Boulder Valley School District
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JKA-E1

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JKA-E1
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Boulder Valley School District
Adopted: 
July 26, 2010
Revised: September 26, 2013, April 10, 2018, November 26, 2018, September 14, 2021, August 22, 2023, April 22, 2025


STUDENT RESTRAINT OR PHYSICAL INTERVENTION
INCIDENT REPORT FORM

 

Student: ___________________________________   School: ___________________________________   Grade: ____ Date:_______________Location: ________________________________________________________________

Staff directly involved in restraint (include names and titles; attach supplemental statements, if any):
__________________________________________________________________________________

Observers (include names and titles):
__________________________________________________________________________________

Description of events immediately before the behavior:
___________________________________________________________________________________________________________
__________________________________________________________________________________________________________
___________________________________________________________________________________________________________

Alternatives offered prior to restraint:
Note: Not all strategies are appropriate for all students.

Student-specific IEP
accommodations or other
alternative supports
           Showing Empathy through active
listening, restorative questions, I
Statements, feelings / needs cards
          
Teaching interaction   Removed the audience  
Offered choices   Offer alternate location  
Verbal de-escalation   Remove objects  
Self-control strategies   Alternative seating  
Wait time   Alternate location  
Reduce Sensory Stimuli (e.g., noise,
light)
 

Other:

 
Continuum of Restorative Language      

 

Type of physical intervention used:
_____ Physical Intervention (less than one (1) minute)
_____ Physical Restraint (hold cumulatively exceeded one (1) minute)
_____ Seclusion

Type(s) of physical restraint used:
Note: Mark all that apply and time each type was used.

CPI Hold Low            Medium      High        
2 person seated      
2 person standing      
1 person child standing      
1 person child seated      
Team control    
 


Time:

Time restraint began and ended:  _________________________________________________________________________________________
Total elapsed time of restraint (include minutes and seconds):____________________________________________________

Estimated time away from educational setting: _____________________________________________

Description of the incident (include chronology of behavior, statements made, actions
taken):

___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________

Resolution:
_____   Reintegrated into classroom/educational programming
_____   Additional time provided for de-escalation outside of instructional setting
_____   Additional support requested (medical/mental health/parent/police)
_____   Other(s) (please describe): ______________________________________________________________________________

Injuries or property loss/damage:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________

Persons notified of incident (include name, title, date and time notified):
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________

Checklist Date Comments
Building Principal (or designee) and/or Transportation
Supervisor verbally notify Parent by end of the school
day.
                                                                                
Complete copy of this form sent to Special Education
Director and CPI trainer (Kelly Miller) for review.
   
Submit student accident report and/or staff incident
report if an injury to staff or student has occurred.
   
Review documentation to consider appropriate
preventative strategies, behavior support plan, and to
assure use of alternative strategies and appropriate
adjustments to procedures.
   
E-mail or mail completed report to Parent within 5
calendar days.
   
If requested by parents or the school, convene a
meeting (that may be an IEP, BSP or 504 meeting) to review the incident and consider any repair needed.
   
Restorative Conversation with those involved.    

                            

______________________________________________                              ______________________________________________
Name of Person Writing Report                                                           Signature

______________________________________________                              ______________________________________________
Name of Supervisor                                                                                Signature
(Principal/Transportation)