Emergency Intervention Plan

Student: D.O.B: Date:

School: Grade:

TEAM Members:

Van Buren Intermediate School District's “Emergency Intervention Plan (EIP)” has been written to describe the reasons for the use of emergency seclusion and/or emergency restraint. You are being provided with a copy of this plan because your student's target behavior may not be modified within a reasonable amount of time by the Positive Behavior Support Plan (PBSP) to enable the student to participate in specified activities in a safe and healthy manner.

The special behavioral interventions listed below may only be used to control unpredictable, spontaneous behavior that poses a clear and present danger of serious physical harm to the student with a disability or others, and that cannot be immediately prevented by a less restrictive or severe response. Should the PBSP be ineffective in stopping a behavior which poses an imminent threat to the student, other pupils, or staff, emergency interventions will be utilized. [Michigan Department of Education Policy for the Use of Emergency Seclusion and Restraint, Mar. 2017]

EMERGENCY SITUATION means a situation in which a student's behavior poses imminent risk to the safety of the individual student or to the safety of others. An emergency situation requires an immediate intervention.

EMERGENCY SECLUSION is defined as “last resort emergency confinement of a student in a room or space from which the student is physically prevented from leaving and which provides for continuous adult observation of the student.”

EMERGENCY PHYSICAL RESTRAINT is defined as "a last resort action that prevents or significantly restricts a student's movement that is necessitated by an ongoing emergency situation and that provides an opportunity for the pupil to regain self-control while maintaining the safety of the pupil and others.”

Possible Undesirable Outcome(s) regarding the health, safety, and/or educational progress of the student and/or others if the target behavior is not reduced or eliminated.

Risk of injury to student, peers, or staff Injury to staff or student (possible during special Interference with instructional activities behavioral interventions of emergency seclusion Hindering skill acquisition or emergency restraint)

Positive Behavior Intervention and Supports:Has the team conducted an FBA to identify triggers associated with the behavior requiring the use ofEmergency Seclusion and/or Emergency Restraint? Yes No

The team is strongly encouraged to conduct or review a FBA related to the behaviors that triggered the use of Emergency Seclusion and/or Emergency RestraintIf the student has a current PBIS Plan, the team must review and revise if necessary

If the student does not have a PBIS Plan, the team must create one.  Specify the date on which the team will be meeting to create a PBIS Plan:

Emergency seclusion is NOT permitted: with preschool students, with students who are severely self-injurious or suicidal, as a form of discipline, or as a substitute for adequate staffing or programming.

Describe in detail additional limits (if any) on the use of emergency seclusion with this student (i.e. medical condition, trauma history, etc.)

Emergency Restraint must NOT: include mechanical or chemical means, prone restraint (face down on floor), or be used as a substitute for adequate staffing or programming.

Describe additional limits in detail (if any) on the use of emergency restraint with this student (i.e. medical condition, trauma history, etc.)

Detail the Emergency Intervention ProceduresSpecify definitions of behavior requiring emergency seclusion and/or emergency restraint procedures that will be used in an emergency situation.

Emergency Seclusion Procedures:Behavior(s) Procedures

Emergency Restraint Procedures:Behavior(s) Procedures

The team has made inquiry to the pupil's medical personnel, with parent consent, regarding any known medical or health contra indications for the use of emergency seclusion or restraint

Parent Signed Authorization to Release Information to student's physician

Date: Name of Physician:

Parent Declined to sign Authorization to Release Information to student's physician

The team has conducted a peer review by knowledgeable PERSONNEL

The parent or guardian has been provided with all the following, in writing and/or orally:A detailed explanation of the positive behavioral intervention and support strategies that will reduce the risk of the pupil's behavior creating an emergency situation or restraint

An explanation of what constitutes an emergency, including examples of situations that would fall within the definition and situations that would fall outside the definition

A detailed explanation of the intervention procedures to be followed in an emergency situation, including the potential use of emergency seclusion or restraint

A detailed explanation of the legal limits on the use of emergency seclusion, including examples of legally permissible and prohibited use

A detailed explanation of the legal limits on the use of emergency restraint, including examples of legally permissible and prohibited use;

A description of possible discomforts or risks

Answers to any questions

The student has been told or shown the circumstances under which emergency seclusion or physical restraint could be used. If not, explain why:

Signature of the person completing this form: Date: