St. Lucie County Public Schools
SCHOOL WIDE INCIDENT REPORT
Student Name: First Last
Grade
Incident Location: (circle one)
1. Restroom
2. Bus Zone
3. Classroom
4. Hallway
5. Media Center
6. Office
7. Playground
8. Other _____________________
Date
Time
Referring Staff
HR Teacher
Possible Motivation: (circle one)
1. Avoid Adult
5. Obtain Peer Attention
2. Avoid Peer
6. Obtain Items
3. Avoid Task/Activities 7. Don’t know
4. Obtain Adult Attention 8. Other ____________
EXPECTATION VIOLATED: (circle one)
Safe
Polite On Task Treat others with respect
Show how to be responsible
11. Other: (Give a detailed description)
Incident Type: (circle one)
1. Dress Code
2. Use of Profanity/Name calling
3. Intentional disruption to classroom
4. Defiance to adult
5. Lying/Cheating
6. Teasing
7. Property Damage- less than $25
8. Minor stealing- less than $25
9. Improper use of food
10. Inappropriate use of hands/feet
Intervention: (circle all that apply)
1. Student Conference
2. Re-teach expectation
3. Seating change
4. Note to parent
5. Phone to parent
6. Peer mediation
7. Parent conference
8. Curricular accommodation
9. Time out
10. Loss of privilege
DATE
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
DATE
11. Refer to guidance
12. Sent to room # ___
13. Apology letter
14. Use of behavior chart
15. Confiscation
16. Lunch Detention
17. Restitution: _____
18. Verbal reprimand
19. Intervention book
page and # ______
___________
___________
___________
___________
___________
___________
___________
___________
___________
Please sign and return to school
Student Signature: ___________________________
Parent Signature: ____________________________
Comments:
White: Teacher
Canary: Student Folder
Pink: Parent
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