- J
- Students
File: JKA-E1 (pdf)
Adopted: July 26, 2010
Revised: September 26, 2013, April 10, 2018, November 26, 2018, September 14, 2021, August 22, 2023
REPORT OF USE OF
PHYSICAL INTERVENTION OR RESTRAINT
Student: ___________________________________ School: ___________________________________ Date:_______________
Location: ___________________________________________________________________________________________________
Staff directly involved in physical intervention or restraint (include names and titles; attach supplemental statements, if any):
___________________________________________________________________________________________________________
Witnesses (include names and titles):
___________________________________________________________________________________________________________
Description of events immediately before the behavior occurred:
___________________________________________________________________________________________________________
__________________________________________________________________________________________________________
___________________________________________________________________________________________________________
| Prior alternatives offered | Environmental Supports | ||
|---|---|---|---|
| Teaching interaction | Removed the audience | ||
| Offered choices | Offer alternate location | ||
| Verbal de-escalation | Remove objects | ||
| Self-control strategies | Alternative seating | ||
| Wait time | Reduce Noise | ||
| Alternate location |
Type of physical intervention used:
[ ] Physical Intervention (less than one (1) min)
[ ] Restraint (hold cumulatively exceeded one (1) minutes)
| Please mark all that apply and time in each | Low | Medium | High |
|---|---|---|---|
| CPI seated hold | |||
| CPI standing hold | |||
| CPI Children's Control | |||
| CPI Team control |
Time:
Time restraint began: _________________________________________________________________________________________
Elapsed time of restraint (include total minutes and seconds:____________________________________________________
Chronological description of incident (include behavior, statements made, actions taken):
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Resolution:
_____ Student calm/reintegrated into classroom/educational programming
_____ Student calm/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 |
|---|---|---|
| If an injury to staff or student has occurred, submit student accident reportand/or staff incident report. | ||
| Building principal (or designee) and/or Transportation Supervisor verbally notify parent by end of the school day that the restraint was used. | ||
| Review documentation to ensure use of alternative strategies and recommend adjustments to procedures, if appropriate. | ||
| Distribute copies of Report to student's file, Director of Special Education, CPI Trainer, Supervisor (Principal or Transportation) | ||
| Report e-mailed, mailed or faxed to parent within 5 calendar days of the use of restraint. | ||
| If requested by parents or the school, convene a meeting (that may be an IEP, BSP or 504 meeting) to review the incident. |
______________________________________________ ______________________________________________
Name of Person Writing Report Signature
______________________________________________ ______________________________________________
Name of Supervisor Signature
(Principal/Transportation)
End of File: JKA-E