Behavior Incident Report Form

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Behavior Incident Report
Child’s ID:____________________
Date: ________________________
Staff ID: ______________________
Time of Occurrence: ________________________
Program ID:________________________
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 withdrawal/
Trouble falling asleep
Inconsolable crying
isolation
Other_______
Activity (check one)
Arrival
Meals
Departure
Classroom jobs
Quiet time/Nap
Clean-up
Circle/Large group activity
Outdoor play
Therapy
Small group activity
Special activity/ Field trip
Individual activity
Centers/Indoor play
Self-care/Bathroom
Other________
Diapering
Transition
Others Involved (check all that apply)
Teacher
Family Member
Peers
Assistant Teacher
Support/ Administrative
None
Therapist
staff
Other________
Substitute
Possible motivation (check one)
Obtain desired item
Gain adult
Obtain sensory
Obtain desired activity
attention/comfort
Avoid sensory
Gain peer attention
Avoid adults
Don’t know
Avoid peers
Avoid task
Other________
Strategy/ Response
(check one or the most intrusive)
Verbal reminder
Re-teach/practice
Family contact
Curriculum modification
expected behavior
Loss of item/privilege
Move within group
Time in different
Time out
Remove from activity
classroom
Physical guidance
Remove from area
Time with support staff
Physical hold/restrain
Provide physical comfort
Redirect to different
Other________
Time with a teacher
activity/toy
If applicable, administrative follow-up
(check one or most intrusive)
Non-applicable
Arrange behavioral
Transfer to another program
Talk with child
consultation/team
Reduce hours in program
Contact family
Targeted group
Dismissal
Family meeting
intervention
Other________
Comments:
___________________________________________________________________________________________
___________________________________________________________________________________________
TACSEI_8.25.10

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