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
*
Kindergarten
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
Grade 7
Not Sure
Student's Homeroom Teacher's Name
*
Melaynie Campbell (K)
Tracy Klein (K-1)
Jennifer Jang (Gr.1-2)
James Mitchell (Gr.2)
Jon Allen (Gr.3)
Shari Heal (Gr.4)
Meghan Adamsky (Gr.5)
Andrea Webber (Gr.6-7)
Other
Not Sure
What was the problem behaviour (select all that apply)
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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
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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