Skip to main content
Login
Top Navigation Menu
Home
About
District
Bulletin
Lunchroom
School Board
School Board Publications
Policies, Forms & Handbooks
School Calendar
Media Center
Overdrive Ebooks
Yearly Testing Schedule
MCA Testing Schedule
Parents
Parent VUE
SchoolPay-pay bills online
BRIC Special Ed Services
Meals Application
Student Enrollment Form
Students
Classlink
Student VUE
Clubs and Organizations
Financial Aid Information
Athletics
Mustang Sports
Sportsmanship
Spirit Store
Sports Physical Form
Staff
Staff Resources
Staff & Teacher Pages
Old School
Events and Rentals
Daycare
Early Childhood Center
Businesses
Community
Alumni
Community Education and Wellness
Community Service
Employment
Job Listings
Superintendent Search
Job Application
Background Check Application
Kelliher School — Classroom Incident Form
Kelliher School — Classroom Incident Form
MUSTANG PRIDE · Rigor · Relevance · Respect
Section 1 — Student & Incident Information
Student Name
*
Teacher Name
*
Date
*
Period
*
Select...
Homeroom
Period 1
Period 2
Period 3
Period 4
Period 5
Period 6
Period 7
Before School
After School
Other
Course / Location
*
Incident number for this behavior this quarter
−
1
+
1st incident
Section 2 — Behavior Observed
Behavior(s) observed
*
Tardy
Unprepared / Missing Materials
Disruption
Put-Downs / Inappropriate Language
Insubordination
Refusing to Work
Throwing Object
Academic Dishonesty
Dress Code Violation
Unauthorized Electronic Device
Unauthorized Food or Beverage
Other (describe below)
Describe what happened
*
— factual and objective
Antecedent
— what was happening before?
Possible motivation
Attention-seeking
Avoidance / Task refusal
Peer influence
Sensory / Emotional regulation
Unknown
Section 3 — PBIS Interventions Used
PBIS Reminder:
Document behavior only after proactive prompting and re-direction have been attempted. Focus on re-teaching the expected behavior — be consistent and patient.
Interventions used
*
Positive re-direction
Re-taught expected behavior
Proximity / Nonverbal cue
Verbal warning
Student conference (1:1)
Offered choice or break
Seat change
Counselor referral
Detention
Phone call home
Email home
Other interventions or notes
Section 4 — Student Response & Outcome
How did the student respond?
*
Resolved at classroom level?
*
Select...
Yes — resolved in class
No — behavior continued or escalated
Partially resolved
Section 5 — Parent / Guardian Contact
Required
for all classroom-managed behaviors. Contact parent before submitting an office referral.
Contact made?
*
Select...
Yes
No — attempted, no answer
No — will contact tomorrow
No — other reason (explain below)
Date of contact
Method
Phone call
Email
In person
Spoke with
Notes / summary
Section 6 — Admin Referral (3rd Incident)
This is the 3rd incident.
Complete this section and submit all three incident forms to the Dean of Students. The referral is now Admin-managed.
Behavior being referred
Documentation being submitted
Incident 1 form attached
Incident 2 form attached
Incident 3 form (this form)
Summary of all interventions attempted this quarter
Clear form
Submit report
✓
Report submitted
New report
Print / Save as PDF
Action Required
Okay
