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SAFE CRISIS MANAGEMENT (SCM)
INCIDENT REPORT
**This report MUST be returned to your Principal no later than
the end of the day when the incident occurred. **
Student Name:
D.O.B:
School:
Grade:
Reporting Staff Member’s Name:
Name(s) of other staff involved in incident:
Date of Incident:
Beginning Time:
Ending Time:
Please describe the incident in the spaces below. Use appropriate SCM
terminology as needed:
1. Describe the Antecedent Event(s). Indicate Time, Place and Cause:
2. Describe the initial behavior displayed by student:
3. Specifically list the initial actions taken by staff as a result of the
student’s displayed behavior:
4. List the de-escalation techniques used by staff with the student:
Revised December 5, 2002
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5. Time the SCM Physical Assist began:
Time the SCM Physical Assist ended:
6. List the SCM Physical Assists used by staff with the student:
7. Describe, if any, the counseling or guidance the student received
after the incident:
8. Please list and/or describe any injuries that occurred to either the
staff or to the student. Also specifically indicate who was injured during
the incident:
9. Follow-up suggested by principal:
10. Principal Signature and Date:
11. Follow-up Suggested by School Director:
Revised December 5, 2002
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12. School Director Signature and Date:
13. Parent/Guardian Contacted by: __________________
(Staff Name)
on ________
________
(Date)
(Time)
14. Parent/Guardian Comments:
15. Follow-up Suggestions by SCM Incident Review Team (Optional):
16. SCM Review Leader Signature & Date:
(Please make copies for your files and send a copy to your School Director)
Revised December 5, 2002