It is the goal of the school district that all students can learn and grow in a safe and peaceful environment that nurtures the students and models respect for oneself and others. On occasion, trained district employees and others may have to use behavior management interventions, physical restraint, and/or seclusion of students. The goal of these interventions is to promote the dignity, care, safety, welfare, and security of each child and the school community. With this objective in mind, the district will prioritize the use of the least restrictive behavioral interventions appropriate for the situation.
PHYSICAL RESTRAINT means a personal restriction that immobilizes or reduces the ability of a student to move their arms, legs, body, or head freely. Physical restraint does not mean a technique used by trained school employees, or used by a student, for the specific and approved therapeutic or safety purposes for which the technique was designed and, if applicable, prescribed. Physical restraint does not include instructional strategies such as physically guiding a student during an educational task, handshaking, hugging, or other non-disciplinary physical contact.
SECLUSION means the involuntary confinement of a student in a seclusion room or area from which the student is prevented or prohibited from leaving; however, preventing a student from leaving a classroom or school building are not considered seclusion. Seclusion does not include instances when a school employee is present within the room and providing services to the student, such as crisis intervention or instruction.
PHYSICAL RESTRAINT OR SECLUSION IS REASONABLE OR NECESSARY ONLY
Prior to using physical restraint or seclusion, employees must receive training in accordance with law. Any individual who is not employed by the school district but whose duties could require the individual to use or be present during the use of physical restraint or seclusion on a student will be invited to participate in the same training offered to employees on this topic.
When required by law, the Executive Director of Student Services [or designee] will ensure a post-occurrence debriefing meeting is held, maintain documentation, and fulfill reporting requirements for each occurrence of physical restraint or seclusion as required by law.
Adopted: 2/21
Reviewed: 10/23
Related Policy: 502.1; 502.1-R; 502.7; 502.14-R; 502.14-E1-E3
Legal Reference (Code of Iowa): §§ 279.8; 280.21; 281 IAC 103
IASB Reference: 503.06
The Linn-Mar Community School District will comply with 281 Iowa Administrative Code Chapter 103 for the use of physical restraint and seclusion of students including but not limited to:
Adopted: 1/21
Revised: 10/23
Related Policy (Code#): 502.1; 502.1-R; 502.7; 502.14; 502.14-E1-E3
Legal Reference (Code of Iowa): §§ 279.8; 280.21; 281 IAC 103
IASB Reference: 503.06-R(1)
CLICK HERE TO DOWNLOAD THE DOCUMENTATION OF USE OF PHYSICAL RESTRAINT FORM
Physical restraint or seclusion is used to protect the safety of the student or to protect others who are likely to be in jeopardy should a student’s actions continue. All instances of physical support in the form of restraint or seclusion will be documented.
Student's Name:
Building:
Date of Occurrence:
Grade:
Teacher:
Time of Seclusion:
Time of Restraint:
Duration of Total Occurrence in Minutes:
Employee’s Full Name, Title, and Date of Last Training on Restraints and/or Seclusion: Include all who were involved with or implemented the restraint or seclusion, as well as those who observed the occurrence. Include the information of the administrator who approved the extended time, if applicable. Employees are to initial next to their name after the completed form is reviewed.
Describe the antecedent that led to the restraint/seclusion: Provide a brief description of the trigger/cause-setting events of the behavior, including both the student and adult behaviors.
Student:
Adult:
What approaches were used to deescalate the student: (Check all that apply)
____Silence/Wait Time
____Choice/Options Given
____Verbal Redirections
____Removal of Demand
____Planned Ignoring
____Time Out in Hallway
____Time Out in Classroom
____Written Redirections
____Adult Proximity (Near or Far)
____Visual Redirections
____Other (Please specify)
If there is a Behavioral Intervention Plan (BIP) for the student, what strategies were used from it:
Describe the student and adult behaviors during the restraint/seclusion:
Student:
Adult:
Describe the restraint/seclusion utilized and the reason why:
____Seclusion
____CPI Restraint & Name of the CPI Restraint Used
Why Used: ____Danger to Self ____Danger to Others
What was the exact safety concern:
Describe the student and adult behaviors after the restraint/seclusion:
Student:
Adult:
Is there any property damage: ____Yes ____No
List any repairs or replacements needed:
Injury Documentation:
If "yes" is checked for any items below, please complete and return an Injury Report Form.
Describe future approaches to the student's behavior, including possible IEP meetings to address behavior concerns:
If the occurrence involved a period of physical restraint or seclusion that exceeds 15 minutes an administrator [or designee] must authorize approval of the continuation:
Time Approved:
Administrator's Name/Title:
Reason for length of occurrence:
If the occurrence involved a period of physical restraint or seclusion that exceeds 30 minutes from the last approval time, an administrator [or designee] must authorize approval of the continuation:
Time Approved:
Administrator's Name/Title:
Reason for length of occurrence:
If the occurrence lasts longer than 15 minutes a break for bodily needs should be offered if it is safe to do so:
Time break offered:
Student: _____Accepted ____Declined
If break was not offered, please explain why:
Coping Method:
Coping Model Check in:
Student
Date:
Time:
Staff Present:
Staff
Date:
Time:
Staff Present:
Parent/Guardian Notification:
Parents/guardians will be notified as soon as practicable once the occurrence is under control but no more than one hour after or the end of the school day, whichever occurs first.
