Behavior Incident Report

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    Client Name Date of Birth

    Date of Incident
    Time of Occurence

    Reporter Name

    What happened?
    Problem Behavior (Check most intrusive)

    If "Other" was checked, please describe:

    What was going on when it happened?

    What consequences were administered?

    0

    Incident Narrative

    0

    Always complete when a child engages in the following kinds of behavior:

    1. Aggression towards another child or adult that results in physical pain or harm to that person (includes hitting kicking, biting, scratching).
    2. Running out of room, out of yard, or from group without responding to the calls of the adult.
    3. Intentionally injuring self in a manner that may cause serious harm (severe head banging, biting self).

    Always complete when a child continues to engage in problem behavior despite efforts to redirect or use alternative skills. These behaviors may be:

    1. Tantrums
    2. Inappropriate Language
    3. Hitting
    4. Property Destruction
    5. Disruptive Behavior
    6. Any incident that lasts longer than 10 minutes.