Boulder Valley School District

JKA-E1

  • J
  • Students

File: JKA-E1  (pdf)
Adopted:    July 26, 2010
Revised: September 26, 2013, April 10, 2018, November 26, 2018


STUDENT RESTRAINT INCIDENT REPORT FORM

Student: _________________________    School: ________________________   Date:_______________
Location: ______________________________________________________________________________
Staff directly involved in restraint (include names and titles; attach supplemental statements, if any):
______________________________________________________________________________________
Witnesses (include names and titles):
______________________________________________________________________________________
Description of events immediately before the behavior occurred:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

Alternatives offered prior to restraint                  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 restraint used:  

 

please mark all that apply and time in each Low            Medium      High        
CPI seated hold      
CPI standing hold      
CPI Child Control      
CPI Team control      
Other      

 

Time:
Record duration of restraint, not duration of incident, reflecting times of release (example 1:02-1:08, 1:09-1:16)

Time restraint began:  ___________________________________________________________________
Time restraint ended:  ___________________________________________________________________

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):
_____________________________________________________________________________________
_____________________________________________________________________________________

Name and Signature of Person Writing Report               Signature Principal/Transportation Supervisor

______________________________________            ________________________________________
                                

Checklist Date Comments
If an injury to staff or student has occurred,
submit student accident report
and/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.
   
Conduct internal review of incident of restraint.
 
   
Review documentation to ensure use of
alternative strategies and recommend
adjustments to procedures, if appropriate.
   
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, BIP
or 504 meeting) to review the incident.
   

 

Copies:  Parent, student's confidential file [required], Director of Special Education, transportation file [if applicable]

End of File: JKA-E