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Code of Conduct Violation Incident Report
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Name of Child
*
First
Last
Parent's Name
*
First
Last
Who is in violation of BU Rules? (copy)
*
Child
Parent
Name of Child 2
First
Last
Parent's Name 2
First
Last
Who is in violation of BU Rules?
Child
Parent
Name of Child 3
First
Last
Parent's Name 3
First
Last
Who is in violation of BU Rules?
Child
Parent
Reporting Leader's Name
*
First
Last
Leader's Email
*
Community
*
Reason for Submission:
*
Major Incident
Minor Incident
Documentation
Request for Support
Other:
Problem Behavior:
*
Bullying
Teasing/Taunting
Fighting
Physical Aggression
Inappropriate Language/Comments
Inappropriate Sexual Behavior
Defiance
Repeated/Severe Defiance
Severe Disrespect to Adult/Staff
Destruction of Plants/Trees
Endangering Animals
Property Damage/Destruction
Theft
Left Group without permission
Unsafe Behavior
Upset Parent
Other:
Date & Time of Incident:
*
Date
Time
Location of Incident:
*
Describe the incident with as much detail as possible:
*
Please list other witnesses:
if applicable
Response or Action Taken:
*
Conflict Resolution/Apology
Helped Facilitate a Break for Student
Re-Teach Expectations
Verbal Warning Given
Reported Incident Documented
Written Warning Issued (CC BU)
Possible Motivating Factors
*
Obtain Peer Attention
Obtain Adult Attention
Obtain Preferred Item
Avoid Peers
Avoid Task
Avoid Adult
Sensory Seeking
Outside of School Issue
Student Did Not Understand Expectations
Unknown
Additional Info
Was property damaged?
*
Yes
No
If yes, please explain:
*
Was another member injured?
*
Yes
No
If yes, please explain:
*
Parent Communication (by you prior to this submission)
*
Spoke on Phone
Parent Meeting Held
Email Communication
Parent Not Contacted
Recommend Follow-Up with Parent
Family Contact Not Necessary
None:
Other:
Other Parent Communication:
*
Email Incident: violation
Next steps, request for support, or any other additional information you would like to add!
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Leader Signature
*
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