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Behavior Incident Report Form

This behavior incident report documents a behavior issue involving a child in a program. It describes the problem behavior as physical aggression and occurred during outdoor play. A teacher and peers were also involved. The child was removed from the activity and given time out as a response. There may be follow up with the child's family.

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Akash Rana
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109 views2 pages

Behavior Incident Report Form

This behavior incident report documents a behavior issue involving a child in a program. It describes the problem behavior as physical aggression and occurred during outdoor play. A teacher and peers were also involved. The child was removed from the activity and given time out as a response. There may be follow up with the child's family.

Uploaded by

Akash Rana
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Behavior Incident Report

Child’s Name: Date:


Staff Name: Time of Occurrence:
Program :

Behavior Description:

Problem Behavior (check most intrusive)


 Physical aggression  Inappropriate language  Running away
 Self-injury  Verbal aggression  Property damage
 Stereotypic Behavior  Non-compliance  Unsafe behaviors
 Disruption/Tantrums  Social  Trouble falling asleep
 Inconsolable crying withdrawal/  Other ___________
isolation
Activity (check one)
 wakeup/ Fresh-up  Meals  Dinner
 House cleaning jobs  Quiet time/Nap  Study time
 Morning devotion group activity  Tea & snacks  Therapy/Medication
 Breakfast  Outdoor play  Individual activity
 Centers/Indoor play  Clean-up  Other __________
 Schooling  Evening Devotion
Others Involved (check all that apply)
 Teacher  Family Member  Peers
 Assistant Teacher  Support/  None
 Therapist Administrative staff  Other ________________
 Substitute
Possible motivation (check one)
 Obtain desired item  Gain adult  Obtain sensory
 Obtain desired activity attention/comfor  Avoid sensory
 Gain peer attention t  Don’t know
 Avoid peers  Avoid adults  Other _________
 Avoid task
Strategy/ Response
(check one or the most intrusive)
 Verbal reminder  Re-teach/practice  Family contact
 Curriculum modification expected  Loss of item/privilege
 Move within group behavior  Time out
 Remove from activity  Time in  Physical guidance
 Remove from area different  Physical hold/restrain
 Provide physical comfort classroom  Other _________
 Time with a teacher  Time with support staff
 Redirect to
different
activity/toy
If applicable, administrative follow-up
(check one or most intrusive)
 Non-applicable  Arrange  Transfer to another program
 Talk with child behavioral  Reduce hours in program
 Contact family consultation/team  Dismissal
 Family meeting  Targeted group  Other _________
intervention

Comments:
BTC-AGB UNIT

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