"Incident Action Plan" - Massachusetts

Incident Action Plan is a legal document that was released by the Massachusetts Department of Early Education and Care - a government authority operating within Massachusetts.

Form Details:

  • Released on September 20, 2010;
  • The latest edition currently provided by the Massachusetts Department of Early Education and Care;
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INCIDENT ACTION PLAN
Regulation 606 CMR 7.11(5)(f)
(Behavioral Incidents, Accidents, Property Destruction, Emergencies)
It is important for administrators and educators to identify the reasons why a child may be exhibiting certain types
of behavior through the process of evaluating the program’s environment, transitional patterns, triggering
behavioral patterns, and the quality interactions between child and educators. This preventative tool begins the
process of working with a child and their parents to identify concerns and offer solutions to assist the child in
integrating successfully into the program and when appropriate, offering referrals. EEC recommends that
program administrators and educators meet with parents as soon as an issue is identified to build a partnership of
trust and to avoid suspension and termination.
Child’s Name: _____________________________________________________________________________________
Date of Incident: ______________________________________Time of Incident: _______________________________
Description of Incident (be specific):____________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Is this the first time this incident occurred, if not when was the last time it occurred? ______________________________
__________________________________________________________________________________________________
Is this child receiving any additional services? ____________________________________________________________
__________________________________________________________________________________________________
Was there something different about the child’s day that led to the incident occurring? ____________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
What actions could the program take to prevent this incident from occurring? ___________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
What actions did the educator take immediately preceding the incident? ________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
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SG/LG/SAIncidentPlan20100920
INCIDENT ACTION PLAN
Regulation 606 CMR 7.11(5)(f)
(Behavioral Incidents, Accidents, Property Destruction, Emergencies)
It is important for administrators and educators to identify the reasons why a child may be exhibiting certain types
of behavior through the process of evaluating the program’s environment, transitional patterns, triggering
behavioral patterns, and the quality interactions between child and educators. This preventative tool begins the
process of working with a child and their parents to identify concerns and offer solutions to assist the child in
integrating successfully into the program and when appropriate, offering referrals. EEC recommends that
program administrators and educators meet with parents as soon as an issue is identified to build a partnership of
trust and to avoid suspension and termination.
Child’s Name: _____________________________________________________________________________________
Date of Incident: ______________________________________Time of Incident: _______________________________
Description of Incident (be specific):____________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Is this the first time this incident occurred, if not when was the last time it occurred? ______________________________
__________________________________________________________________________________________________
Is this child receiving any additional services? ____________________________________________________________
__________________________________________________________________________________________________
Was there something different about the child’s day that led to the incident occurring? ____________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
What actions could the program take to prevent this incident from occurring? ___________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
What actions did the educator take immediately preceding the incident? ________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
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SG/LG/SAIncidentPlan20100920
How did the child respond to the educator’s intervention? ___________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
What was the outcome of the incident that occurred? Any injuries to this child or other children? Any property damage?
Was 911 or other emergency personnel contacted?
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Who contacted the parent/guardian? ____________________________________________________________________
How? ____________________________________ Date/Time parent/guardian notified? __________________________
Was a meeting scheduled with the parent to discuss the incident?
Yes or No
(circle one)
Date of meeting: ____________________________Time of meeting: _________________________________________
Who was present at the meeting? Who was representing the program? Who was representing the family?
__________________________________________________________________________________________________
__________________________________________________________________________________________________
With parental consultation and authorization, has a referral been made on behalf of the child? By whom?
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
In cooperation with the parents/guardian, what plan was developed to address any concerns?
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Signature of Staff
Date
__________________________________________________________________________________________________
Signature of Parent/Guardian (optional)
Date
_____Administrative Review
_____Placed in Child’s file
_____Entered in Central Log or File
**This form should be completed by all staff involved in or observing the incident and reviewed by the program administrator
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SG/LG/SAIncidentPlan20100920
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