Individual Safety Plan*

* to be made available to all staff including occasional teachers/TAs in the event that there is a risk of safety
to self / others and to be reviewed regularly

Student: Kerry-Ann, Jacqueline, Cynthia and D.O.B.:

Kamoi

School: Grade: 4

Safety Concerns:
Physical Aggression Specific behaviours:
Hitting, kicking, drops to the floor, throwing furniture and takes a
long time to calm down.

Self-Abuse Trigger events:

Being last in line
Wanting a specific toy
Putting self/others in danger Not being able to access stuff in the class room
Not wanting to share materials
Other:

Critical Proactive Supports as outlined in IEP: (i.e. supportive, proactive interventions)

Using social story to teach her that Its ok to be last
in line.
Its ok to let someone else have a toy
Teaching her its ok to have task not completed
Use first and then strategy to teach her that she needs
to complete her task first then, she might be allowed
to access stuff in the classroom.

Cool down bin (has complete 3 activities to move

on to the next task)

Escalation Cycle: ( i.e. staff will implement the following procedures)

Observed Behaviour Staff Response
Stage 1: Anxiety (Increased agitation Supportive:
or excitement e.g. losing self-regulation
Provide lots a support
Tapping Redirect by using first and then
Shaking of the head Show empathy and listen attentively
Language barrier (ESL) Avoid being judgemental
Kicking
Hitting

Note: Incidents of physical intervention must be documented.

 Individual Safety Plan*
* to be made available to all staff including occasional teachers/TAs in the event that there is a risk of safety
to self / others and to be reviewed regularly
Stage 2: Defensive (beginning stages Directive:
of the loss of Rational Control) Isolate the area by removing the staff and students
ensuring their safety.
Drops herself to the ground Give her time to calm down
Taking a long time to complete Giving her limited choices by choosing between two
task given things
Give her time to complete her task

Stage 3: Acting-Out (Unsafe Non-violent Physical Crisis Contact Office to initiate

Behaviour) Intervention: Emergency Protocol:

Wetting herself on purpose. Avoid physical contact with

Aggression to staff and students. the student. At this stage staff needs to
Hit and kick staff and students. Remove staff and students contact the office.

Throwing furniture. away from the area for

Self injury by biting herself or safety.
hitting her head. Allow time for her to calm
down.
Monitor her for safety.

Stage 4: Tension Reduction: Therapeutic Rapport: Reduction (Re-establishing Rapport and

Debriefing Staff Interventions)
Laying on the floor crying Being calm and reassuring
Want to rejoin the class Showing empathy
Give her a hug
Telling her its ok next time just tell me how you feeling

Note: Incidents of physical intervention must be documented.

 USE OF PHYSICAL RESTRAINT REPORT
STUDENT INFORMATION

Name: D.O.B.:

School: Classroom
Placement:

DESCRIPTION OF INCIDENT

Date: Time: Location:

Staff Member(s) Involved in the Use of

Restraint and date of training for Critical
Education Intervention:

Witness(es) (if applicable):

Precipitating Circumstances:

Description of Injuries/Damage:

Restraint Used and Any

Injuries Incurred:

Community Personnel Notified:

(e.g. medical, police, etc.)

Next Steps:

Name of Parent (Guardian) Notified: _______________________Date: ________________

Parent (Guardian) Notified by: ______________________
Signature of Principal: ____________________________ Date: _________________
c.c. Superintendent of Education