Behavior Incident Report Form
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3Behavior Incident Report
Child’s Name: __________________________________________ Date: ________________________
Time of Occurrence: ________________________
What happened?
Problem Behavior (check most intrusive)
Physical aggression
Inappropriate language
Property damage
Self injury
Verbal aggression
Unsafe behaviors
Stereotypic Behavior
Non-compliance
Trouble falling asleep
Disruption/Tantrums
Social withdrawal/isolation
Other___________________
___________________________________
Inconsolable crying
Running away
What was going on when it happened?
Arrival
Meals
Departure
Routine job
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
_____________________________
Provider response: ___________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Behavior Incident Report
Child’s Name: __________________________________________ Date: ________________________
Time of Occurrence: ________________________
What happened?
Problem Behavior (check most intrusive)
Physical aggression
Inappropriate language
Property damage
Self injury
Verbal aggression
Unsafe behaviors
Stereotypic Behavior
Non-compliance
Trouble falling asleep
Disruption/Tantrums
Social withdrawal/isolation
Other___________________
___________________________________
Inconsolable crying
Running away
What was going on when it happened?
Arrival
Meals
Departure
Routine job
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
Provider response: ___________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
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