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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)
_____Use a calm, neutral voice
_____Validate feelings
_____Provide wait time
_____Provide reasonable choices
_____Move to an alternative place of safety (Calm down space, etc.)
_____Set positive limits
_____Verbal interventions/nonjudgmental questioning
_____Make the environment safe (Remove unnecessary items, etc.)
_____Provide visual and/or written redirections
_____Disengagements to release/escape
_____Other (Please specify)
Describe the less restrictive approaches checked above that were used as alternatives to restraint and seclusion.
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. Include any disciplinary actions that may be imposed on the student.
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:
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 one)
_____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
Revised: 10/26
Related Policy: 502.14; 502.14-R; 502.14-E2-E3
IASB Reference: 503.06-E(1)