Free Student Behavior Incident School Report Template
Student Behavior Incident School Report
Date: May 3, 2055
Student Name: Taylor Johnson
Grade/Year: 8th Grade
Teacher/Staff Reporting: Ms. [Your Name]
Incident Location: School Cafeteria
Time of Incident: 12:15 PM
Incident Summary
At approximately 12:15 PM, Taylor Johnson engaged in disruptive behavior in the cafeteria by throwing food at another student during lunch. This action caused a significant disturbance among students and staff present. When approached by the cafeteria supervisor to cease the behavior, Taylor responded with inappropriate language, further escalating the situation.
A. Individuals Involved:
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Taylor Johnson (Offender)
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Jamie Lopez (Affected Student)
B. Witnesses:
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Liam Carter (8th Grade, Student)
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Sara Nguyen (Cafeteria Supervisor)
Actions Taken
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Immediate Action:
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Taylor was escorted from the cafeteria to the principal’s office by staff.
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The affected student, Jamie Lopez, was provided support and removed from the situation for safety.
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Parent Notification:
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Taylor’s parents were contacted by phone at 2:00 PM and informed of the incident.
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Scheduled Interventions:
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A behavioral counseling session was arranged for May 5, 2055, at 3:00 PM with the school counselor.
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Peer mediation between Taylor and Jamie is scheduled for May 6, 2055, to promote reconciliation and accountability.
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Follow-Up Notes
Taylor expressed remorse during a follow-up meeting with the principal and agreed to actively participate in the scheduled counseling and mediation sessions. A written apology to Jamie Lopez is expected by May 4, 2055.
Signatures
Reporting Staff Member:
Ms. [Your Name]
Date: May 3, 2055
Principal’s Approval:
Mr. Daniel Greene
Date: May 3, 2055
