This sample template is provided as a resource, for the consideration of each school board in developing their own form. Each school board is responsible for ensuring that the version of the form they use, and their procedures around the form, are compliant with their responsibilities under the Municipal Freedom of Information and Protection of Privacy Act (MFIPPA ), OHSA , and other legislation.
Sample template
Do not post
Notification of potential risk of physical injury (truncated student safety plan)
[Insert school board name and logo]
This form is intended to facilitate the school board’s duty under s.32.0.5 (3) of the Occupational Health and Safety Act to provide information to workers related to a risk of workplace violence from a person with a history of violent behaviour. This form must be completed by a principal or vice principal and provided to a worker at school if: a) the worker can be expected to encounter that person in the course of his or her work; and b) the risk of workplace violence is likely to expose the worker to physical injury.
Section A: Board policy and procedure
[Insert hyperlink to Board Policy and Procedure]
Section B: How to summon immediate assistance
[Insert information as to how to summon immediate assistance]
Section C: Identifying information
[Insert student’s name]
[Insert school name]
[Insert department name or room number]
[Insert student’s photo]
Section D: Brief description of behaviour(s) that presents a risk of physical injury
Known triggers
[Insert a description of known triggers.]
Indicators of escalation
[Insert a list of physical signs or cues that the student is about to become aggressive or assaultive.]
Indicators of full escalation
[Insert a list of indicators of full escalation.]
Section D: Strategies for avoiding a risk of physical injury
Do take the following action
[Insert what a person should do when in contact with the student.]
Do not take the following action
[Insert what a person should not do when in contact with the student.]
Section E: Emergency and intervention strategies
[Insert what strategies a person can use when dealing with the student.]
Completed by[insert name]
Retain in a central and secure location
