Please complete this survey every time you evacuate your classroom.  Your name and the details of the incident will be kept confidential and will not be shared with anyone unless you have given consent.

Last name, First name

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* 1. Last name, First name

Email address:

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* 2. Email address:

School:

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* 3. School:

Date/time incident occurred.

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* 4. Date/time incident occurred.

Date / Time
Student('s') Initials:

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* 6. Student('s') Initials:

Name(s) of any other staff members present at the time of the incident:

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* 7. Name(s) of any other staff members present at the time of the incident:

Forms completed and submitted to administration (check all that apply):

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* 8. Forms completed and submitted to administration (check all that apply):

Who responded to assist with the classroom evacuation (check all that apply)?

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* 9. Who responded to assist with the classroom evacuation (check all that apply)?

Has the student's behaviour resulted in a classroom evacuation in the past?

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* 10. Has the student's behaviour resulted in a classroom evacuation in the past?

Does the student have behaviour plan?

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* 11. Does the student have behaviour plan?

Does the student have a safety plan?

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* 12. Does the student have a safety plan?

If this student has a safety plan were you involved in the creation/maintenance of it?

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* 13. If this student has a safety plan were you involved in the creation/maintenance of it?

Does the student receive additional support in the classroom?

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* 14. Does the student receive additional support in the classroom?

Were you injured as a result of the incident that caused the classroom evacuation?

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* 15. Were you injured as a result of the incident that caused the classroom evacuation?

If you answered yes to question 14, have you, or will you seek medical attention for your injury? Please note seeking medical attention requires that you AND your physician complete a WSIB form.

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* 16. If you answered yes to question 14, have you, or will you seek medical attention for your injury? Please note seeking medical attention requires that you AND your physician complete a WSIB form.

Has the incident that led to your classroom being evacuated made you feel unsafe in your work environment?

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* 17. Has the incident that led to your classroom being evacuated made you feel unsafe in your work environment?

Was any of your personal property damaged as a result of incident that led to your classroom being evacuated?

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* 18. Was any of your personal property damaged as a result of incident that led to your classroom being evacuated?

If you answered YES to QUESTIONS 14, 15, 16 please call the ETFO-UCL Office at 613-345-4893 or ETFO Provincial at 1-888-838-3836 and state that your call is urgent.

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