1. APPENDIX A
    2. Niagara Catholic District School Board 
    3. PHYSICAL INTERVENTION INCIDENT REPORT
    4. (TO BE COMPLETED BY THE SCHOOL)
    5. Niagara Catholic District School Board 
    6. PHYSICAL INTERVENTION INCIDENT REPORT





    APPENDIX A

     

    Page 1 of 2





    altNiagara Catholic District School Board  





    PHYSICAL INTERVENTION INCIDENT REPORT





    (TO BE COMPLETED BY THE SCHOOL)

     
    Name of Student
    [ ]  M [ ] F
    		Date of Birth

    (yyyy mm dd)
    Parent/Guardian OEN#
    Address Street City Postal Code
    Phone number Home Work Cell(s)  

     

     

       
    School               Grade  
    Principal
    Classroom Teacher
    Educational Resource Teacher
    Date of Incident
    Time of Incident
    Location of Incident
     

    CEC Staff Involved (if any)
    Staff Training [ ]   SMG  [ ]   BMS   
    This information is being collected pursuant to the provisions of the Municipal Freedom of Information and Protection of Privacy Act

    and under the Authority of the Education Act, and will be used by Special Education. Questions about this collection should be directed to the Superintendent of Education – Special Education, Niagara Catholic District School Board,427 Rice Road, Welland, Ontario L3C 7C1, 905-735-0240.

     

     
    Description of Incident- Antecedent, Behaviour, Consequence/Outcome
     

     

       
    CONTAINMENT PROCEDURE EMPLOYED): Name of Containment, Duration of Containment
     

     

       


    Page 2 of 2





    alt Niagara Catholic District School Board  





    PHYSICAL INTERVENTION INCIDENT REPORT


     

    This information is being collected pursuant to the provisions of the Municipal Freedom of Information and Protection of Privacy Act and under the Authority of the Education Act, and will be used by Special Education.  Questions about this collection should be directed to the Superintendent of Education – Special Education, Niagara Catholic District School Board,427 Rice Road, Welland, Ontario L3C 7C1, 905-735-0240.


     
    REVIEW AND DEBRIEFING: Injury assessment, Reassurance and follow up with student(s), Staff and administrator debriefing, Re-establish relationships
     

     

     

       
    FOLLOW UP TO INCIDENT
     

    [ ] Communication Protocol/Notification to parent

     

    [ ] Documentation sent to Area Special Education Coordinator

     

    [ ] Report of staff injury (if needed)

     

    [ ] Other : explain_________________________________________

       
    Physical Intervention Incident Report Completed By:

     

          		Date Completed:
    PARENT/GUARDIAN INFORMED BY: DATE:  

    [ ] by phone [ ] in person  
    PHYSICAL INTERVENTION PERFORMED BY:
    Staff Member  

                  		Date  
    Staff Member      

              		Date  
    Staff Member  

                  		Date  


     


     
    PHYSICAL INTERVENTION INCIDENT WITNESSED BY:
    Staff Member  

                  		Date  
    Staff Member      

              		Date  
    Staff Member  

                  		Date  


     

     
    Signature of Principal           Date  


     

     

    [ ] Copy to Parent/Guardian   [ ] Board Special Education Copy   [ ] Copy to FACS Worker custodial/guardian


     

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