William Beatty School Incident Report
Working with families to
help our children become responsible citizens.
Name:
_________________________________
Date of Incident: ___________________
Homeroom:
_____________ Homeroom Teacher: ___________________________
Hallway
Where:
Yard
Classroom
Washroom
Nutrition break
When:
Before School
During class: at __:_____
Outdoor recess
Other: _______________
Other students involved:
_________________________________________________________
I made my problem
smaller 1 2 3
4 5 6
7 8 9 bigger by:
<-------- (circle one)---------->
_________________________________________________________
_________________________________________________________
I felt ____________________________ when it happened.
My body told me I was feeling this because I felt: (circle any that are true)
[ Hot all over
Butterflies in my stomach My hands were in fists
I wanted to: _________________
There were tears in my eyes. ]
What would you do differently next time?
Counting
to 10
Walking away
Taking a deep breath
Stopping to think
Asking questions Taking
a time-out
Getting help from: ___________________
OR: ____________________________