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Cunningham Elementary School Incident Report Form
To be completed by Teachers & Staff each time a student is referred for Administrative intervention, to address ongoing patterns of behavior that classroom interventions have not corrected and/or for all alleged bullying incidents.
Student Being Referred
First
Last
Grade of Student Being Referred
Select
PreSchool
Kindergarten
First Grade
Second Grade
Third Grade
Fourth Grade
Fifth Grade
Name of Teacher/Staff Referring Student
First
Last
Email of Teacher/Staff Referring Student
Behaviors Addressed in Classroom/Other School Setting Prior to Current Referral
(Select all that apply):
Use of Inappropriate Language
Physical contact with other student(s)
Disrupting classroom environment (calling out, making noises, distracting other students)
Defiance/Disrespect
Misuse of Classroom Tools, Property or Technology Device
Theft of others property
Other
Reason for Current Referral
(Select all the apply):
Alleged Bullying
Physically Dangerous Behavior (Hitting, Kicking, Pushing, Throwing Objects)
Illegal Behavior (i.e., Weapons, Vandalism, Stealing)
Harrassment based on race, color or national origin (intimidation or abusive behavior toward a student based on actual or perceived race, color or national origin)
Repeated Use of Inappropriate Language
Excessive Talking
Repeated Misuse of Classroom Tools, Property or Technology Device
Unsafe Behaviors (i.e., leaving classroom without permission, inappropriate use of playground structure, leaving school property)
Other
Date and Time of Incident
MM
/
DD
/
YYYY
HH
:
MM
AM
PM
AM/PM
Location of Incident
Provide Name, Grade and Homeroom of other student(s) involved & Name (s) of other Staff involved, if any and if known:
Provide Summary of Incident
Description
Follow-up Actions (if any)
Have you been in contact with the parent/guardian? *
Yes
No
Notes from Parent communication
Notes
Additional Information
