INDIVIDUAL STUDENT SAFETY PLAN

An individual student safety plan, unlike a typical behavior plan, addresses

Date: 9/11/19 specific behavior that is dangerous to the student and/or others.
Updated:
10/14/2019

Student Name: Cecillia Holtman DOB: 9/5/11 Synergy ID: 787078 School: Chapman Grade: 2
Special Education Eligible? ☒ No ☐ Yes If yes, Casemanager:      
504 Eligible? ☐ No ☐ Yes If yes, Casemanager:      

Contact Information
Parent/Guardian: Jenifer Morris
Cell Phone: 850-418-5997 Home Phone: na Other:      
Emergency Contact: Alexis Smith Phone: 503-498-7346

Places Student May Be if Missing During School Hours

On School Grounds: auditorium
Off School Grounds: hidden - behind a bush or corner

Medical Information
Physician: Dr. Jim Brown Phone: not listed
Diagnoses:      
Medications: Prozac 20mg 
Allergies/Special Considerations:      

Description of Specific Unsafe Behaviors (why student requires a safety plan)

Cecilia begins to rearrange furniture, hide in unsafe locations or throw books when she no longer wants to engage in
classwork. She will then engage in running and hiding or avoiding adult interaction both in school and off school grounds.
Cecillia has run out of the school and off school property. Cecillia may destroy or misplace classroom or school based items
when upset or seem to disengage completely and look for alternative activities like getting art supplies out or wanting to
lead a play in auditorium.

CRISIS RESPONSE PLAN

What to do if student exhibits above described behavior Who will do what/backup staff
Attempt to de-escalate behavior by offering breaks in and outside of class per Ms. K/Administrator/Counselor(s),
BSP. classroom teacher, available specialist.
Teacher 1:1 discussion in the hall to help de-escalate. Radio for admin or
counselor to escort Cecillia to Mrs. V’s office to calm down The auditorium is a favorite spot to
1. If Cecillia leaves the school grounds mom will be contacted to pick her up hide- custodian will keep all doors to the
2. If Cecillia must leave class to calm down or avoid property destruction or peer auditorium locked whenever it is not in
injury she will work with Ms. K/admin/counselor for 40 minutes or less. If Cecillia use.
cannot safely return to class after 40 minutes mom will be contacted for pick up.

Portland Public Schools Individual Student Safety Plan 1 Rev. 2/2016

Scan and send to studentservices@pps.net
 Warning Signs/Triggers Strategies That Work Strategies That Do Not Work
Hiding in classroom, moving books or Breaks in the calm corner/Ms. Kates Verbal redirection when escalated,
furniture, getting into off limit supplies room or short walks. Spike in the engaging in power struggle or
in classroom, opening cupboards admin's office, snack argument

BEHAVIOR SUPPORTS
What will staff, student, and family do to lessen the likelihood of unsafe behavior (i.e., Who / Back-up person?
supervision, transition planning, transportation to and from school, plan for unstructured
time, closed campus, searches, etc.)?
Ms. K will work on teaching C how to use her calm corner and her telling wheel for calming Admin/Counselor/Classroom
strategies. Ms. K/Counselor/admin will teach Cecillia about safe places to run to when teacher
wanting to leave class (Ms. K’s office or Mrs. Vawters room if escalated.
How will plan be monitored? Who/Back-up person?
Classroom teacher will utilize a behavior tracking chart to monitor safety plan behaviors: Admin/Counselor/Classroom
destroying property, leaving class. When parent must be contacted, referrals will be written teacher
to document.
How will decision be made to terminate the plan? Who/Back-up person?
If Cecillia can successfully make it through 2 weeks of school without needing to contact a Admin/Counselor/Classroom
parent, the plan can be terminated. teacher

Current Agencies or Outside Professionals Involved

Name Agency Phone
1. Dan Rogers Multnomah County 503-314-0574
2. Nicole Christoff WPS      
3.                  
4.                  

Student Safety Team Members

Name/Signature Title Date
1. Kate Leddy TIC 10/14/2019
2. Katy Vawter AP 9/11/19
3. Allyson Sievers teacher 9/11/19
4. Holly Altiero Counselor/Admin Intern 9/16/19
5. Pamela Vanderwolf Principal 9/11/19
6. Ariel Frager Safety Plan Coordinator 9/11/19

Next Review Date: TBD (approximately two weeks from initiation of plan or last review date)

Portland Public Schools Individual Student Safety Plan 2 Rev. 2/2016

Scan and send to studentservices@pps.net