502.14-E1 - Documentation of Use of Physical Restraint and/or Seclusion of Students

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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.

  1. Visible marks noticed on student prior: ____Yes    ____No
  2. Injury to student (damage to body) during intervention: ____Yes    ____No
  3. If you answered "yes" in item 2, did the nurse check them: ____Yes    ____No
  4. If you answered "no" in item 3, why were they not checked:
    Details of student injury:
  5. Injury to staff (incident report filled out) during intervention: ____Yes    ____No
  6. If you answered "yes" in item 5, did the nurse check them: ____Yes    ____No
  7. If you answered "no" in item 6, why were they not checked:
    Details of staff injury:

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:

  • Control: Check in with student and staff
  • Orient: What happened
  • Patterns: Look for patterns of past behavior
  • Investigate: Discuss alternatives to the behavior
  • Negotiate: Proceed with plan involving student and staff
  • Give: Give encouragement and praise to the student and staff

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