SD33 Student Violence Risk Assessment
OHS Email
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Date
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Date Format: MM slash DD slash YYYY
Did you receive a REPORTABLE BEHAVIOUR REPORT with an incident Id#?
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Yes
No
Incident Id #
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If you received multiple reports for the same incident, please enter the additional Incident ID numbers below
ENTER ONE INCIDENT NUMBER PER LINE
Location
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A.D. Rundle Middle
Bernard Elementary
Central Elementary Community School
CHANCE Alternate
Cheam Elementary
Chilliwack Middle
Chilliwack Secondary
Cultus Lake Elementary
East Chilliwack Elementary
Education Centre
Evans Elementary
F.G. Leary Fine Arts Elementary
Fraser Valley Distance Education
G.W. Graham Secondary
Greendale Community Elementary
Little Mountain Elementary
McCammon Traditional Elementary
Mt. Slesse Middle
Promontory Heights Elementary
Robertson Elementary
Rosedale Traditional Community
Rosedale Traditional Community
Sardis Elementary
Sardis Secondary
Shxwetetilthet: Sto:Lo
Strathcona Elementary
Tyson Elementary
Unsworth Elementary
Vedder Elementary
Vedder Middle
Watson Elementary
Yarrow Community Elementary
Incident Date
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Date Format: MM slash DD slash YYYY
Name of employee reporting concern
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First
Last
Email of concerned person
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Name of person completing this risk assessment
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First
Last
Your Email Address
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A copy of this report will be sent to this address and to District H&S Manager
Student initials
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Pen #
Student age
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Intensity
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****High - a severe injury requiring hospitalization ***Medium - moderate injury such as a sprain or fracture **Low - a minor injury such as a bruise or scratch
High
Medium
Low
Frequency
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****High - at least once a week up to once or more a day ***Medium - at least once a month up to once a week **Low - at least once a year up to once a month
High
Medium
Low
Preliminary Risk Assessment outcome
This student/person does not present a risk of violence toward staff
Preliminary Risk Assessment outcome
This student/person presents a risk of violence toward staff
Risk Assessment
Describe the behaviour/risk/hazard
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Previous incidents
Click on the + button to add multiple incidents
Date
Name(s) of employee involved
Who is at risk
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Select all that apply
All staff members
Teacher/TOC
SEA
YCW
Bus Driver/Monitor
Noon Supervisor
Administrator
Admin Assistant
Custodian
Other
If other, explain
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Risk locations
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Select all that apply
All areas
School grounds / playground
Library
Classroom
Off school grounds
Gym
Shop
Resource room
Office
Other
If other, explain
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When are staff most at risk
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At all times
Certain times of the day
When working alone
During specific activities
Non identifiable
Other
Interim Safety measures/safe job procedures to follow
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Ensure safe distances are maintained
Provide student time to de-escalate
Use calm, neutral voice/body language
Reduce/eliminate demands/requests
Allow activity/provide choice/allow wait time
Consider alternatives to punitive measures
Offer student calm, quiet space/help
Reduce audience (staff/peers)
Remove trigger/stimulus causing escalation
Other
If other, explain
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Does the student have a Positive Behaviour Support Plan?
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Yes
No
Is there a safety plan in place for this student?
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Yes
No
Actions required
Administrator to arrange a meeting with applicable staff and school based team to create an Employee Safety Plan. The safety plan must be communicated to all affected staff and staff must sign off on the safety plan.
A Positive Behaviour Support plan may be needed
Contact Learning Support for assistance
A Positive Behaviour Support Plan is needed
Was the safety plan followed?
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Yes
No
Does the current safety plan address the conditions and/or behaviours leading up to this incident?
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Yes
No
Actions requrired
Administrator to arrange a meeting with applicable staff to review/update the Safety Plan. If the intensity and/or frequency is rated MEDIUM or HIGH, you should include your integrated support teacher in the meeting. Revisions to the safety plan must be communicated to all affected staff and staff must sign off on the revised plan.
Who will act
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First
Last
By what date
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Date Format: MM slash DD slash YYYY
Notifications/Actions
NOTE:
Send corrective measures/safe job procedures to the concerned employee?
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Yes
No
