Calming Room Report

Student Information
Name: ______________________________________________________________

Age:___________

School/Grade/Class:
Description of Incident
Date of Incident: __________________________

Time of Incident:____________________________

Staff Member(s) Involved:

Job/Position:

1.

_________________________________

_________________________________

2.

_________________________________

_________________________________

Witness(es), if Applicable:________________________________________________________________________
Location of Incident:_____________________________________________________________________________
Total Duration in Calming
Room:________________________________________________________________________________________
Strategies Employed Prior to the use of the Calming
Room:________________________________________________________________________________________
______________________________________________________________________________________________
Events Precipitating the
Crisis:_________________________________________________________________________________________
______________________________________________________________________________________________
Was Physical Intervention used?

YES

Was the student escorted to the Calming Room?

NO
YES

NO

If yes, by whom: ______________________________________________________________________________

Follow Up:
Plan for Tension Reduction: (i.e. therapeutic rapport, revision of safety plan, etc)
______________________________________________________________________________________________
______________________________________________________________________________________________
School Administration Notified:

Date:______________________

Time:__________________________

Parent(s)/Guardian Notified:

Date:______________________

Time:__________________________

Signature of Principal:_______________________________________

Date:__________________________

Report completed by:________________________________________

Date:__________________________

Personal information is collected pursuant to the Education Act, as amended, and will be used towards the prevention of future
incidents. See the School Principal for more information.
FILE: Original to OSR
RETAIN: Current school year + 12 months