Boulder Valley School District

JKA-E1

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JKA-E1

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