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PBIS Minor Report Form

Teacher:

Date:

Time:

Grade:

Student:

Incident

Incident Location:

If Other:

Incident Description:

Prior Teacher Action Taken:

Teacher Intervention for current incident (What/When?):

Possible cause/function for behavior:

Revenge:

Attention:

Power/Control:

Inadequacy/Avoidance:

Reason for function of behavior checked above, if know:

* Indicates Required fields.

Send a copy of the completed form to this email address :

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