Los Angeles Unified School District
SAMPLE - Individualized Student Safety Plan
Student: _____________________________
Date:_________________________________
Safety is our number one priority! Keeping students safe requires a comprehensive approach that
involves the responsibility and specific actions by all stakeholders.
The following safety plan has been discussed and developed for (Student name)_______________ _
on _(date)__________ . This plan is NOT to take the place of an IEP. If the student has an IEP, then stop
and defer to it.
Administration responsibilities and strategies:
1. I will continue to communicate and enforce the rules as set forth by the district School-Wide
Positive Behavior Support policy.
2. I will take all reported incidents of bullying seriously.
3. I will be neutral and gather the facts from all involved parties.
4. I will follow-up with the teacher to provide him/her with the support to address the various
concerns.
5. I will follow-up with the involved parents and students to monitor that the bullying has stopped.
6. I will__________________________________________________________________________
Teacher responsibilities and strategies:
1.
2.
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9.
I will establish a safe school environment for all students.
I will take all reported incidents of bullying or misconduct seriously.
I will remain neutral and gather all the facts from the involved parties.
I will monitor that the bullying has stopped by checking in with _____________ on
____________________ to ensure that the bullying it has stopped.
I will remind all students of the appropriate play areas and rules of conduct when they are
outside for recess and lunch.
I will meet with parents of all involved students to discuss concerns, consequences and
strategies for reconciliation.
I will work collaboratively with the administration, counselors, other involved teachers, staff and
parents.
I will make a referral for counseling.
I will ____________________________________________________.
Student responsibilities and strategies:
1.
2.
3.
4.
I will report all incidents of bullying immediately to _my teacher, Ms. Smith or other adult_____.
I will tell the person who is bothering me to “stop”.
I will avoid areas that may not be safe.
I will follow all rules of conduct in the classroom, on the playground, before and after school,
and going to and from school.
5. I will keep my hands to myself.
LAUSD, Office of Human Relations, Diversity and Equity http://humanrelations.lausd.net
04/18/12
Los Angeles Unified School District
SAMPLE - Individualized Student Safety Plan
6.
7.
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10.
I will not tease or call anyone names.
I will join a club that promotes peace and respect.
I will apologize if I hurt someone’s feelings.
I will do my best.
I will ___________________________________.
Parents responsibilities and strategies:
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I will listen and gather information.
I will monitor that the bullying has stopped.
I will work with positively with the teacher and administration.
I will not encourage my child to fight with his/her fist, but to use alternative methods.
I will enroll my child in counseling.
I will not confront the child who is allegedly bullying my child.
I will set positive expectations of behavior for my child.
I will be a good role model.
I will ____________________________________________________________.
By signing you have agreed to abide by the aforementioned plan.
We will revisit this plan on ___(date)_________ at ___(time)_____ in room ________.
Student name (print & sign): _____________________________ Date:___________________________
Parent/Guardian name (print & sign): _____________________________ Date:___________________
Teacher name (print & sign): _____________________________ Date:___________________________
Administrator (print & sign): _____________________________ Date:___________________________
Other (print & sign): _____________________________ Date:__________________________________
LAUSD, Office of Human Relations, Diversity and Equity http://humanrelations.lausd.net
04/18/12