- J
- Students
File: JKA-E1 (pdf)
Adopted: July 26, 2010
Revised: September 26, 2013, April 10, 2018, November 26, 2018, September 14, 2021
STUDENT RESTRAINT OR PHYSICAL INVERVENTION 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 physical intervention used:
[ ] Physical Intervention (less than 5 min)
[ ] Restraint (hold cumulatively exceeded five minutes)
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 Name and 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