Action Plan Outline

The purpose of the Action Plan is to look at the situation from a learning lens. What was the situation?

How were others affected? What will help me to make a new choice in the future? What practice will help

me prepare for it? What can I do to repair it?

Student: ___________________________

Date of Incident: ____________________

Date of Action Plan:__________________

1. Let's look at the situation- what happened? (what did I try first, who was involved, where was
it, what was going on for me…etc.)

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

2. How did your choice affect others?

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________
3. What is a New Choice that you could make if something happens again?

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

4. What could you do to repair this situation?

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

5. What practice can I do to prepare myself better for next time?

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

6. What are the consequences of your choices?

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________
7. What will be the consequence if a situation happens again?

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Purposeful Practice;

_________________________________________

_________________________________________

Staff Comments:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Staff Signature: _____________________ Student Signature: __________________ Parent

Signature: ____________________ Date: ______________________________