of body gesture and inappropriate actions convey feelings of disrespect or
gestures arrogance.
Biting Biting children or adults.
Moving out of assigned area / Leaving the supervised area alone and without permission.
Running away
Inappropriate language Use of bad language, strong language, coarse language, foul language, bad
words, vulgar language, swearing, cursing or cussing.
Excessive attention-seeking Behaving in a way which is in pursuit of attention from others where such
behaviors behavior is excessive and inappropriate.
Property damage Deliberately impairing or destroying items.
Refusing to follow directions Refusal to follow the rules, instructions or indications.
Unsafe behavior Engaging in dangerous acts with materials.
Running away Leaving the supervised area alone and without permission.