STUDENT INCIDENT REPORT FORM – PBPS
STUDENT INCIDENT REPORT FORM
Punchbowl Primary School
Student Name: __________________________________ Class: ____________________
Date of Incident: ___________________ Time of Incident: _______________
Reporting Teacher: ________________ Witness: ______________________
TIME OF INCIDENT:
1.(Before School 2.( Recess 3.(First Lunch
4.(Second Lunch 5.(After School 6.(In School
PLACE OF INCIDENT: I. (Infant Toilets T. (Primary Toilets
N.(Netball Court O.(Main Oval F. (Flagpole area
E.(Play Equip Area C. (Classrooms A. (Asphalt Area
H.(Hit Up Wall Area B. (Out of Bounds S. (Shade Area
L. ( Little oval(cricket nets) M.(Multi P/Room
UNACCEPTABLE BEHAVIOUR:
Incident description:________________________________________________________________
__________________________________________________________________________________
Teacher communication mode (please circle): Educate Counsel Coach Confront
Type of Behaviour: (Bullying (Harassment (Teasing
Behaviour: (Body (Damage to Property (Exclusion (Racial
(Extortion (Gesture (Littering (Non Co-operation
(Physical (Psychological (Verbal (Written
ACTUAL CONSEQUENCE:
Time out seat:___________________________(length of time)
Shadowing:_____________________________(length of time)
Area exclusion:_________________________________________________(where/length of time)
NB. If Consequence is ongoing, please write on whiteboard in staffroom.
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