JKA-E1

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

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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)