SPECIAL PROGRAMS

4585 Harvest Drive

DELTA BC V4K 5B4
PH: (604) 946-4101
FAX: (604) 946-7803

Safety Plan Outline

This Safety Plan Outline must be completed for each student who knowingly poses
a safety concern in the Delta School District. Please complete this outline, discuss
it with the students parents and all staff that interact with identified student, file it
in the students confidential file, and send a copy of if to Special Programs. For
further assistance in completing this form, please see the attached example.
Date: March 3, 2014
Student Name: xxxxx
School: Chalmers Elementary School

Program: Grade 7 English Program

Safety Issues
Nature of the safety concern (what does the student do that makes him/her a safety
concern, e.g. pinches staff, kicks, runs away from school, etc.):

Flight Risk
Hits/hurts other student
Cuts herself
Emotional Outbursts
Defiant (ODD)
Throws things
Chases other students

Known triggers (what do you know causes the student to act this way, e.g. work
that is challenging, changes in schedule, not getting his/her way, etc.):

Changes in routine, environment, or staff

Left over emotions from home, known or unknown
Doing something she has never done before
Attention seeking
Not getting her way, and doing things the schools way
If she is corrected
When the opportunity arises (i.e. teacher is not looking)

 Can be random and/or unknown triggers

Proactive Strategies
Ecological Changes (What changes have been or can be made in the physical
interpersonal, or program environment to better fit the students needs, e.g.
decrease task difficulty, provide (picture) schedule, reduce noise, etc):

Increased (full time) E.A. support at school including recess and lunch
Social skills education: learn different coping mechanisms
Safe place room where she can go
Safety plan
Breaks
Structured assignments and routine classroom environment

Positive Programming (Longitudinal instruction designed to teach skills to

facilitate behavioural changes, e.g. counselling, social skills instruction, relaxation
training, etc.):
Social Skills Instruction
Daily Communication with grandmother or Aunt (consequences are
followed up at home)
Positive Reinforcement for Positive Behaviour (Behaviour Chart)
Educational Assistant working with xxxx
Mainstream support teacher seeing her on a weekly basis
Focussed Support (Specific strategy to reduce or eliminate the need for a reactive
strategy, e.g. reinforcement programs such as Alt-R, DRO, DRL, etc.):

Full time E.A. support (including recess and lunch)

Regular contact with grandparent/Aunt
Weekly check-in with Mainstream Support Teacher
Reinforce positive appropriate behaviour often and consistently

Reactive Strategy

Situational Management (What to do if the student acts out, usually a list of

interventions to follow to attempt to de-escalate the immediate safety concern, e.g.
remove demands, give in to student wants, move away from student, change
activity, if student gets physical then use CPI restraint until student is calm, etc):
Designated staff will implement the following crisis management
plan when necessary.
Precursor Behaviours (What you see)
Anxiety:
(Noticeable increase or change in)
Impatient (wants something)
Angry
Agitated
Arms crossed, lack of participation,
sullenness

Staff Responses (What you do)

Be Supportive:
(Empathetic, non-judgmental response)

Defensive:
(Cues that this student is beginning to lose
the ability to think or process information)
Physically agitated
Angry
Defiant
Refusals, doing the opposite of
what she has been told to do
Makes noise
Acting Out:
(risk to self or others)
Bolts from room and/or school
Harms herself or others
Goes after students
Throws objects
Yells emotional outbursts
Hitting, kicking
Breaking materials

Go to a quiet place with EA to talk

about what is making her upset and
for work on strategies to help her
calm down
Go with EA for a walk and talk about
the situation.
Brainstorm alternative choices
Go and do a job around the school

Be Directive:
(Set simple, clear, enforceable limits)
EA escort her out of the classroom
Go for a walk around the school with
EA
Go and sit on the bench outside
office with EA
Crisis Intervention Plan*:
(Plan if he takes off)
EA escorts her out of the classroom,
remove self from close vicinity
Remove other students students
may need to leave the classroom if
she becomes violent
Call the Principal or take her to the
office
If she bolts from the school call the
office to let them know, office calls
police/aunt

Tension Reduction:
(cues that this student is calm)
Decreased body agitation
Stops the aggressive behaviour
Seems more relaxed
Voice is at a conversational level,
Question, Are you ready? student
is able to respond

Therapeutic Rapport:
(re-establish rapport - do not recriminate)
Discuss incident and how it could be
handled differently next time with EA
and teacher
Notify grandmother
As soon as she is calm, reinforce
calmness and appropriate behaviour

Response Progression Crisis Intervention Plan *:

a) EA and teacher let each other know that xxxx has taken off (and the direction) b) EA goes to
look for her c) runner is sent to office with assistance card d) Office staff looks for xxxx
Post Incident Debriefing: (ensure all involved employee(s) are included)
Direct teaching personnel to reflect on safety plan
Log incident
Other means to minimize risk: (i.e. clothing, earrings, etc.)
Remind her of the expectations and boundaries for each environment
Criteria for calling home:
If she bolts out of the school
Violent behaviour (hurting others or herself)
Reintegration Plan: (if required)
N/A
This plan will be reviewed:
a. Regularly by the principal or designate;
b. If any change in behaviour occurs such that the risk of violence is
different and/or an incidence of violence occurs.
A safety plan meeting will be convened:
The principal or designate will call a safety plan review meeting if new information
indicates that the safety plan needs to be reviewed or modified.
TERMINATION DATE:
(To be completed ONLY if a new WVRA indicates there is no risk of violence toward staff)

2014 /03/ 04
Y

I have read this plan and I am aware of the safety procedures to follow when working
with xxxxx
Signature:

Title:

Date: