School Name______________________________

Behavior Incident Report Form 2007-2008

Student Name: Date Family Contacted Y N (Circle)

Referring Staff: Time of Incident: AM or PM (Circle)

Special Education: Yes _____ (Case Manager: ____________________________________) No ______

PART 1: DISCOVERY Infraction Information:

Level II Behaviors Observed

q (1424) Attendance (skipping class/tardy) q (1426) Hazing

q (1425) Bullying (PATTERN of intentional harm-
doing/negative actions, between individuals with power
differential)
q (1407) Computer ( estimated cost: $__________)
q (1408) Disruptive/Disorderly Conduct/Insubordination
(failure to comply with request; persistent lack of
cooperation)
q (1412) Harassment (circle: racial/sexual/sexual
orientation/disability/religious)
Level III Behavior Observed:
q (1401) Alcohol
q (1402) Arson (estimated cost: $_________)
q (1403) Assaults (circle: Physical/ Sexual)
q (1405) Bomb Threat; (1404) Bomb (estimated cost:
$__________)
q (1406) Controlled Substances/Prescription (circle: use or sold)
q (1409) Extortion
Describe events occurring just prior: (Others involved?
Extenuating circumstances? If gang related behavior, give specifics)
q (1414) Over-the-Counter Medications against school
policy
q (1415) Pyrotechnics (detonation of explosive fireworks)
(estimated cost: $__________)
q (1417) Theft ( estimated cost: $__________)
q (1419) Tobacco
q (1421) Verbal Abuse (disrespectful language)
q (1418) Threat/Intimidation
q (1423) Other (e.g., cheating, fire alarms, trespassing, etc.)
______________________________________________
q (1410) Fighting
q (1413) *Illegal Drugs (circle: use or sold)
q (specify type of drug _________________________)
q (1416) Terroristic Threats
q (1420) Vandalism/Property Related (estimated cost:
$__________)
q (1422) *Weapon (specify: ______________________)
Describe incident: (Others involved? Extenuating circumstances? If
gang related behavior, give specifics):

Location of Incident: Possible Purpose/Function of Observed Behavior:

q (01) Classroom q (10) Obtain peer attention
q (02) Hallway q (20) Obtain adult attention
q (03) Restroom q (30) Obtain items/activities
q (04) Other Indoor School Building Location q (40) Avoid tasks/activities
q (05) School Bus q (50) Avoid work
q (06) Parking Lot q (60) Avoid peers
q (07) Other Outdoor School Building Location q (70) Avoid adults
q (08) Off Campus q (80) Unclear/Dont know
q (31) Cafeteria q (90) Other _____________
q (32) Gym q (99) Unknown motivation
 PART 2: DISCOVERY Action Information
Others Involved (PBIS): Administrative and/or Youth Counselor
Actions taken:
q (BEH1) Out of room time out/behavior support with
q (10) None alt. instruction provided short term (1-3 hrs)
q (20) Peers q (BEH2) Out of room time out/behavior support with
q (30) Staff alt. instruction provided day (3-6 hrs)
q (40) Teacher q (BEH3) Out of room time out/behavior support with
q (50) Substitute alt. instruction provided full day (6 or more hrs in
q (60) Unknown single day)
q (70) Other q (BUS) Bus Suspension
____________________________________ q (CAF) Cafeteria Suspension
q (DET) Detention (After-School or Lunch) Circle One
q (FMCON) Family Conference
q (INSUS) In-school suspension (removal from any
instruction but kept in school)
q (PEER) Peer Mediation
q (REM) Removal from instruction (e.g., sent home for
the remainder of the day, but allowed to come back
the next day)
q (REST) Restitution/Community Service
q (RFPST) Referral to Problem Solving Team
q (SATSC) Saturday School
q (SUSP) *Out-of-school suspension (i.e., removed
from instruction by sending home for MORE THAN
ONE school day)
q (TMCON) Team Conference
q (OTHER) Other
________________________________

Data STATUS
q Entered into DISCOVERY (if yes, check box)
q If suspension MORE than 5 CONSECUTIVE school days, then an alternative educational
service is required as the status (additional DISCOVERY codes need to be used)
Notes:

Updated 10/3/2007 * These infractions types also require an additional classification entry on DISCOVERY

October 10, 2007 | Key to Student Success 36