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DOÑA ANA COUNTY HEAD START CHILD
BEHAVIOR INCIDENT REPORT FORM
Children between the ages of 3-5 years old will test and question authority to determine what is and is not
allowed. Developmentally and age appropriate, they will try limits and boundaries to figure out the
expectations and rules of their surrounding environment. Please use your professional judgment.
This form is to be utilized when a child intentionally or unintentionally hurts another child and a Child Accident
Report is completed, or when a child’s behavior(s) becomes persistent and maladaptive to a level that impedes
the child’s learning process or a child who is exhibiting severe/significant aggression towards self or others.
Aggressive behavior includes but is not limited to; biting, pinching, punching, kicking, spitting, scratching and
pulling hair.
Name of child: ________________ Center: ________
Date/day of incident: Time of incident: _____________________
Activity: □ Arrival □ Meals □ Quiet time/Nap □ Outdoor play □ Special activity/ Field trip
□ Self-care/Bathroom □ Transition □ Classroom jobs □ Circle/Large group activity
□ Small group activity □ Centers/indoor play □ Diapering □ Departure □ Clean-up
□ Therapy □ Individual activity □ Other_______________________________________________
Who witnessed incident? ________________________ Adults present: ________________________________
Name Name
Describe the occurrence: _______________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Strategy/Response: (Please specify; verbal reminder, provided physical comfort, reteach/practice expected
behavior etc.,)
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Did child injure another child? □ Yes □ No
Was a Child Accident Report Form completed for the other child? □ Yes □ No
Report prepared by: __________________________________________________________________________
Name & Signature
Was the parent/guardian notified? □ Yes □ No
Signature of Parent/Guardian _______ _ _ _ _ _ _ Date ________ __
ENTERED INTO CHILDPLUS
By: __________________
Date: ________________
- THIS FORM MUST BE COMPLETED AND SIGNED BY STAFF MEMBER & PARENT ON THE SAME DAY
OF THE INCIDENT
- PROVIDE PARENT WITH A COPY OF THE INCIDENT REPORT
- RETURN ORIGINAL TO MENTAL HEALTH SPECIALIST FOR CHILDPLUS ENTRY
- FORM WILL BE RETURNED TO THE CENTER FOR FILING IN CHILD’S FILE
PLEASE USE FIRST AND LAST NAMES FOR CHILD, WITNESSES, TEACHER, OTHER ADULTS PRESENT