Oregon Area School District: OMS Behavior Intervention Form... http://www.oregonsd.org/schools/oms_bif_pbis.

cfm

OMS Behavior Intervention Form (ONLINE)

OMS Behavior Intervention Form:

OMS Behavior Intervention Online Form

Form used for detentions, documentation of incidents, office referrals and other behavior related
incidents. This form is in compliance with PBIS research and SWIS data format
1. Form Type
*
If you are referring a detention or office referral, be sure to call home and document the information on the
form so that this can be processed.
Document Detention
Office Referral Other
2. * Student Name

3. Grade/Team

4. * Date and Time of Incident:

5. * Referring Staff

6.
*
Location of Incident (1 required)

Classroom Cafeteria
Computer Lab Bathroom
Library Locker Room
Hallway Bus Area
Playground Study Hall
Other
7. Location Other (if you selected other above)

8. Repeated Infraction (if you select Yes, then please attach your previous referrals,
strategies, conversations, documentation, so that this can be processed)
No Yes
9. * Behavior (1 required)
Inappropriate Language Physical Contact/Aggression
Defiance/Non-Compliance Disruption
Dress Code Property Misuse
Tardy Electronic Violation
Other
10. Behavior Other (if Selected "other" in Behavior Column) Please write what the 'other'
behavior is in box.

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Oregon Area School District: OMS Behavior Intervention Form... http://www.oregonsd.org/schools/oms_bif_pbis.cfm

11. Automatic Office Referral (select this only if you are referring to the office, if behavior is
in the "Behavior" column it is not an officer referral, unless you have previously referred
student and have supporting documentation)

12. Automatic Office Referral Other (if Selected "other" in Office Referral Column) Please
write what the 'other' behavior is in box.

13. Possible Motivation ( It is important that we try and identify motivation for
students. It has become more evident through research that they don't just
(1
* 'choose' to be 'bad' there are underlying circumstances. Figuring those out is
required)
part of creating a positive environment and the teaching necessary for our
students to be successful)
Obtain Peer Attention Obtain Adult Attention
Obtain Items/Activity Avoid Peer
Avoid Adult Avoid Task/Activity
Don't Know Other
14. Other Motivation (if selected other for motivation please fill in what 'other' is text box)

15. NVCI Behavior Level at Beginning of Incident ( Since we have all received NVCI
Training - we have learned the importance of non-threatening behavior to resolve
* situations. Yelling at students or getting into arguments is not effective. NVCI trained us
to identify the behavior of a student and choose the appropriate response so that we
diffuse the situation. Afterall, we are the adults, they are the students. We know better.)

16. * NVCI Behavior Level at End of Incident

17. Staff Incident Report (Who, What, Where, When, Why - Specify times, places, those
* involved,what happened before, during and after the event and initial steps to address the
problem, include any suggested actions for administration or restorative practice.)

Parent Contact (Contacting parent or guardian for office referrals or detentions is required before further action is taken with this form.)
18. Name of Parent/Guardian Contacted:

19. Phone Number

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Oregon Area School District: OMS Behavior Intervention Form... http://www.oregonsd.org/schools/oms_bif_pbis.cfm

20. Date and Time of Call

21. * Left Message (1 required)

Spoke to Parent Guardian Left Message
22. Comments/Notes from Phone Call

Submit Reset

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