Sample Behavior Incident Report



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PROBLEM BEHAVIOR LOCATION OTHERS INVOLVED
Externalizing Physical aggression Inappropriate language Property destruction Internalizing Crying, Whining throughout an activity Isolated play after prompt to join others Non-compliance Refusals Disruption of learning Self-abuse/stimulation Other: Structured classroom activity Unstructured classroom activity Transition Hallway Playground Bus Other: Peer s Teacher Aide Specialist Bus driver Substitute Administration Others: 
INITIAL TRIGGER FOR BEHAVIOR RESPONSE TO BEHAVIOR CONSEQUENCE FOR BEHAVIOR 
Adult request/redirection Unstructured play Peer provoked Difficult task Adult not in close proximity No peer attention Other: Attention Adult verbal attention Adult physical attention Adult eye contact Peer verbal attention Peer physical attention Ignore Adult ignored behavior Peer ignored behavior Sensory strategy: Other: Level One Prompt/redirection Reteaching of rule/routine Practice of Skill Behavior choice given Communication method provided Level Two Removal from activity Conference with student Loss of privilege Level Three Moved to Safe Spot Think Sheet/Student Conference Parent Contact Behavior Contract Other: Comments: Comments: Comments: This report will not be sent home..

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