Incident Report

Hospital Schools 3450 East Tremont Avenue Bronx, New York 10465 The New York City Department of Education

Phone 718-794-7260 Fax 718-794-7263

Mary Maher, Principal

Steven Klein, Assistant Principal Cynthia Blondi, Assistant Principal

PBIS INCIDENT FORM - SCHOOL:_____________SITE:_______________ DATE OF INCIDENT __________________________

TIME OF INCIDENT __________________________________

PreK K 1 2 3 4 5 6 7 8 9 10 11 12 (circle one)

STUDENT______________________________________

GRADE:

OSIS #: ___________________________

DOB: ____________________

REFERRING STAFF________________________________ TITLE ______________________ OFFICIAL CLASS_______ DATE OF INCIDENT __________________________ TIME OF INCIDENT __________________________________ TEACHER ASSIGNED AT TIME OF INCIDENT ___________________________FILE #:___________________________ WITNESSES: ________________________________________ LOCATION (check only one)  Classroom___________  Cafeteria  Bathroom  Hallway/Stairway  Common Area________  Gym PROBLEM BEHAVIORS MINOR  Inappropriate language  Physical contact  Defiant/ Disrespectful/ Non Compliant

(Check the most intrusive) MAJOR  Abusive/Inappropriate lang.  Fighting/Physical aggression  Defiant/Disrespectful/ Insubordinate/Non-Compliant  Property Damage  Harassment/Bullying  Forgery/Theft

 Disruption  Property misuse  Other ______________ POSSIBLE MOTIVATION (check only one)  Obtain peer attention  Obtain items/activities  Obtain adult attention  Avoid tasks/activities OTHERS INVOLVED (check only one)  None  DOE Staff  Peers  Agency Staff ADMINISTRATIVE DECISION (check only one)  Conference w/student  Agency contact ___________  Loss of privilege  Time out of class OTHER INFORMATION

 Special Event, e.g., Assembly, Field Trip  Office (Administrative)

    

Disruption Inappropriate Affection Technology Violation Inappropriate location Tobacco

Other ________________

       

Alcohol Drugs Combustibles Vandalism Bomb Threat Arson Weapons Other Behavior _________

 Avoid peers  Avoid adults

 Don’t know  Other _________________

 Substitute  Unknown

 Other _________________

Extra Information 1:______________________________________________________________ Extra Information 2:______________________________________________________________ Extra Information 3:______________________________________________________________ COMMENTS:

DOE Staff’s Signature: ___________________________________ Date: _______________

PLEASE FAX TO YOUR SUPERVISOR IMMEDIATELY: (718) 794-7263

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