WV Incident Report 2019-20

Westview Elementary School Incident Report
Student Name: ________________ Date:__________ Grade: ____ Time: ________a.m. p.m.

Classroom Teacher: _________________ Teacher Completing:__________________
What happened? (One sentence summary please—use back side for note-taking and details)
______________________________________________________________________________________________
______________________________________________________________________________________________
Problem Behavior: o Controlled Substance Violation o Physical Aggression Location:

o Abusive Language o Disrespect of School Property o Technology Misuse o Bathroom
o Bullying—Cyber o Disruptive Behavior o Theft o Bus/Bus Stop
o Bullying—Physical o Dress Code Violation o Unsafe Conduct o Classroom
o Bullying—Verbal o Lying o Verbal Intimidation o Hallway
o Cheating/Plagiarism/Forgery o Insubordination o Weapon(s) o Library
Other________________ o Lunchroom
Possible Reason for Behavior: o Avoid Work o Outside
o Attention from peer(s) o Obtain Item(s) o Playground
o Attention from adult(s) o Lack of Anger Control o Other:______________
o Avoid peer(s) o Other______________________
o Avoid adult(s) o Unknown
Step 1—Reminder/Intervention Step 2—Parent Contact Step 3—Consequences (Provide Date) Step 4—Suspension (Office
Only)
______________________ o Phone Call Details: Restorative Conversation_________ Bus Suspension ____day(s)
Dates:______________________
______________________ Date:_______________
Loss of privilege_______________
______________________ Time: ______________ Lunch Detention_______________ In School Suspension ____day(s)
______________________ Spoke With:_________ Dates:______________________
Recess Detention_______________
or Msg._____________
______________________ o In Person Other ________________________ Out-of-School Suspension__day(s)
______________________ Dates:______________________
Date for Follow Up to Ensure Improvement: ____________ or Not Necessary (If date is given, do not come to office unless directed by an adult at school.)
Student Reflection (Student please complete this section at home with a parent)
Parents/Guardians: Please discuss the incident with your child and return this form on the next school day.
Student Name: __________________________________ Date: _______________
1. The personal behavior expectation(s) that were broken include:
Be Respectful Be Responsible Be Safe
2. What did you want?

o I wanted attention from others o I wanted to cause others problems because they don’t like me
o I wanted to challenge adults o I wanted to be in control of the situation
o I wanted to be sent home o I wanted to avoid doing my work
o I wanted to cause problems because I feel bad inside o I wanted revenge
o I wanted to hurt others because I was angry. o I wanted to have a break
o Other: _____________________________________
3. What will you choose to do differently next time? If I am in the same situation again I will…
_________________________________________________________________________________
_________________________________________________________________________________
Student Signature: _______________________________________Staff Signature: _________________________________________
Parent/Guardian Signature: _____________________________________________________
Thank you for your cooperation!

Revised 08/2019
Westview School Behavioral Response Guidelines
Revised Fall, 2019
Staff member is to complete top (Outlined) portion of incident report and send to office for processing.
In ALL cases: 1. Confront misbehavior 2. Correct & Communicate 3. Document

NOTES:
Restorative Conversations: Relationships, Respect, Responsibility, Restoration, Reintegration

When speaking to someone who has caused harm: When speaking to someone who was harmed:
 What happened?  What did you think when it happened?
 What were you thinking at the time?  What have you thought about since?
 What have you thought about since?  How have you been affected?
 Who do you think has been affected by what you did? In what way?  Who else has been affected?
 What do you need to do to make things right?  What's been the hardest part?
 How can we make sure this doesn't happen again?  What's needed to make things right?
 How can we make sure this doesn't happen again?
When needing to go deeper…
Was it the right or wrong thing to do? Was it fair or unfair? What exactly are you sorry for? If you had to do over, what would you do differently?
Revised 08/2019

WV Incident Report 2019-20

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Westview Elementary School Incident Report

Student Name: ______ Date: Grade: Time: a.m. p.m.

Problem Behavior: o Controlled Substance Violation o Physical Aggression Location:

Student Name: ____________________ Date: _

1. The personal behavior expectation(s) that were broken include:

Be Respectful Be Responsible Be Safe

2. What did you want?

Parent/Guardian Signature: _____________________________________________________

Thank you for your cooperation!

In ALL cases: 1. Confront misbehavior 2. Correct & Communicate 3. Document

Restorative Conversations: Relationships, Respect, Responsibility, Restoration, Reintegration

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