Teacher:_________________________ Time:_______________

Student behavior prior to the incident:

Description of incident:

Did behavior endanger the safety of students or disrupt the learning environment? If yes, how?

Description of teacher action to correct the misbehavior:

Results of action:

Remarks:

Parents notified: ___Yes  ___ No

Signatures

Teacher: ____________________________

Principal: ____________________________

Witness: _____________________________

Parents: _____________________________