Behavioral Emergency Incident Report Form
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09/04 9–Praising others 10– Reminders of past success/goals 11– Clarify expectations 12– Provide choices offered alternate activity 13– Verbal Counseling 14–Model or rehearse appropriate behavior 15– Reminders for upcoming activities/events 17– Removal of stimuli 18– Time away in class 19– Time away outside of class 20– Separate student from group 21– Separate the group from student 22– Other (specify) 16– Reminders about consequences White – Site Canary – Teacher Pink – Parent Page 3 of 6 BEHAVIORAL INCIDENT EMERGENCY REPORT Student School Teacher Date of Incident Day: M T W Th F Incident Start Time: Student Injury (All injuries must be reported to an Administrator) Type Area(s) NO INJURY Bruise Bite Swelling Cut Blood/bodily fluid Discomfort/pain Other Chest Neck Back Abdomen Buttocks Head/face Mouth/teeth Feet/legs Hands/arms Other Medical Attention Required First Aid Required Type of First Aid Applied Apparent Cause/Source of Injury Injuries to other students and staff must be documented..
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