Special Education Student Incident Analysis

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  Report Date Report Date
 
Student   Birth Date   School
 
   
   
  Last First  
 
Name of person completing this form
 
THIS FORM IS TO BE COMPLETED WHEN A STUDENT DOES NOT HAVE A BEHAVIOR INTERVENTION PLAN (BIP) ADDRESSING THE INCIDENT.
 
AREA OF REVIEW INCIDENT DATA
Give the name of the TARGET BEHAVIOR observed (e.g., aggression, property destruction, tantrum, etc.) Give the name of the TARGET BEHAVIOR observed (e.g., aggression, property destruction, tantrum, etc.)
Where was the student when behavior occurred? Where was the student when behavior occurred?
Who was working with the student at the time the incident occurred? Who was working with the student at the time the incident occurred?
Where was the staff at the time of the incident? Where was the staff at the time of the incident?
Who was next to the student at the time of the incident? Who was next to the student at the time of the incident?
What was the general atmosphere (Noise level, others tantrumming, staff attitude) in the classroom or in the situation at the time of the incident? What was the general atmosphere (Noise level, others tantrumming, staff attitude) in the classroom or in the situation at the time of the incident?
What was the student doing at the time of the incident? Describe the activity, task, event, or interaction occurring at the time. What was the student doing at the time of the incident? Describe the activity, task, event, or interaction occurring at the time.
What occurred immediately before the incident? Describe demands, changes in activities, interactions with staff or other students, requests, initiation of assigned activities, etc. What occurred immediately before the incident? Describe demands, changes in activities, interactions with staff or other students, requests, initiation of assigned activities, etc.
Describe what the student did during the incident (e.g., Hit with a fist, kicked with foot, broke window with brick, etc.) Describe what the student did during the incident (e.g., Hit with a fist, kicked with foot, broke window with brick, etc.)
Describe the severity of the incident (e.g., Damage to the environment, injuries to others, etc.) Describe the severity of the incident (e.g., Damage to the environment, injuries to others, etc.)
Describe who or what the incident was directed at (Name of the student, name of staff, object) Describe who or what the incident was directed at (Name of the student, name of staff, object)
Describe the immediate reaction to the behavior. How did staff and other students react to this behavior? Describe the immediate reaction to the behavior. How did staff and other students react to this behavior?
What action was taken to de-escalate or redirect the behavior? What action was taken to de-escalate or redirect the behavior?
Describe the methods used to manage the problem (Active listening, relaxation, deflection, if physical containment was used, how long was it used?). Describe the methods used to manage the problem (Active listening, relaxation, deflection, if physical containment was used, how long was it used?).
Briefly give your impression of why the student engaged in the above described incident (e.g., she was angry because I asked her to "stop teasing"). Briefly give your impression of why the student engaged in the above described incident (e.g., she was angry because I asked her to "stop teasing").