"Student Incident Report Form - St. Lucie County School District"

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St. Lucie County Public Schools
Student Incident Report
Parents,
We respectfully request your support to resolve the problem behavior mentioned below. This form is used to document a recurring classroom behavior
incident. The student has been given a warning and re-taught the expectation and specific rule concerning the infraction prior to recording on this
form. As of today, this incident has been documented 3 times. Please sign below stating that you understand, should it occur again, a discipline referral
will be written.
Gender
Student
Teacher
Grade
Incident Type
(Check One):
Prohibited Materials
Dress Code Violation
False/Misleading Information
Skipping class
Forgery(non-legal documents)
Disruption
Cheating
Theft
Inappropriate language/materials
Disrespect
Defiance
Property Misuse/Damage
Teasing/Taunting
Tardy
Other: Specify_________________________
st
1
Incident Verbal Warning/Expectation Re-taught (Date_________________[optional])
nd
2
Incident
Date: _______________ Time: ___________ Location:_________________________
(i.e. Hallway, classroom, etc. )
Parent Contact Required
Interventions:
Possible Motivations:
Others Involved
Parent Contact
Avoid Adult
None
Student conference
Student Behavior Contract
Avoid Peer(s)
Peers
Re-teach expectation Loss of item/privilege
Avoid Task/Activities
Staff
Seating Change
Curricular modification
Obtain Adult Attention
Teacher
Peer/Adult Mentor
Extra time spent on task
Obtain Peer Attention
Substitute
Consult Colleague
Time Out
Obtain Item/Activities
Unknown
(10 mins. Out of class)
Time Out (in class)
Other:
Other:
Other:
Academic Support
Specify:________________
____________________________
____________________
Model Behavior
Lunch Detention
Apology
Reward Desired Behavior
rd
3
Incident Date: _________________ Time: _________ Location:___________________________
(i.e. Hallway, classroom, etc.)
Interventions:
Possible Motivations:
Others Involved
Student conference
Student Behavior Contract
Avoid Adult
None
Re-teach expectation Loss of item/privilege
Avoid Peer(s)
Peers
Seating Change
Curricular modification
Avoid Task/Activities
Staff
Peer/Adult Mentor
Extra time spent on task
Obtain Adult Attention
Teacher
Consult Colleague
Time Out
Obtain Peer Attention
Substitute
(10 mins. Out of class)
Time Out (in class)
Other:
Obtain Item/Activities
Unknown
Academic Support
Other:
Other:
Specify:________________
Model Behavior
Lunch Detention
____________________________
____________________
Parent Contact
Reward Desired Behavior
Apology
PARENT SIGNATURE ______________________________________ DATE ________________
th
4
Incident Date: ____________ Time: ____________ Location:______________________________
(i.e. Hallway, classroom, etc.)
Intervention:
Discipline Referral
White: Parent
Canary: Teacher
Pink: Dean
WGK0001 Rev. 6/08
St. Lucie County Public Schools
Student Incident Report
Parents,
We respectfully request your support to resolve the problem behavior mentioned below. This form is used to document a recurring classroom behavior
incident. The student has been given a warning and re-taught the expectation and specific rule concerning the infraction prior to recording on this
form. As of today, this incident has been documented 3 times. Please sign below stating that you understand, should it occur again, a discipline referral
will be written.
Gender
Student
Teacher
Grade
Incident Type
(Check One):
Prohibited Materials
Dress Code Violation
False/Misleading Information
Skipping class
Forgery(non-legal documents)
Disruption
Cheating
Theft
Inappropriate language/materials
Disrespect
Defiance
Property Misuse/Damage
Teasing/Taunting
Tardy
Other: Specify_________________________
st
1
Incident Verbal Warning/Expectation Re-taught (Date_________________[optional])
nd
2
Incident
Date: _______________ Time: ___________ Location:_________________________
(i.e. Hallway, classroom, etc. )
Parent Contact Required
Interventions:
Possible Motivations:
Others Involved
Parent Contact
Avoid Adult
None
Student conference
Student Behavior Contract
Avoid Peer(s)
Peers
Re-teach expectation Loss of item/privilege
Avoid Task/Activities
Staff
Seating Change
Curricular modification
Obtain Adult Attention
Teacher
Peer/Adult Mentor
Extra time spent on task
Obtain Peer Attention
Substitute
Consult Colleague
Time Out
Obtain Item/Activities
Unknown
(10 mins. Out of class)
Time Out (in class)
Other:
Other:
Other:
Academic Support
Specify:________________
____________________________
____________________
Model Behavior
Lunch Detention
Apology
Reward Desired Behavior
rd
3
Incident Date: _________________ Time: _________ Location:___________________________
(i.e. Hallway, classroom, etc.)
Interventions:
Possible Motivations:
Others Involved
Student conference
Student Behavior Contract
Avoid Adult
None
Re-teach expectation Loss of item/privilege
Avoid Peer(s)
Peers
Seating Change
Curricular modification
Avoid Task/Activities
Staff
Peer/Adult Mentor
Extra time spent on task
Obtain Adult Attention
Teacher
Consult Colleague
Time Out
Obtain Peer Attention
Substitute
(10 mins. Out of class)
Time Out (in class)
Other:
Obtain Item/Activities
Unknown
Academic Support
Other:
Other:
Specify:________________
Model Behavior
Lunch Detention
____________________________
____________________
Parent Contact
Reward Desired Behavior
Apology
PARENT SIGNATURE ______________________________________ DATE ________________
th
4
Incident Date: ____________ Time: ____________ Location:______________________________
(i.e. Hallway, classroom, etc.)
Intervention:
Discipline Referral
White: Parent
Canary: Teacher
Pink: Dean
WGK0001 Rev. 6/08