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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