Student safety plan template

1 STUDENT SAFETY PLAN

STUDENT NAME: _______________________________

D.O.B.: ______________________

SCHOOL NAME: ________________________________

DATE: _______________________

OBJECTIVE: To ensure that staff working with _____________________________ are aware of responses and safety procedures to maintain an productive learning environment for _________________, students, and staff.

RATIONALE: On occasion ___________________ will _________________________________ ____________________________________________________________________________ ____________________________________________________________________________

STAFF WORKING WITH _________________________ MUST READ AND SIGN THE FOLLOWING SAFETY PLAN. THE PLAN WILL ADDRESS SHORT AND LONGTERM ACTIONS REQUIRED TO ENSURE ________________________ SAFETY AND THE SAFETY OF STUDENTS AND STAFF. THE PLAN IMPLEMENTATION MUST BE FOLLOWED BY REVIEW.

This plan is adapted from SD33 Chilliwack’s safety plan.

2 Prior Events (warning signs)

Strategies

(prior situations that might difficulty for the student during the day. i.e. missed breakfast, changes in medication, negative interactions at classmates or family members, allergies, illness…)

(Immediate actions to take when the student presents as anxious, unwell or upset. i.e. steps to prevent escalation, change in schedule, alternate activities, discussion, medication…)

Antecedents (triggers that provoke)

Strategies

(Actions or event that often occurs immediately before a problem behaviour. i.e. verbal overload, non-preferred task demand, noisy environment, unstructured social situation, student perception, change in routine…)

This plan is adapted from SD33 Chilliwack’s safety plan.

(immediate actions that might help to prevent escalation. i.e. warning before transition, breaks outside classroom, regulating exercises, correct tone of voice…)

3

Precursor (what you see)

Staff responses (what you do)

Anxiety (noticeable increase or change)

Be supportive (empathetic, nonjudgemental)

Defensive (cues that this student is beginning to lose the ability to think or process)

Be directive (set simple, clear, enforceable limits)

Acting Out (risk to self or others)

Crisis intervention 1. Keep a safe distance.

2. Clear the area 3. Assign one person to direct the actions of intervening adults 4. Physical restraint strategies as a last resort when there is a danger to self or others.

Tension Reduction (cues that this student is calm)

Therapeutic rapport (re-establish rapport, do not recriminate)

This plan is adapted from SD33 Chilliwack’s safety plan.

4 OTHER MEANS TO MINIMIZE RISK: It is essential to consider any environmental factors that may affect risk, such as the wearing of clothing or jewelry, the positioning of furniture and doorways/exits, and any loose objects that might affect safety) ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________

CRITERIA FOR CALLING HOME: (be compassionate and objective in your language) ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________

POST INCIDENT DEBRIEFING: (ensure all involved employees are included) ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________

This plan is adapted from SD33 Chilliwack’s safety plan.

5 REINTEGRATION PLAN IF REQUIRED: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ THIS PLAN WILL BE REVIEWED: • •

Regularly by the principal or designate.

If there is any change in behaviour that occurs and/or that presents new safety risks to staff and students.

A SAFETY PLAN MEETING WILL BE CONVENED: •

Given new information is reported and/or noticed that indicated the plan should be reviewed or modified.

I have read this plan and am aware of safety procedures to follow when working with ___________________________________.

Signature:

Title:

Date (M/D/Y):

____________________________ ____________________________ ______________ ____________________________ ____________________________ ______________ ____________________________ ____________________________ ______________ ____________________________ ____________________________ ______________ ____________________________ ____________________________ ______________ ____________________________ ____________________________ ______________ ____________________________ ____________________________ ______________ ____________________________ ____________________________ ______________ ____________________________ ____________________________ ______________

This plan is adapted from SD33 Chilliwack’s safety plan.