INDIVIDUAL STUDENT SAFETY PLAN
026670000INDIVIDUAL STUDENT SAFETY PLAN164782539370An individual student safety plan, unlike a typical behavior plan, addresses specific behavior that is dangerous to the student and/or others.00An individual student safety plan, unlike a typical behavior plan, addresses specific behavior that is dangerous to the student and/or others.Date: FORMTEXT ?????Student Name: FORMTEXT ?????DOB: FORMTEXT ?????Synergy ID: FORMTEXT ????? FORMDROPDOWN FILLIN School: \* MERGEFORMAT School: FORMTEXT ????? FILLIN School: \* MERGEFORMAT Grade: FORMTEXT ?????Special Education Eligible? FORMCHECKBOX No FORMCHECKBOX Yes If yes, Casemanager: FORMTEXT ?????504 Eligible? FORMCHECKBOX No FORMCHECKBOX Yes If yes, Casemanager: FORMTEXT ?????Contact InformationParent/Guardian: FORMTEXT ?????Cell Phone: FORMTEXT ?????Home Phone: FORMTEXT ?????Other: FORMTEXT ?????Emergency Contact: FORMTEXT ?????Phone: FORMTEXT ?????Places Student May Be if Missing During School HoursOn School Grounds: FORMTEXT ?????Off School Grounds: FORMTEXT ?????Medical InformationPhysician: FORMTEXT ?????Phone: FORMTEXT ?????Diagnoses: FORMTEXT ?????Medications: FORMTEXT ?????Allergies/Special Considerations: FORMTEXT ?????Description of Specific Unsafe Behaviors (why student requires a safety plan) FORMTEXT ?????CRISIS RESPONSE PLANWhat to do if student exhibits above described behaviorWho will do what/backup staff FORMTEXT ????? FORMTEXT ?????Warning Signs/TriggersStrategies That WorkStrategies That Do Not Work FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????BEHAVIOR SUPPORTSWhat will staff, student, and family do to lessen the likelihood of unsafe behavior (i.e., supervision, transition planning, transportation to and from school, plan for unstructured time, closed campus, searches, etc.)?Who / Back-up person? FORMTEXT ????? FORMTEXT ?????How will plan be monitored?Who/Back-up person? FORMTEXT ????? FORMTEXT ?????How will decision be made to terminate the plan?Who/Back-up person? FORMTEXT ????? FORMTEXT ?????Current Agencies or Outside Professionals InvolvedNameAgencyPhone1. FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????2. FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????3. FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????4. FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Student Safety Team MembersName/SignatureTitleDate1. FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????2. FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????3. FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????4. FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????5. FORMTEXT ?????Principal FORMTEXT ?????6. FORMTEXT ?????Safety Plan Coordinator FORMTEXT ?????Next Review Date: FORMTEXT ????? (approximately two weeks from initiation of plan or last review date) ................
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