8/9/2019 Keys to Student Success (6 of 7) School-wide Positive Behavior P35-36

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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  (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/sexualorientation/disability/religious)

q  (1426) Hazingq  (1414) Over-the-Counter Medications against school

policyq  (1415) Pyrotechnics (detonation of explosive fireworks)

(estimated cost : $__________)q  (1417) Theft ( estimated cost : $__________)q  (1419) Tobaccoq  (1421) Verbal Abuse (disrespectful language)q  (1418) Threat/Intimidationq  (1423) Other (e.g., cheating, fire alarms, trespassing, etc

 _____________________________________________Level III Behavior Observed:

q  (1401) Alcoholq  (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

q  (1410) Fightingq  (1413) *Illegal Drugs (circle: use or sold)q  (specify type of drug _________________________ )q  (1416) Terroristic Threatsq  (1420) Vandalism/Property Related (estimated cost :

$__________)q  (1422) *Weapon (specify: ______________________)

Describe events occurring just prior: (Others involved?Extenuating circumstances? If gang related behavior, give specifics)

Describe incident: (Others involved? Extenuating circumstances? If gang related behavior, give specifics): 

Location of Incident: Possible Purpose/Function of Observed Behavior:q  (01) Classroomq 

(02) Hallwayq  (03) Restroomq  (04) Other Indoor School Building Locationq  (05) School Busq  (06) Parking Lotq  (07) Other Outdoor School Building Locationq  (08) Off Campusq  (31) Cafeteriaq  (32) Gym

q  (10) Obtain peer attentionq 

(20) Obtain adult attentionq  (30) Obtain items/activitiesq  (40) Avoid tasks/activitiesq  (50) Avoid workq  (60) Avoid peersq  (70) Avoid adultsq  (80) Unclear/Don’t knowq  (90) Other _____________q  (99) Unknown motivation

8/9/2019 Keys to Student Success (6 of 7) School-wide Positive Behavior P35-36

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October 10, 2007 | Key to Student Success 36

PART 2: DISCOVERY  Action InformationOthers Involved (PBIS): Administrative and/or Youth Counselor 

Actions taken:

q  (10) Noneq  (20) Peersq  (30) Staff q  (40) Teacher q  (50) Substituteq  (60) Unknownq  (70) Other 

 ____________________________________

q  (BEH1) Out of room time out/behavior support with

alt. instruction provided short term (1-3 hrs)q  (BEH2) Out of room time out/behavior support with

alt. instruction provided ½ day (3-6 hrs)q  (BEH3) Out of room time out/behavior support with

alt. instruction provided full day (6 or more hrs insingle day)

q  (BUS) Bus Suspensionq  (CAFÉ) Cafeteria Suspensionq  (DET) Detention (After-School or Lunch) Circle One q  (FMCON) Family Conferenceq  (INSUS) In-school suspension (removal from any

instruction but kept in school)q  (PEER) Peer Mediationq  (REM) Removal from instruction (e.g., sent home for

the remainder of the day, but allowed to come backthe next day)

q  (REST) Restitution/Community Serviceq  (RFPST) Referral to Problem Solving Teamq  (SATSC) Saturday Schoolq  (SUSP) *Out-of-school suspension (i.e., removed

from instruction by sending home for MORE THANONE school day)

q  (TMCON) Team Conferenceq  (OTHER) Other 

 ________________________________  

Data STATUSq 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