Behavioral Emergency Report
(This form can generate more than one printed page)
   
  Report Date Report Date
   
 
Name   Birth Date   Age
 
   
   
  Last First  
 

 
District of Residence   District of Attendance   School
 
   
   
 

 
Select all that apply: Emergency Intervention Used:
 
 

 
If containment was used, describe in detail: If containment was used, describe in detail:


Date of Incident Date of Incident Time incident began Time incident began Time incident ended Time incident ended


Describe what occurred including setting, location, and events that led up to the emergency: Describe what occurred including setting, location, and events that led up to the emergency:
 
Name of staff/others involved: Name of staff/others involved:
 
Injuries sustained by student: Injuries sustained by student:


Injuries sustained by others (including other students and staff): Injuries sustained by others (including other students and staff):


Other pertinent information: Other pertinent information:
 

 
Signature of person completing this form:  
 


Print name and position of person completing this form: Print name and position of person completing this form:  
 

Copy Sent to Administrator/Designee (date of incident)
Parent(s) Notified (within 24 hours)
Copy Sent do District of Residence
Copy Sent to NCCSE
Copy Placed in Student File
Copy Sent to Behavior Intervention Case Manager
Attach NCCSE 23 or Behavior Intervention Plan (BIP)
Date:
By Whom:
 

 
Student     have a current Behavior Intervention Plan:

- Student does not have a current Behavior Intervention Plan: Within two days of the behavioral emergency, the designated responsible administrator shall schedule and IEP meeting to review the emergency report, to determine the necessity for a functional analysis assessment, and to determine the need for an interim behavior intervention plan.

- Student has an existing Behavior Intervention Plan: When an incident involving a previously unseen serious behavior problem occurs or where a previously designated intervention is not effective, student should be referred to the IEP team to be reviewed and determine if the incident constitutes a need to modify the plan.