Behaviour Incident Form Aggressor Target Name(s): Name(s): Date: Person Completing Form: Type: Against an Adult (Y or N): Non-Prejudice - Emotional Form of Bullying: Non-Prejudice - Physical Actual Physical Assault Non-Prejudice - Sexual Comment general Prejudice - Age Cyber - text, email, social networking Prejudice - Disability Damaging, Hiding or Stealing Property Prejudice - Gender Re-assignment Displaying Badges, Slogans or Propaganda Prejudice - Marital Status/Civil Partnership Excluding from Group Prejudice - Pregnancy Extortion Prejudice - Race Graffiti Prejudice - Religion/Belief/Non Belief Indirect (ignoring) Prejudice - Sex or Gender Name Calling or Similar Prejudice - Sexual Orientation Physical Contact Session (Time): Who Reported: How Reported: School Before School Parent/Carer Breaktime Pupil at the receiving end Correspondence During Lessons Witness - Pupil(s) Email Lunchtime Witness - Teacher or other adult In Person Location: Telephone Classroom PE Changing Rooms Corridor Playing Fields Dining Room School Grounds or Playground On Bus to/from School Toilets Outside School Walking to/from School OFFICE USE Outcome: Resolved - Bullying Resolved Not Bullying – Action Fixed Term Exclusion Resolved - Prejudice Taken: Group Work Resolved - Not Prejudice Individual Work Resolved - Aggressor Withdrawn Internal Sanction Resolved - Target Withdrawn No Further Action Required Unresolved Bullying – Aggressor Unresolved Prejudice – Contacted Unresolved - Aggressor Withdrawn Parent/Carer Target Unresolved - Target Withdrawn Contacted LA Involvement Permanent Exclusion Progressed to Agency Restorative Meeting Police Involvement Section 47 (Child Protection) Staff Member _____/______/_____ responsible for outcome: Date:
Behaviour Incident Form Aggressor Target Name(s): Name(s): Date: Person Completing Form: Type: Against an Adult (Y or N): Non-Prejudice - Emotional Non-Prejudice - Physical Non-Prejudice - Sexual Prejudice - Age Prejudice - Disability Prejudice - Gender Re-assignment Prejudice - Marital Status/Civil Partnership Prejudice - Pregnancy Prejudice - Race Prejudice - Religion/Belief/Non Belief Prejudice - Sex or Gender Prejudice - Sexual Orientation Form of Bullying: Actual Physical Assault Comment general Cyber - text, email, social networking Damaging, Hiding or Stealing Property Displaying Badges, Slogans or Propaganda Excluding from Group Extortion Graffiti Indirect (ignoring) Name Calling or Similar Physical Contact Session (Time): Who Reported: How Reported: School Before School Breaktime During Lessons Lunchtime Parent/Carer Pupil at the receiving end Witness - Pupil(s) Witness - Teacher or other adult Correspondence Email In Person Telephone Location: Classroom PE Changing Rooms Corridor Playing Fields Dining Room School Grounds or Playground On Bus to/from School Toilets Outside School Walking to/from School Resolved - Bullying Resolved – Not Bullying Resolved - Prejudice Resolved - Not Prejudice Resolved - Aggressor Withdrawn Resolved - Target Withdrawn Unresolved – Bullying Unresolved – Prejudice Unresolved - Aggressor Withdrawn Unresolved - Target Withdrawn LA Involvement Progressed to Agency Police Involvement Section 47 (Child Protection) OFFICE USE Outcome: Fixed Term Exclusion Group Work Individual Work Internal Sanction No Further Action Required Aggressor Contacted Parent/Carer Target Contacted Permanent Exclusion Restorative Meeting Action Taken: Staff Member responsible for outcome: Date: _____/______/_____
behaviour-incident-recording-form.docx