Sample intervention report
Name of student___________________________________ Grade______

Date of incident____________Time of incident______

Location__________________________________________________

 

Please check the categories on the violence continuum that best described the student infraction:

 _____eye rolling /"the look" _____writing graffiti  _____stealing  _____name calling
 _____starting rumors _____threatening  _____sexual harassment  _____shoving/punching
 _____damaging property _____taunting/ridiculing  _____stalking  _____hitting/kicking
 _____gesturing _____demeaning comments  _____intimidation  _____flashing weapon
 _____staring/leering _____extortion  _____spitting/pushing  _____physical contact

Briefly describe the incident.

 


What intervention did you take?

 


Parent contacted______________date______time_______

Staff signature___________________date form completed________________________ date filed in office_______________

Note: this form should be completed by the teacher for low level or high level offenses: however, it should not take the place of sending students to the office of getting immediate administrative assistance when serious offenses occur.

 

 

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Lesson One- Lack of Violence and Bullying

Lesson Two- Intervention Strategies

Lesson Three- Implementing a Non-Bullying Program

Sample Incident Report

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