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District of Residence |
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District of Attendance |
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School |
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If containment was used, describe in detail:
If containment was used, describe in detail:
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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:
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Name of staff/others involved:
Name of staff/others involved:
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Injuries sustained by student:
Injuries sustained by student:
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Injuries sustained by others (including other students and staff):
Injuries sustained by others (including other students and staff):
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Other pertinent information:
Other pertinent information:
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Signature of person completing this form: |
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Print name and position of person completing this form:
Print name and position of person completing this form:
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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)
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Date:
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By Whom:
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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.
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