Spaces below for documenting multiple attempts to notify parents/guardians are listed in case they cannot be reached on the first attempt.
Notification Attempt One:
Employee Attempting Notification:
Parent/Guardian Contacted:
Time/Manner of Notification:
Was notification successful: ____Yes ____No
Notification Attempt Two:
Employee Attempting Notification:
Parent/Guardian Contacted:
Time/Manner of Notification:
Was notification successful: ____Yes ____No
Notification Attempt Three:
Employee Attempting Notification:
Parent/Guardian Contacted:
Time/Manner of Notification:
Was notification successful: ____Yes ____No
A written copy of this form was sent to the student’s parents or guardians within three school days of the occurrence. Unless the parent or guardian agreed to receive the report by email, fax, or hand delivery; the report must be sent by mail and postmarked by the third day following the occurrence. This report cannot be placed in a student’s backpack.
Enclosed with a copy of this form was an invitation for the parents or guardians to participate in a debriefing meeting scheduled in accordance with law set for the following:
Date:
Time:
Location:
Reporter's Name:
Date:
Building Administrator/Designee Signature:
Documentation Provided by: (Please check all that apply)
____By mail and postmarked within three school days of occurrence
____By electronic email upon written request of the parent/guardian
____By electronic fax
____By hand delivery
____Other by written request of the parent/guardian (Please specify other mode below)
Copies provided to: Parent/guardian, student file, and Executive Director of Student Services
Adopted: 2/21
Reviewed: 10/23
Related Policy: 502.14; 502.14-R; 502.14-E2-E3
CLICK HERE TO DOWNLOAD THE NOTICE OF DEBRIEFING MEETING REGARDING USE OF PHYSICAL RESTRAINT
Date:
Dear [Names of Parents/Guardians],
Recently your student, [Add student’s full legal name here], was involved in an occurrence at school that required their physical restraint and/or seclusion as defined by 281 Iowa Administrative Code, Chapter 103; which is included with this letter. A report related to the occurrence is also included with this letter.
I am inviting you to attend a debriefing meeting to engage with us on topics related to this occurrence. With your assistance, we want to foster the continued health, safety, and educational growth of your student. The law requires debriefing meetings be held for such occurrences under the following circumstances:
This letter is intended to inform you that a debriefing meeting, due to reason ________ listed above, will be held on:
Date:
Time:
Location & Address:
The following employees will be in attendance at the meeting (include name and title):
If you need to reschedule this meeting, please contact me as soon as possible via email or phone and at least one school day prior to the original date and time listed above.
Your student is allowed to attend this meeting with your consent, and you are welcome to bring a representative of your choosing, if you wish. If you plan to bring a representative, please let me know at least one school day prior to the meeting so that we have an opportunity to make the necessary arrangements to accommodate their attendance.
We look forward to working with you.
Administrator’s Name and Title:
Date:
Administrator's Email:
Phone:
Enclosures:
*Report related to student occurrence
*Copy of 281 Iowa Administrative Code, Chapter 103
Disclaimer: This letter and the included items must be mailed via postage, prepaid, first class mail to the parent/guardian within three school days of the original occurrence unless it is agreed upon to have it transmitted electronically via email/fax or picked up in person.
Adopted: 2/21
Reviewed: 10/23
Related Policy: 502.14; 502.14-R; 502.14-E1; 502.14-E3
CLICK HERE TO DOWNLOAD THE DOCUMENTATION OF DEBRIEFING MEETING REGARDING USE OF PHYSICAL RESTRAINT
Student Name:
Building:
Date of Original Occurrence:
Date of Debriefing Meeting:
Time of Meeting:
Location of Meeting:
Names of all attendees including titles and/or relation to student:
(*Denotes a role required for attendance)
Parent:
Student:
*Administrator:
*Administrator not involved in occurrence:
*Names of those who administered seclusion/restraint:
Behavior/Mental Health Expert:
Others in Attendance (Name and Title):
Documentation reviewed during the meeting: (Check all that apply)
____Seclusion/Restraint Report
____Individualized Education Plan (IEP)
____Behavioral Intervention Plan (BIP)
____Individualized Health Plan (IHP)
____Safety Plan
____Other (Please specify)
Identification of patterns or behavior and proportionate response, if any, in the student and employees involved:
Possible alternative responses, if any, to the incident; or less restrictive means, if any:
Additional resources, if any, that could facilitate alternative responses in the future:
Plans for additional follow up actions, if any:
Names and Title of Employee Completing Form:
Date:
Date Delivered to Parent/Guardian:
Method of Transmittal:
Adopted: 2/21
Reviewed: 10/23
Related Policy: 502.14; 502.14-R, 502.14-E1-E2