Student: ________________________________________ Date: _________________________

School: ___________________________________________ Grade: ______________________

Reason for crisis/emergency plan: _______________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

Persons responsible for developing the plan (indicate position): _________________________________

_________________________________________________________________________________

_________________________________________________________________________________

Parental Approval

Indicate level of parent/guardian participation and approval of the plan. ___________________________

_________________________________________________________________________________

Parent/guardian signature: _____________________________________________________________

________________________________________________________________________________

1. Give a full description of the behavior that poses a risk of physical injury to the student or to others, damage to physical property and/or serious disturbance of the teaching/learning process and for which a crisis/emergency plan is required, including both the frequency of occurrence and magnitude of behavior.

 

 

 

 

 

 

2. Give a full description of previous interventions (including those in the student’s IEP or existing behavioral intervention plan) that have been applied and have not been successful, including length of implementation.

 

 

 

 

 

 

 

 

3. Give a full description of the strategies or procedures included in the plan, the times, places, and situations under which the plan may be introduces, person(s) responsible for its implementation, and any potential risks associated with the plan.

 

 

 

 

 

 

 

 

4. Give a full description of how, when, and where measurement procedures that will be used to evaluate the effectiveness of the plan, the criteria against which the plan will be judged, and the timetable for its evaluation.

 

 

 

 

 

 

 

5. Give the timetable for review of the plan.

 

 

 

 

 

 

6. Give a description of the behavior that will be strengthened and/or taught to the student to replace the behavior of concern, including steps to provide frequency opportunities for the student to engage in and be reinforced for the desired behavior.

 

 

 

 

 

 

 

7. Give a full description of the plan for withdrawing the crisis/emergency plan and the less restrictive and intrusive intervention that will replace it, including the time table for withdrawal of the crisis/emergency plan.

 

 

 

 

 

 

 

 

8. Give a full description of the steps that will be taken to eliminate future occurrences of the behavior, including changes in the social/physical environment, teaching of replacement behavior, or both.

9. Indicate the person(s) responsible for notifying the parent/guardian when the crisis/emergency plan has been introduced and the way in which that notification will be documented.

 

 

 

 

 

 

10. Indicate the person(s) responsible for the written report of the outcome of the crisis/emergency plan.