BEHAVIOR EMERGENCY REPORTDirections: To be completed by appropriate staff member when severe property damage has occurred or a behavioral

emergency intervention has been used to control unpredictable, spontaneous behavior which poses clear and present danger of severe physical harm to the individual with exceptional needs, or others, and that cannot be immediately prevented by a response less restrictive than the temporary application of an intervention used to contain the behavior.

Student Name:

Grade: SSID:

Primary Eligibility:

Secondary Eligibility:

Date of Incident:

Report Completed by: Title:Name:

Location and Setting of Incident:

Start Time: End Time:

LEA:

School of Attendance (If Different than LEA):

Date of Birth: Age:

Does the student have a Behavior Intervention Plan (BIP)?

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Yes. Date:

Within two days of the behavioral emergency, the designated responsible administrator shall schedule an IEP meeting to review the emergency report, to determine the necessity for a functional behavioral assessment and to determine the need for an interim behavior intervention plan. The IEP team must also document the reasons for not conducting a FBA and/or developing an interim BIP.

Yes. Date: No.If Yes, is the BIP based on a Functional Behavior Assessment?

When an incident involving a previously unseen severe behavior problem occurs or where a previously designated intervention is ineffective, student should be referred to the IEP team to be reviewed and determine if the incident constitutes a need to modify the plan. Meeting Scheduled for:

Describe how strategies from the BIP were implemented:

Describe what occurred, as observed, including what led up to the emergency and interventions used:

Provide a specific description of any emergency intervention(s) used:

Within two days of the behavioral emergency, the designated responsible administrator shall schedule an IEP meeting to review the emergency report, to determine the necessity for a functional behavioral assessment and to determine the need for an interim behavior intervention plan. Meeting Scheduled for:

Did staff/student require medical attention? If so, please explain:

No: Student does not have a current Behavior Intervention Plan (BIP):

Name(s) and/or role(s) of staff and other persons involved in emergency intervention:

Description of any severe property damage:

Other pertinent information:

Name

Date:

Role Date of CertificationNonviolent Crisis Intervention Trained? (CPI)

Describe location of injury and mark on diagram above.

FRONT BACK

Check all that apply:

A Student Incident Report was filed as a result of this incident.

A Report of Employee Injury was filed as a result of this incident.

Law enforcement personnel were involved in this incident.

Copies of this report sent to:

Site Administrator*

* California Ed. Code section 56521.1 requires these people shall receive a report immediately** California Ed. Code section 56521.1 requires these people shall receive a report within one school day

Signature of Person Completing this Report:

Signature of Site Administrator or Designee:

R L L R

Date:

Date:

Parent or Residential Care Provider (within 24 hours)**

Date:

Date:

District of Residence/Special Education Director

Teacher

Student’s File*

Name:

Name:

Name:

Name: