Student Incident Report Form

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STUDENT INCIDENT REPORT FORM
Student Name:
Class:
__________________________________
____________________
Date of Incident
Time of Incident:
: ___________________
_______________
Reporting Teacher
Witness: ______________________
: ________________
TIME OF INCIDENT:
TIME OF INCIDENT:
1.
qBefore School
2.q Recess
3.qFirst Lunch
4.qSecond Lunch
5.qAfter School
6.qIn School
I.
PLACE OF INCIDENT:
qInfant Toilets
T. qPrimary Toilets
PLACE OF INCIDENT:
N.qB-ball Court
O.qMain Oval
F. qFlagpole area
E.qPlay Equip Area
C. qClassrooms
A. qAsphalt Area
H.qHit Up Wall Area
B. qOut of Bounds
S. qShade Area
L. q Little oval (cricket nets)
M.qMulti P/Room
UNACCEPTABLE BEHAVIOUR : :
UNACCEPTABLE BEHAVIOUR
Incident description:______________________________________________________________
__________________________________________________________________________________
Teacher communication mode (please check):
q Educate
q Counsel
q Coach
q Confront
Type of Behaviour:
qBullying
qHarassment
qTeasing
Behaviour: qBody
qDamage to Property
qExclusion
qRacial
qExtortion
qGesture
qLittering
qNon Co-operation
qPhysical
qPsychological
qVerbal
qWritten
ACTUAL CONSEQUENCE:
ACTUAL CONSEQUENCE:
Time out seat:
(length of time)
Time out seat:
(length of time)
Shado wing:
wing:
(length of time)
Shado
(length of time)
Area exclusion:
(where/length of time)
Area exclusion:
(where/length of time)
NB. If Consequence is ongoing, please write on whiteboard in staffroom.

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