Safety Plan

SAFETY PLAN
Student: Frankie @ Alma Public School

Category
Risk of injury behaviour:
d.o.b. 10/8/2002
Specific behaviours:
Triggers: During lessons, during transitions, during lunch/recess,
being told no or stop
Physical Aggression
Self-Abuse
Putting self in danger
Other
Specific Behaviours: Begins with teasing other students at lunch

and recess, verbally assaulting other students, hitting and
slapping at recess/lunch/class
Indicators of imminent risk of

injury behaviour:
- Facial ticks
Non-Physical intervention methods to be used in response to

indicators:
- quickly move away from others
- Defiance and swearing

- Any verbal aggression towards
- redirect Frankie using other tasks

- reinforce positive language
- bring student outside classroom (e.g. going for a walk, going to
others
sensory room)
- verbally direct Frankie to ALE room
Intervention Team (Staff)
Mr. Filch (teacher)
Safety Intervention
Using Physical Containment
Description of Physical Containment
UMAB Trained
techniques to be used:
Yes
- Mrs. P is called for support to where the
Ms. Charlton (EA)
Yes
incident is occurring. If not available Mrs. K or
Mrs. P (Behavioural EA)
Yes
Mr. W is called for support.
Mrs K. (Principal)
Yes
Mr. W (Vice-Principal)
Yes
Team member responsible for monitoring

students condition during restraint:
Mr. Filch responsible for monitoring Frankies
condition during restraint.
- Mr. Filch directs restraint procedure, Mrs. P

preforms restraint procedure
- (If able) Mrs. P verbally asks Frankie to come

out in to the hall; If Frankie continues to hit
herself in the hall, Mrs. P is to perform restraint
procedure
- (If not able to verbally) Mrs. P gently guides

Frankie into the hall; If Frankie continues to hit
herself in the hall, Mrs. P is to perform restraint
procedure
- (If able) bring Frankie to ALE room

- (If not able) to remove student from classroom,
follow physical restraint procedure:
- Physical Restraint Procedure

- If Frankie continues to hit herself or others Mrs.
P is to perform basket hold and release;
continue until student is calm.
- If unable to clam, hold and notify office to call

Mother
Note: Basket hold- Frankie arms are crisscrossed
across her chest and her hands are help by Mrs.
*Resource for basket hold explinationwww.blisstree.com
Note: No protective equipment required as of now.
Physical Containment will be discontinued when:
- Frankie is able to calm herself and we are able to bring her to ALE room
- Containment will continue until Frankie is calm, if Frankie continues with self-harm continue and call
mother
Additional Support (including calling 911) will be requested when:
- Frankie is unable to calm herself, all restraints have been exhausted with little to no improvement in
Frankies behaviour.
Immediate Follow-up to Use of Containment
Procedure to be followed in case of injury:
- If Frankie is injured, contact mom, notify her
Responsibility for
Assessment of Injury:
Ms. Charlton
If necessary, Mrs. P and principal.
about the situation that occurred, extent of the

injury and what is being done (e.g. ice is being
applied) or call 911 for assistance.
- For staff injury, first aid treatment or escort to

doctors or hospital. Complete an
Accident/Injury Form and Violent Incident Form.
Reassurance & follow-up support for student:
- Ensure 5 consecutive minutes of non-violence behaviour in ALE room before giving choices to
Frankie on what to do to calm down or relax
Choices options: going for a walk, completing puzzles (e.g. mazes), calming exercises
- Provide at least 25 minutes of rest before Frankie returns to class

Responsibility for
Responsibility for
Communication with Administration:

Mr. Filch
Communication with Parents:

Mr. Filch or Principal
Communication with agency, CAS, etc:

Mr. Filch
Ongoing Follow-up to Use of Containment
Documentation to be completed:
Board Response:
Accident/Injury
Form
and
Violent
Incident
Form
(describe circumstances for the following)
(if Frankie or staff is injured, if mom or 911 is
called)
- Suspension occurs after 2 incidents of physical

harm has occurred to another student or an
- Behavioural log - document with detail every

-
behaviour that occurred during incident and

triggers noticed
Behaviour Tally Sheet - completed daily about
adult
- Denial of access to classroom

- Denial of access to recess if behaviour occurs
the behaviours that occurred
during the eating portion of break

Mom is contacted about behaviour, voluntary
withdrawal if planned and mom is available
Debriefing & Review Procedures for Staff:

- All staff describe their actions that were
Ongoing Staff Support Plan:

- Monthly meetings with mother regarding
involved in incident
- Review possible changes to physical

intervention
- Review prevention strategies - observation of

triggers of incident
- If injury has occurred, review completed

incident forms
behavioural log and behaviours that have been

seen at home.
Principal meets with staff as a team to discuss
progress and observations made.
- Principal meets with staff individually to monitor

staffs stress and give staff appropriate support
if needed.
- Review and debrief about daily behaviour tally

-
sheet weekly
Review and debrief about behavioural log
weekly
Participant
Family:
- Mother - Primary Contact
- Grandma - Secondary
Development of the Safety Plan

Name(s)
- Cindy - contacted in case of injury or report of behavior

- Kelly - grandma (Cindys mom) in case mom is not available
Contact
- Father
- Siblings
School Staff:
- Educational
- Educational Assistants
- School
- Bob - has not been able to get ahold of

- Samantha and David - Frankie is the eldest
- Mr. Filch - Teacher

- Ms. Charlton (EA in classroom), Mrs. P (Behavioural EA)
- Mrs. K (Principal), Mr. W (Vice-Principal)
Principals Signature & Date
Parents Signature & Date

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What behaviors does the safety plan aim to address?

What behaviors does the safety plan aim to address?

What non-physical and physical intervention methods are outlined in the safety plan?

What non-physical and physical intervention methods are outlined in the safety plan?

SAFETY PLAN

Student: Frankie @ Alma Public School

Specific Behaviours: Begins with teasing other students at lunch

Indicators of imminent risk of

Non-Physical intervention methods to be used in response to

- Defiance and swearing

- redirect Frankie using other tasks

- verbally direct Frankie to ALE room

Intervention Team (Staff)

Mr. Filch (teacher)

Ms. Charlton (EA)

incident is occurring. If not available Mrs. K or

Mrs. P (Behavioural EA)

Mr. W is called for support.

Team member responsible for monitoring

- Mr. Filch directs restraint procedure, Mrs. P

- (If able) Mrs. P verbally asks Frankie to come

- (If not able to verbally) Mrs. P gently guides

- (If able) bring Frankie to ALE room

- Physical Restraint Procedure

- If unable to clam, hold and notify office to call

about the situation that occurred, extent of the

- For staff injury, first aid treatment or escort to

- Provide at least 25 minutes of rest before Frankie returns to class

Communication with Administration:

Communication with Parents:

Communication with agency, CAS, etc:

- Suspension occurs after 2 incidents of physical

- Behavioural log - document with detail every

behaviour that occurred during incident and

- Denial of access to classroom

the behaviours that occurred

during the eating portion of break

Debriefing & Review Procedures for Staff:

Ongoing Staff Support Plan:

- Review possible changes to physical

- Review prevention strategies - observation of

- If injury has occurred, review completed

behavioural log and behaviours that have been

- Principal meets with staff individually to monitor

- Review and debrief about daily behaviour tally

Development of the Safety Plan

- Cindy - contacted in case of injury or report of behavior

- Bob - has not been able to get ahold of

- Mr. Filch - Teacher

Principals Signature & Date

Parents Signature & Date

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