Safe Crisis Management Report - DOC - DOC by OAgU85U

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									                                                      Magoffin County Schools

                                              Safe Crisis Management Report

TO BE SUBMITTED WITHIN ONE DAY TO:
1) Child’s Original Folder 2) Principal 3) Director of Special Education

Student                                                         Date

   Safe Crisis: Start time:                         End time:                       Total Duration:
   Seclusion: Time In:                              Time Out:                       Total Duration:

Specific Behavior Addressed:
   Physical safety for another student was in immediate danger
   Physical safety for an adult/staff was in immediate danger
   Physical safety for self was in immediate danger

Less Intrusive Intervention Attempted (De-escalation Strategies attempted prior to physical intervention):
   Differential Reinforcement            Reminder            Positive Correction        I Message           Verbal Redirection

   Planned Ignoring                      Signal              Proximity                  Touch               Positive Problem-solving

  Para-Verbal (Vol., Tone, Rate)         Relaxation Prompts          Allow Isolation        Other

Safe Crisis Management Technique(s) Used (if applicable):
   Extended Arm          Cradle Assist        Upper Torso Assist          Crossed Arm Assist     Shoulder Assist

   Cradle to Floor      Upper Torso to Floor          Cradle Transport      Hook & Carry Transport

Personnel Involved (include observer):

Student’s condition at the completion of the incident:
Marks:       None observed      Red Blotch        Rug burn      Scratch       Other (describe)

Injury: Complete incident report

Breathing:     Normal        Shallow      Rapid Breathing        Hyperventilating

State:   Crying       Asleep     Requesting to be left alone      Needed more time to de-escalate

         Calm – rejoined group after Processing Time (“Normal Baseline”)            Other

Type of follow - up:
  Teachable Moment           Life Space Interview      STAR Model          Processing Model in Student’s Written Behavior Plan
  Other

Parent contacted:        Phone         School Visit          Home Visit         Note Home           Other

Chronological Events of Incident (Before and during event including the actions of the staff involved -
BE SPECIFIC (observable actions – what was seen and heard):



                                                                                                                                 2/2012

								
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