Behavior Incident Report

Child’s ID:____________________ Date: ________________________

Staff ID: ______________________ Time of Occurrence: ________________________
Program ID:________________________

Behavior Description:

Problem Behavior (check most intrusive)

‰ Physical aggression ‰ Inappropriate language ‰ Running away
‰ Self injury ‰ Verbal aggression ‰ Property damage
‰ Stereotypic Behavior ‰ Non-compliance ‰ Unsafe behaviors
‰ Disruption/Tantrums ‰ Social withdrawal/ ‰ Trouble falling asleep
‰ Inconsolable crying isolation ‰ Other_______

Activity (check one)

‰ Arrival ‰ Meals ‰ Departure
‰ Classroom jobs ‰ 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
Others Involved (check all that apply)
‰ Teacher ‰ Family Member ‰ Peers
‰ Assistant Teacher ‰ Support/ Administrative ‰ None
‰ Therapist staff ‰ Other________
‰ Substitute
Possible motivation (check one)
‰ Obtain desired item ‰ Gain adult ‰ Obtain sensory
‰ Obtain desired activity attention/comfort ‰ Avoid sensory
‰ Gain peer attention ‰ Avoid adults ‰ Don’t know
‰ Avoid peers ‰ Avoid task ‰ Other________

Strategy/ Response
(check one or the most intrusive)
‰ Verbal reminder ‰ Re-teach/practice ‰ Family contact
‰ Curriculum modification expected behavior ‰ Loss of item/privilege
‰ Move within group ‰ Time in different ‰ Time out
‰ Remove from activity classroom ‰ Physical guidance
‰ Remove from area ‰ Time with support staff ‰ Physical hold/restrain
‰ Provide physical comfort ‰ Redirect to different ‰ Other________
‰ Time with a teacher activity/toy
If applicable, administrative follow-up
(check one or most intrusive)
‰ Non-applicable ‰ Arrange behavioral ‰ Transfer to another program
‰ Talk with child consultation/team ‰ Reduce hours in program
‰ Contact family ‰ Targeted group ‰ Dismissal
‰ Family meeting intervention ‰ Other________

Comments:
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TACSEI_8.25.10