Harassment, Intimidation or Bullying - Targeted Student Safety Plan Template Definitions & Guidance:
Our school provides a safe and secure learning environment that is free from of harassment, intimidation or bullying (HIB). Especially vulnerable students who have been the alleged targets of HIB may need special protection to ensure their emotional and physical safety is secure during investigations and/or after sanctions have been imposed on aggressor students.
This safety plan template raises key issues for you to consider to assist in the protection of a vulnerable student and in the writing of a safety plan. It is understood that each situation is different and that additional considerations may be included.

It is recommended that this Student Safety Plan be completed by the school’s existing safety, discipline or student support team. Examples of such groups include a school’s Care Team, Student Intervention Team (SIT), 504 Implementation Team, Multidisciplinary Intervention Team (MDT), or HIB Prevention- Intervention Team. It is also recommended that the targeted student and a member of the targeted student’s family be involved in the development of the plan. Once the plan has been developed by the team, the principal or his/her designee will see that it is implemented with the student and his/her family. The principal will also share this plan with all necessary school staff. The classroom teachers will leave a copy of the plan for any substitute teachers who come in.

The plan involves two components: the actions school staff will engage in and the actions the student will engage in. The plan has a definite start and a proposed end date. It is meant to cover the entire school day, from the time a student boards a bus in the morning until he/she departs the bus at the end of the day. The targeted student needs to be safe during before-school and after-school activities, and protected from any new bullying done by others in support of the initial aggressor or in retaliation for reporting or discipline actions.

The plan designates a Primary Staff Contact for the targeted student. This person might be the staff person to whom the student first reported the HIB, or with whom the student feels most comfortable. It might also be his/her homeroom teacher, counselor or another classroom teacher.

It is the intent of this plan that it be carried out in a way which is minimally intrusive. School layout, passing times, grade levels and configurations and availability of staff may impact the plan. It will be necessary to adapted to the building. For example, if there are locations which are known to be particularly dangerous for the student, those areas need to be identified and monitored. (An additional template is available which more closely fit the needs of primary grades.)

HIB - Targeted Student Safety Plan

Student’s Name: 	

Primary Staff Contact :  	

Classroom/Homerooom Teacher:   	
Grade Level: 	Room Number: 	

Plan start date: 	Proposed End date:  	

School/Staff:
All school staff will be apprised of this safety plan and will make every effort to implement it successfully.
Any school staff who witness or are otherwise made aware of any harassing, intimidating or bullying behavior directed toward the student will intervene immediately and will report such behavior to the principal.
Classroom and Passing Times:
Mr./Mrs. 	will be designated as the student ‘s primary point of contact (trusted adult) on staff.
Mr./Mrs. 	, the classroom teacher, will keep the student and his/her aggressor separated in the classroom and during class activities.
Classroom teachers will keep the student and his/her aggressor separated in the classroom and during class activities
 Our school security officer (or other appropriate staff member) will be visible in the hall and will monitor the student during all passing times.
Mr./Mrs. 	is designated as the student’s recess monitor and will be visible and available during recess.
The student will visit our school counselor (nurse / principal / AP) on a daily basis at an agreed upon time to ensure that the plan is working. If the student does not or cannot visit this person at that time, the designated person will locate and check with the student.
The bus driver will be instructed to intervene immediately and to report any bus incidents immediately to the school principal.
The school will immediately report any harassing, intimidating or bullying behavior which it is made aware of to the student ‘s parents.

Other:  	
The Targeted Student:
 The student will not have face to face contact or online contact with the aggressor while this plan is in effect.
The school counselor and the student will identify a friend or friends with whom he/she feels safe.
The student will remain as close to the trusted friend(s) as is reasonable during the school day.
The student will visit the school counselor (nurse / principal / AP) on a daily basis at
 	o’clock to check in to see that the plan is working.
The student will share all passwords and will ‘friend’ his/her parents on all social networking sites so that they can monitor for any adverse online experiences.
(NB: The student will not ‘friend’ teachers or other school staff.)
The student will report any breach of this plan to his/her parents, designated trusted adult, teacher, or other staff person immediately
The student will also report any such behavior which occurs as a result of this plan off campus and/or outside of the regular school day.
Other:
 	.

Parents/Family:
Parents and other family members agree to monitor and support the student with this Safety Plan, monitor the student’s use of technologies, and contact school if the problem persists.
Parents are welcome to contact the school at any time to check on the effectiveness of the plan. If threats and harassment continue and/or escalate, law enforcement may be called in.
This plan is in place from 	through 	, at which time it will be reviewed, revised or continued, if necessary.

We agree to the Safety Plan as stated above.

Student	Parent

Principal	Date

Completed / Modified / Extended: 	(Date)