Crisis Incident Critical Incident (Suicide Threat)
N.P.C.S.D
Crisis Incident FormStudent Name: ______Date of Incident: ______
Teacher/Class: ______Grade: ______
School: Duzine Lenape Middle School High School
Crisis Incident Critical incident (Suicide Threat)
Student has a behavior plan. Student Does not have a behavior plan Student has an IEP
Was Crisis Response Team Called: Yes NoCrisis Team Members Present: (Add as needed)
Time of Incident: ______am pm
Duration of Incident: 0-15 min 15-30 min 30-45 min 1 hr. More than 1 hour
On what day of the week did the incident occur? Mon. Tues. Wed. Thurs. Fri.
Where did it happen?
Classroom Hallway Bathroom PE Cafeteria Bus
School Grounds Off Grounds School Trip Other ______
Were there any apparent antecedent (triggers) for the behavior?
Verbally Unanticipated change in directions
Physically provoked by a student Denied a request
Had a negative interaction with a peer Expected to work independently
Had a negative interaction with an adult Routine was changed
Redirected during activity Change in staff
Refused direction/asked to do something Interrupted during something pleasant
Frustrated on task In a noisy or crowded place (fire drill)
Other ______
What did the student do?
Was physically aggressive What specifically did the student do? ______
Was verbally inappropriate? What was said? ______
Destroyed property What was the property? ______
Ran away/hid Where did the student go? ______
Non-compliant/Refused Direction What was the behavior? ______
Other ______
Staff Intervention
Planned Ignoring Positive Reinforcement/Feedback
Redirection Other Student(s) Removed
Active Listening Choices of preferred activities
Time Away/Break Restraint (please complete the physical restraint
As per behavior plan (describe or attach) documentation section of this form)
Suicide Assessment by Social Worker
Other/Explain: ______
______
______
What happened after the incident?
Administrative Intervention Sent to Nurse Completed Work
Student Received Consequences Talked to counselor Parent Contacted
Student Received 1:1 Support Life Space Interview Student Dismissed to ______
Other (Police/CPS/Ambulance): ______
Why did this seem to occur (what function did the behavior seem to serve)?
Gaining staff or peer attention Control Revenge
Escaping an unpleasant situation Obtaining an item Avoiding Demands
Other ______
Physical Restraint Documentation
School personnel involved in physical restraint: ______
______
______
Describe physical restraint used: ______
______
______
Describe actions of student and school personnel that occurred during the physical restraint: ______
Life Space Interview Conducted: Yes No
Describe alternative(s) behavior student identified: ______
Nurse Report: ______
Nurse Signature: ______Date: ______
Parent Notified How: ______
By Whom: ______Date: ______
Is this common behavior for the student? Yes No
If Yes, has an ICMP been developed? ______
______
______
If No, did anything happen within the last day that may have contributed to it occurring (i.e. could any setting, event, (condition) be identified? ______
______
______
Debriefing Notes:
______
______
______
______
______
______
______
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Signature of staff member completing form: ______Date: ______
Signature of Administrator: ______Date: ______