- J
- Students
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)