MT. DIABLO UNIFIED SCHOOL DISTRICT SPECIAL EDUCATION BEHAVIORAL INCIDENT EMERGENCY REPORT 1936 Carlotta Drive, Concord, CA 94519 Phone (925) 682-8000 or TDD 685-1962 FAX (925) 687-3139 Community Advisory Committee (CAC) Parent Resource Network (925) 687-2129 ROUTING SLIP Student: ______________________________________________ Student No.: ________________________ Date of Incident: ________________________ Day: M T W Th F Incident Start Time: ____________ Provide name of person to whom the incident was reported, date and initial of person reporting. (Parent/care provider must be notified within one (1) school day.) Who Must Be Notified Name Date Initials Administrator Parents Others Who May be Notified Program Specialist Doctor/Hospital Police CFS(Child and Family Services) Director of Special Education Mental Health Agency Behaviorist Copies of this Report Must be Sent to: Initials Staff File* Cumulative* Incident Report File* Risk Management (if staff or student injury) CFS Director of Special Education* Mental Health Agency* Parent Rev. 09/04 White – Site Canary – Teacher Pink – Parent Page 1 of 6 MT. DIABLO UNIFIED SCHOOL DISTRICT SPECIAL EDUCATION BEHAVIORAL INCIDENT EMERGENCY REPORT 1936 Carlotta Drive, Concord, CA 94519 Phone (925) 682-8000 or TDD 685-2962 FAX (925)687-3139 Community Advisory Committee (CAC) Parent Resource Network (925)687-2129 Complete this form when students exhibit any of the behaviors listed below. This form is to be filled out within 24 hours of the incident. All staff members have the responsibility to report all incidents as they become aware of them. Submit this form to your immediate supervisor for approval and distribution to the appropriate staff and other agencies, as indicated below. Student _________________________________________________ Student ID# __________________________________ School __________________________________________________ Teacher _____________________________________ Date of Incident ___________ Day: M T W Th F Incident Start Time ________ Incident End Time: ________ Location of Incident _____________________________________________________________________________________ PersonsCompleting Report ______________________________________________________________________________ Date of Report _____________________________________ Signatures/Titles _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ Name of Staff Present Title Incident Types (Circle first occurring behavior— Check all others that apply) Aggressive Outburst Self Destructive Behavior Other Behavior Violent threat toward peer Suicidal ideation Atypical/unusual Violent threat toward staff Suicidal behavior behavior Assault toward peer Self abuse Repeated disruption of Assault toward staff Medical (report immed to supervisor) group activity Assault staff during physical Illness/Injury Sexual acting out intervention Medication error On campus/runaway Property destruction Medication refusal Off campus/runaway Medication reaction Rev. 09/04 White – Site Canary – Teacher Pink – Parent Page 2 of 6 BEHAVIORAL INCIDENT EMERGENCY REPORT Student _______________________________ School ______________ Teacher_____________ Date of Incident ____________________ Day: M T W Th F Incident Start Time: ___________ Description of Environment & Activity before Incident(Antecedents):_____________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ Describe the incident: __________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ _________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ In objective Terms, include justification for physical intervention: ______________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ INTERVENTIONS: (Circle) 1– 2– 3– 4– 5– 6– 7– Planned non-response Non-verbal gestures/signals Humor/distraction to diffuse Provide alternate activity/outlet for energy Offer assistance Redirect/divert Tone of voice change 8– Proximity change Rev. 09/04 9–Praising others 10– Reminders of past success/goals 11– Clarify expectations 12– Provide choices; offered alternate activity 13– Verbal Counseling 14–Model or rehearse appropriate behavior 15– Reminders for upcoming activities/events 17– Removal of stimuli 18– Time away in class 19– Time away outside of class 20– Separate student from group 21– Separate the group from student 22– Other (specify) ___________________ 16– Reminders about consequences White – Site Canary – Teacher Pink – Parent Page 3 of 6 BEHAVIORAL INCIDENT EMERGENCY REPORT Student _______________________________ School ______________ Teacher_____________ Date of Incident __________________ Day: M T W Th F Incident Start Time: ____________ Student Injury (All injuries must be reported to an Administrator) Type Area(s) NO INJURY Bruise Bite Swelling Cut Blood/bodily fluid Discomfort/pain Other Chest Neck Back Abdomen Buttocks Head/face Mouth/teeth Feet/legs Hands/arms Other Medical Attention Required First Aid Required Type of First Aid Applied Apparent Cause/Source of Injury Injuries to other students and staff must be documented. • Student Accident report sent to Risk Management • Workers Compensation forms completed Additional Student Injury Type Area(s) NO INJURY Bruise Bite Swelling Cut Blood/bodily fluid Discomfort/pain Other Chest Neck Back Abdomen Buttocks Head/face Mouth/teeth Feet/legs Hands/arms Other Medical Attention Required First Aid Required Type of First Aid Applied Apparent Cause/Source of Injury Injuries to other students and staff must be documented. • Student Accident report sent to Risk Management • Workers Compensation forms completed • Employee/Staff Incident • Multiple copies of this page attached reporting student Injuries Rev. 09/04 White – Site Canary – Teacher Pink – Parent Page 4 of 6 BEHAVIORAL INCIDENT EMERGENCY REPORT Student _______________________________ School ______________ Teacher_____________ Date of Incident ____________________ Day: M T W Th F Incident Start Time: ___________ Physical Intervention (Circle first occurring behavior—Check all others that apply) (If physical intervention lasted over 15 min., supervisor must be notified, if intervention lasted over 30 min., therapist must be notified.) If physical intervention is required, Standing restraint How long? Start Time End Time Escort (walking restraint) Wall-assisted restraint Sitting restraint Floor-assisted prone restraint In objective terms, describe the student’s behavior during restraing: _____________________________ Restraint Observed by (observation must occur every 15 minutes throughout restraint): Signature and Title Print Name Date & Time Comments/observation: _________________________________________________________________ _____________________________________________________________________________________ Signature and Title Print Name Date & Time Comments/observation: _________________________________________________________________ _____________________________________________________________________________________ Signature and Title Print Name Date & Time Comments/observation: _________________________________________________________________ ______________________________________________________________________________________ Attach additional copies if necessary. Name of All Staff Involved in Physical Intervention Rev. 09/04 White – Site Canary – Teacher Title Pink – Parent Page 5 of 6 BEHAVIORAL INCIDENT EMERGENCY REPORT Student _______________________________ School ______________ Teacher_____________ Date of Incident _________________ Day: M T W Th F Incident Start Time: ______________ Describe Student’s Behavior After Physical Intervention: Staff Follow-up and Conclusion to Incident: How could this incident have been prevented/recommended changes: This Constitutes a Behavioral Emergency per Hughes Bill guidelines Yes No q If “Yes”, IEP Scheduled __________________ Supervisor Follow-up/Comments: _______________________________________________________ Supervisor’s Signature Rev. 09/04 Date White – Site Canary – Teacher Tim Pink – Parent Page 6 of 6