Behavior Incident Report - CRTIEC

1 Behavior Incident Report Child's ID:_____ Date: _____. Staff ID: _____ Time of Occurrence: _____. Program ID:_____. Behavior Description: Problem Behavior (check most intrusive). Physical aggression Inappropriate language Running away Self injury Verbal aggression Property damage Stereotypic Behavior Non-compliance Unsafe behaviors Disruption/Tantrums Social withdrawal/ Trouble falling asleep Inconsolable crying isolation Other_____. Activity (check one). Arrival Meals Departure Classroom jobs Quiet time/Nap Clean-up Circle/Large group activity Outdoor play Therapy Small group activity Special activity/ Field trip Individual activity Centers/Indoor play Self-care/Bathroom Other_____. Diapering Transition Others Involved (check all that apply). Teacher Family Member Peers Assistant Teacher Support/ Administrative None Therapist staff Other_____.

2 Substitute Possible motivation (check one). Obtain desired item Gain adult Obtain sensory Obtain desired activity attention/comfort Avoid sensory Gain peer attention Avoid adults Don't know Avoid peers Avoid task Other_____. Strategy/ Response (check one or the most intrusive). Verbal reminder Re-teach/practice Family contact Curriculum modification expected Behavior Loss of item/privilege Move within group Time in different Time out Remove from activity classroom Physical guidance Remove from area Time with support staff Physical hold/restrain Provide physical comfort Redirect to different Other_____. Time with a teacher activity/toy If applicable, administrative follow-up (check one or most intrusive). Non-applicable Arrange behavioral Transfer to another program Talk with child consultation/team Reduce hours in program Contact family Targeted group Dismissal Family meeting intervention Other_____.

3 Comments: _____. _____.