Incident Report

Hidden Valley Elementary School

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HVES Incident Report

* Indicates required field

Date of incident (YYYY/MM/DD) *

Year/Month/Day

Student Name *

First

Last

Your Name *

Grade Level *

Student's Homeroom Teacher's Name *

What was the problem behaviour (select all that apply) *

Abusive Language Fighting/Physical Agression Defiant/noncompliance Property Damage Theft Innapropriate Touching Biting

Action Taken *

Collaborative Problem Solving Non-exclustionary Time Out Repair Relationship Attached to Adult at Recess Sent to Administrator Positive Practice of Expected Behaviour Change in Permanent Environment Loss of Privilege Exclusionary Time Out Call Home to Parents Body Break Sensory Break (not sensory room)

Was there harm caused by the incident? *

Physical Emotional No Harm

Intensity of harm caused by the incident *

I - Very Little Harm 2 3 Moderate (unable to finish the day) 4 5 - Hospitalization No Harm Caused

Other people involved *

None Peer (another student) Staff Member Unknown

Other student involved *

First

Last

Other students involved were *

Harmed by actions Accomplice Bystander No other students involved

Additional Notes *

Submit

| Yukon Education | YESNet | Last modified: August 28, 2018