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: D.O.B.:
“Michael”
School: Grade: 5 Self-contained classroom

Safety Concerns:
Physical Aggression Specific behaviours:
Hitting, kicking, biting staff, complaining, engages in self-harming
behaviour: (head-banging on wall/floor, hitting himself), throwing
desks/chairs, lashing out at staff, yelling, crying, running around the
room.

Self-Abuse Trigger events:

 Being exposed to dark and/or claustrophobic-like small
quarters.
Putting self/others in danger  Hunger (arriving to school hungry)
 Frustration due to difficulty in communication.
 Change in schedule
Other:

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

 Institute the use of a picture-communication
board to allow Michael to communicate
needs/wants.
 Allow Michael to choose soothing activities
during class time (cutting & pasting, other
learned interests, etc.).
 Place soothing activity on a schedule (every
hour) to help Michael self-regulate.
 Avoid putting Michael in situations where big
behaviours might be triggered (ex. Dark
rooms, small spaces, etc.).
 Maintain consistent schedule.
 Teach Michael mindfulness strategies to
recognize how he is feeling emotionally and
physically.
 Teach Michael strategies for self-calming.
 Work toward communication with home-setting
to ensure Michael is properly fed throughout
the day.
 Teach Michael how to ask to take a break.
 Teach Michael to move to a provided cool
down location.
 As per the Occupational therapist, Michael to
wear a protective helmet.

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

Observed Behaviour
Stage 1: Anxiety (Increased agitation
or excitement e.g. losing self-regulation)
 Pupils dilate
 Change in facial expression
 Fidgeting with hands
 Complaining about stomach ache
Note: Incidents of physical intervention must be documented.
Staff Response
Supportive:
 Provide small, soft, calming toy
 Redirect by singing “Twinkle, Twinkle, Little Star”, etc.
 Provide a calming activity based on Michaels’ interests
 Encourage taught mindful strategies
 Encourage use of communication board to communicate
needs to prevent further frustration
 Provide cool down location
 Wait for behaviour to subside (Weber, 2017a)
 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
of the loss of Rational Control)
 Screaming, yelling, crying
 May hit, kick or bite staff as a
communication tool
 Crying getting subsequently louder
Stage 3: Acting-Out (Unsafe
Behaviour)
 Kicking, biting, hitting staff in the
face
 Head banging on wall/floor
 Self-harming behaviour (hitting
himself)
 Upending desks, throwing chairs
 Running around the room in a
frenzy
Note: Incidents of physical intervention must be documented.
 If deviated from regular schedule, revert back.
 Encourage Michael to request a break
Directive:
 Redirect him to cutting and pasting or other soothing
activity of interest
 Offer relocation to an Alternative Learning Environment to
attempt de-escalation (Weber, 2017c)
 Move other students away from Michael
 Use supportive posture by maintaining Michael’s personal
space without leaving the room (Weber, 2017a)
 Monitor the safety of Michael, other students and staff
(Weber, 2017a)
 Do not approach Michael as he may lash out at staff.
Maintain safe distance
 Wait for behaviour to subside (Weber, 2017a)
 Encourage use of communication board to communicate
needs to prevent further frustration
 Staff to wear padded sleeves to guard against biting
Non-violent Physical Crisis Contact Office to
Intervention: initiate Emergency
Protocol:
 Request assistance from the
school team (other EA, Principal,
Vice Principal, etc.)  Office to call 911
 Evacuate other students from the according to
classroom parameters
 Maintain space, if possible
  Call institution
Block physically aggressive
assaults (guardian)
 Wait out the behaviour until he
tires out
 Permit Michael to run to the end
of the hallway. Supervise but
give him personal space (Weber,
2017b)
 If Michael leaves the school,
follow, do not chase.
 If Micheal leaves school property,
follow, do not chase. Call the
office
 Intervene immediately if self-
harming
 Staff to wear padded sleeves to
protect against biting
 If head banging, place pillow
under head to prevent injury
 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 4: Tension Reduction: Therapeutic Rapport: Reduction (Re-establishing Rapport and
Debriefing Staff Interventions)

 Once behaviour de-escalates
(Michael is tired and exhausted),
incorporate self-calming
strategies, like cutting & pasting or
other activities he enjoys
 Return to classroom activities
based on self-readiness. Wait a
minimum of 30 minutes (Weber,
2017b)
 Student-led re-engagement
 Staff to congregate to debrief to: assess injuries, support
student, ensure staff are ready to return to class (Weber,
2017c)
 If injury to Michael, call guardian to inform him/her of what
happened and treatment applied
 If injury to staff, treat or take to hospital or clinic
 Later, conduct a full examination of the incident with the
team. Relook at strategies and amend if needed.
Conduct a safety audit to review the classroom and
school environment to determine if a change would
benefit the student (Weber, 2017c)
 Complete required documentation (Violent incident form if
needed, Behavioural log, Accident form) (Weber 2017b)

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

References

Weber, P. (2017a). Individual safety plan [Classroom handout]. Retrieved from

https://slate.sheridancollege.ca/d2l/le/content/416756/viewContent/6115799/View
 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
Weber, P. (2017b). Safety plan [Classroom handout]. Retrieved from
https://slate.sheridancollege.ca/d2l/le/content/416756/viewContent/5865466/View

Weber, P. (2017c). Challenging behaviour and discipline. Week 9 [PowerPoint presentation].

Oakville, ON: Sheridan College.

Note: Incidents of physical intervention must be documented.