BUL-6269
April 7, 2014
LOS ANGELES UNIFIED SCHOOL DISTRICT
Division of Special Education
ATTACHMENT F
BEHAVIORAL EMERGENCY REPORT FOR STUDENTS WITH DISABILITIES
(Title 5, California Code of Regulations)
DIRECTIONS: School staff are required to thoroughly complete all sections of this fillable form immediately following an
emergency intervention. Electronic fillable versions of this form in WORD are available in the LAUSD and Division of Special
Education E-Libraries under Bulletins. Please submit the completed form via school mail or fax to:
School Mail
Fax
Behavior Support Office
Beaudry Building, 17th Floor
Attention: Behavior Support Office- BER
(213) 241-8916
(To: “Behavior Support Office:
Behavior Emergency Report”)
INFORMATION MUST BE TYPED OR PRINTED LEGIBLY
SECTION I. STUDENT INFORMATION:
Student Name
M
Date of Birth
F
Eligibility
Student currently has
(check all that apply):
Functional Behavior Assessment (FBA)
Interim Behavior Response Plan (IBRP)
Student ID
GR
Language
Current Placement
Behavior Support Plan (BSP)
Behavior Treatment Plan
None of these
SECTION II. INCIDENT DESCRIPTION: (ATTACH ADDITIONAL SHEETS IF NECESSARY)
Location and time of
incident:
Description of Incident and
Personnel Involved:
Description of Emergency
Intervention used and how
long it was used:
Details of any injuries
sustained (including staff)
as a result of incident:
SECTION III. REQUIRED PROCEDURES (must be completed within 48 hours of incident):
Behavior Emergency Report
Completed By:
Date:
Printed Name and Title of Person who
Notified Parent (within 24 hours of incident):
Name of Site Administrator
who Reviewed Report:
Printed
Name:
Title:
Printed
Name:
Signature:
Copy of this Form Filed in Student’s Cumulative Record
Checklist:
Time:
IEP Meeting Scheduled:
Copy of this form sent to Special Education Service Center Administrator
and Behavior Support Office within 48 hours
Page 1 of 1
Date:
Date of IEP Meeting: