keys to student success (6 of 7) school-wide positive behavior p35-36
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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