SAMPLE
Safety/Risk Assessment Plan

Student: 	_	School:  	
Grade: 	_	Protective Equipment:  	
Date: 		PRN: Yes	No	Medication:  Yes	No (if yes, please see office in event 911 is called)
Allergies/Special Considerations:   	
Safety Plan listed on IEP

Triggers/Antecedents	Prevention Strategies	
Actions observed or noted by staff to increase the student’s anxiety
Transitions
Sitting at the carpet
Outdoor recess	Successful Intervention Strategies
5 minute warnings for transitions
use of a visual schedule
Use of “How my Engine Runs” to help in self-regulation
encourage deep breathing (or other strategies identified/practiced)	
Stage One: Early Anxiety Phase Indicators	Staff Response	
Noticeable change or increase in behaviour
Crying
Screaming
Name calling/inappropriate language	Acknowledge anxiety, active listening, show empathy, verbal support
Identify and address the issue/problem
Use a calming voice (e.g. “X”, I can’t understand you. Please talk in a calm voice and I will help you)	

		
Stage Two: Defensive Phase Indicators	Staff Response	
questioning – challenging or manipulative questions
refusals – non-compliance
verbal release – emotional outburst (e.g. swearing, name calling, yelling)
intimidation – non-verbal threats (e.g. raises fist), verbal threats (e.g. “I’m going to hurt you”)
belligerent
attention-seeking behaviour (e.g. “I’m going to hurt myself”)	stay on topic, set limits
remove audience, state non-threatening directives
encourage deep breathing (or other strategies identified/practiced)
take seriously (get assistance if necessary)
quiet time in calming room
guidance and reminders to use the words he wants to express	
Stage Three: Physical Acting-Out Phase Indicators	Staff Response	
acting-out (loss of control)
attempt at physical assault (staff or other students)
self-injury(e.g. repeatedly banging his head on the desk/walls, using pencils or other objects to self-injury)
property damage (e.g. throwing chairs, flipping desks, attempting to break
windows)
running out of the school/off school property	use of non-violent physical intervention techniques (if necessary)
determine if police intervention is required
call for assistance (if necessary)
notify school administration
class removed (if necessary)
use of calming room (if able/necessary)
utilize staff member (or members) trained in CPI
contact parent if is unable to deescalate	
Stage Four: Tension Reduction Phase Indicators	Staff Response: Establish Therapeutic Rapport	
relaxed body posture, able to process information, engage in dialogue
stops yelling/screaming and is quiet (may or may not stop crying as he may be crying due to be remorseful or embarrassed)
can verbally acknowledge that he is ready to rejoin the learning environment	debrief, re-establish rapport
discussion concerning the incident/possible triggers
evaluation of effectiveness of coping strategies
possible discussion of alternate coping strategies
development of future plan of action
communication with parents regarding the incident
debriefing with staff to discuss/identify possible triggers and/or alternate
strategies/interventions
communication with parents/pertinent staff/agency personnel to review or refine the Safety Plan as necessary	

Plan developed on: 		Plan Revised:  	

Plan developed by:
Name	Position	Signature	
	Classroom Teacher		
	Educational Assistant		
	Early Childhood Educator		
	Principal		
	Parent(s)		
			
	Special Education Department		
			
	Agency		

If there is physical injury requiring medical attention the following forms must be completed: (to be reviewed)
Workplace Violence Incident Report (Board Link – need link)
Filed in student’s OSR...
Safe Schools Incident Reporting Form, Parts 1 and 2 (PPM 144) (Board forms under “Suspension” – need link)
Filed in/sent to...
WSIB Forms 6 and 7 Filed in/sent to...

** If no medical attention is required, please complete: (to be reviewed)
1) Supervisor’s Report of Injury/Incident

*** If student must be restrained, the Physical Restraint Form must be completed.