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.:
Amy
School: ABC School Grade: JK

Safety Concerns:
Physical Aggression Specific behaviours:
Crawling on the floor
Growling at staff and students
Punching with a closed fist and kicking
Flops to knees and flailing arms and legs

Self-Abuse Trigger events:

Lots of people
DPA
Putting self/others in danger When she doesnt get her way
Being asked to do something she doesnt want to do (e.g. gluing the
car onto the graph)
Other:

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

Teach alternative ways to ask for a break Use PECS or a hand gesture (i.e. time out)
Relax expectations Allow her to do tasks in small groups
Use visual performance strengths to Use PECS, use fewer words and simple
express her needs. language

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)
Engage in empathic and active listening
Crawling on the floor Avoid being judgemental
Growling at staff and students Provide space

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)
set clear limits in a positive manor and ensure they are
Says I hate you Go away enforceable.
Falling to the floor isolate the situation (move others away)
Flailing arms and legs wait out the behaviour
provide non-verbal support
make no demands

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

Behaviour) Intervention: Emergency Protocol:

Punching with a closed fist Isolate the situation (move

others away)
Create a safe space
Block and move
Provide non-verbal support
Make no demands
Supervise the situation; if
situation escalates call
office for help

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

Debriefing Staff Interventions)
May approach staff for
reassurance or assistance Provide non-verbal support
Follow the students lead as to when they are ready to
resume activities with the class

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