Primary School Incident Report Form Example – [Edit & Example]

Date and Time of Incident: January 22, 2025, at 11:45 AM
Location of Incident: Classroom 4A, Sunnydale Primary School
Person Reporting the Incident: Helen Baxter, Classroom Teacher
Details of Involved Individuals:

• Noah Thompson – Student, Grade 3
• Olivia Sanchez – Student, Grade 3

Witnesses:

• Amy Lee – Teaching Assistant
• Ethan Clark – Student, Grade 3

Description of Incident:
During a group activity, Noah Thompson and Olivia Sanchez had a disagreement over sharing art supplies. The argument led to shouting and minor physical contact (pushing), which was quickly noticed and intervened by the classroom staff.

Immediate Actions Taken:

• Both students were separated and spoken to individually about their behavior.
• Calming strategies were used, and both students were given a short time-out to reflect on their actions.
• The classroom teacher facilitated a discussion between Noah and Olivia to resolve their differences and share more effectively.

Follow-Up Actions:

• Conduct a class lesson on sharing and cooperation to reinforce positive social behaviors.
• Monitor Noah and Olivia’s interactions over the next few weeks to ensure a positive change in behavior.
• Engage parents in a discussion about the incident and the importance of reinforcing positive behavior at home.

Signatures:

• Helen Baxter (Reporter)
• Mark Jennings (Principal)

Additional Notes:
The situation was resolved peacefully, with both students apologizing to each other. They participated in the remainder of the group activity without further issues. This incident will be documented in both students’ records, and continuous support will be provided to develop their interpersonal skills.