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