Daily Behavior Incident Reports
Student name (Last, First)
Your answer
Grade
Date
MM
/
DD
/
YYYY
Time
Time
:
Location
Referring Adult
Yellow Card Referral
Yellow Card Result
Red Card Referral
Questions for Student
What made you upset (elementary level)? What were you trying to get? (middle level)
Your answer
What did you do because you were upset? (elementary level) How did you try to get what you wanted? (middle level)
Your answer
How did you feel after? (elementary level) Did it work? (middle level)
Your answer
What will you do in the future if this happens again? (elementary level) What could you have done to get what you wanted? (middle level)
Your answer
Which types of behavior did you exhibit?
Questions for Teacher
What happened leading up to the behavior?
Your answer
What behavior(s) did the student exhibit?
Your answer
What steps did you take to respond to the behavior?
Your answer
Will you contact the parent concerning the behavior issue?
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