Name:

Refl

Date:.......Afternoon classes

ective Behavior Record

Time (Checkone):
Class

Morning classes

-Before Lunch

After school

class Cafeteria -ln -In

tocation (Check one):

the hall school area

If in other school area oroffschool

-0ther

-Restroom -Off grounds, then where?

school grounds

-P'E.

Trigger (Checkone):

jo*"one

-So*"one

did something I didn't like Someone said something I didn't like Someone took something of mine told me to do something shoved me/ uPset me (Check one):

-someone

-Other: Who was that "someone'?

Administrator

student

Teacher

-substituteteacher

What did You do? fCheck one):

-lntern

-Other:
-Talked
Threatened him/her backlargued Other:

him/her

it out
CornPlY

-Hit it -Complied 1,214

to -Talked Something

-Refused

-Broke -n"poited How angrywere You? (Circle one):

would you use this response in the future? (check one):
If no, then whatwouldyou do if this happens again?

-Yes -No