Behaviour Guidance Incident Form
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Incident Record for <insert child’s name>
Drop off
Parents/ caregiver to fill out
Drop off time : ______________________ Who dropped off?__________________
How did he/she sleep?
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What did he/she eat this morning?
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What has his/her mood been like?
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Educator to fill out
What was he/she like at handover?
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How long does it take to settle in the room? ________________________________
Description of incident
This section has been prepared for a child that has seizures. You may need to adjust this section based on the needs and behaviour of child
Educator to fill out
| Location: ______________________ | Time:________ to ________ | |
| Temperature of the room/ outside: ______________________ | Number of children: _____________ |
What was his/her mood like before this occurred? ________________________________________________________________________________________________________________
Who was he/she with?
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Please Circle.
What was the environment like? Loud/ Quiet/ Busy
Hands: manipulating a toy/ kept still Eyes: Glassy/ Shut/ Blinking
Communication: Verbal/ Non Verbal/ Nodding and or shaking
Head: Down facing chest/ Tilted to side/ Straight ahead Was he/she lethargic after episode?: Yes/ No if so, how long?:__________
Mouth: Open/ Closed
Description of events leading up to incident:
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Description of incident: (please include as much detail as possible).
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Any other notes:
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