RESTRAINT PROCEDURES CHECKLIST
If it is anticipated that restraint may be used in an emergency, school staff must ensure that:
- The student has a Behavior Plan that incorporates a Functional Behavior Assessment, a plan for teaching replacement skills, de-escalation techniques, and a crisis management plan which addresses the circumstances in which physical restraint and/or seclusion might be used.
- Written notification of the type and circumstances in which restraint may be used, and the staff who may be involved, is provided to the parent(s) and student (if appropriate) (see Parent Notification Regarding Restraint).
- A copy of the Parent Notification has been placed in the student’s confidential record.
- If the parent of a student with a disability requests a meeting to discuss the notification, school personnel must ensure that a meeting is convened. (This can take place at the meeting where the student’s Behavior Plan or IEP is developed or reviewed.)
If a student has been physically restrained or secluded:
- Staff administering restraint must immediately notify the school principal/designee that restraint was used.
- The school principal/designee must verbally notify the student’s parents as soon as possible, but no later than the end of the school day on which the restraint was used. The school principal or designee must provide the parents with written notification day of incident via email or in-person.
- Within 1 school day, staff administering the restraint must complete the Restraint Incident Report.
- Within two (2) school days of the incident, the principal/designee will convene a meeting to review the Report and make recommendations for adjustment of procedures (if appropriate) in the Restraint Incident Debriefing Notes.
- Within 5 calendar days following the use of restraint, the school principal/designee must send the Incident Report and Debriefing Notes to the student’s parents via mail, e-mail, or facsimile.
(A sample cover letter is provided for your use.) - A copy of the Report and Debriefing Notes must be placed in the student’s confidential record.
- A copy of the Report and Debriefing Notes must be forwarded to the District Office and to the Executive Director of BOCES or BOCES designee using the BOCES designated reporting procedures.
- If requested by the District or the student’s parents, the District shall convene a meeting with the student’s parents to review the incident. For students with IEPs or Section 504 Plans, such a review may occur through the IEP or Section 504 process.
STUDENT RESTRICTIVE INTERVENTION (RESTRAINT) INCIDENT REPORT FORM
| Student Name: | School: | Today’s Date: | ||||
| Grade: | Date of Birth: | Race/Ethnicity: | ||||
| IEP | 504 Plan | BIP | Crisis Plan | Safety Plan | ||
| Date Incident Occurred: | |||
| Time Safety Intervention Began: ________:________ AM/PM | Time Safety Intervention Ended: _______:________ AM/PM | Duration of Safety Intervention: __________ min __________s | |
| Safety Intervention used (Choose only 1 and if more than 1 occurred, you must fill out an additional sheet):Physical Restraint (1 minute to 4:59 minute)Physical Restraint (5 minutes or more) Seclusion (1 minute to 4:59 minute)Seclusion (5 minutes or more) *If 59 seconds or less, please use alternative incident report form. | Description of Safety Intervention used (Choose only 1 and if more than 1 occurred, you must fill out an additional sheet):Children’s Control PositionStanding/SeatedMedium – levelHigh – levelTeam Control PositionSeclusionOther:_______________________________________ | ||
| Staff administering Safety Intervention: Name:Role: CPI* certification currentConsider staff to student ratio *Crisis Prevention Intervention (CPI) is the Mountain BOCES approved de-escalation and behavior management program. | Staff present and other observers:NameTitleCPI Certified? Yes No Yes No Yes No | ||
| Location of Incident:ClassroomHallwayOfficeOutsideCafeteriaParking lotOther: | Environmental Considerations (Please explain the following environmental factors in detail): Physical Space Seating Arrangement Noise Level Other | ||
| Antecedent to the student’s behavior, if known: | |||
| Chronological description of the emergency situation (i.e., the serious, probable, and imminent threat of bodily injury) that necessitated use of safety intervention: | |||
| Preventative efforts made to de-escalate and/or alternatives that were attempted prior to the use of safety intervention (Please explain using observable language and state facts only. Do not include opinions or personal feelings): | |||
| Description of how student was monitored during safety interventions, including names of staff responsible for monitoring student’s physical safety: | Description of any injury to student and/or staff: | ||
| Cessation of Restraint (check all that apply):☐ Determination by staff member that student was no longer a risk to self or others☐ Security arrived☐ Police arrived☐ Ambulance arrived☐ Staff sought medical assistance☐ Other (describe): | |||
| Parent/guardian notification (Parent/guardian must be verbally notified the same day as incident) | ||
| Name(s) of parent/guardian contacted: _________________________ Phone #s: _________________________ Date of contact:____________________ Time of contact: _____:_____ AM/PM | How was parent(s)/guardian(s) notified? Spoke with parent/guardian Left voicemail | Name/position of school administrator (or designee) who verbally notified parent/guardian: |
This Restraint Incident Report must be sent to parent/guardian within 5 student contact days of the incident.
Date report was sent: _______________________
Report sent by: _______________________
One copy each to the Parent/Guardian, Principal, District Office and Student’s confidential record.
STUDENT RESTRICTIVE INTERVENTION (HOLD) INCIDENT REPORT FORM
| Student Name: | School: | Grade: | ||||
| Today’s Date: | ||||||
| IEP | 504 Plan | BIP | Crisis Plan | Safety Plan | ||
| Date Incident Occurred: | ||
| Time Safety Intervention Began: ________:________ AM/PM | Time Safety Intervention Ended: _______:________ AM/PM | Duration of Safety Intervention: __________ min __________s |
| Safety Intervention used (Choose only 1 and if more than 1 occurred, you must fill out an additional sheet):Hold (0 seconds to 59 seconds) *If longer than 59 seconds, please use alternative incident report form. | Description of Safety Intervention used (Choose only 1 and if more than 1 occurred, you must fill out an additional sheet):Children’s Control PositionStanding/SeatedMedium – levelHigh – levelTeam Control PositionSeclusionOther:_______________________________________ | |
| Staff administering Safety Intervention: Name:Role: CPI* certification currentConsider staff to student ratio *Crisis Prevention Intervention (CPI) is the Mountain BOCES approved de-escalation and behavior management program. | Staff present and other observers:NameTitleCPI Certified? Yes No Yes No Yes No | |
| Location of Incident:ClassroomHallwayOfficeOutsideCafeteriaParking lotOther: | Student Behavior (describe specific behavior):Aggression towards adult ___________________________________________ Aggression towards peer ___________________________________________ Property Destruction ___________________________________________ Self-Injury ___________________________________________ Other___________________________________________ | |
| Antecedent to student behavior:Work demand/request Social demand/requestDenied access to preferred item/activityDiverted attentionTransitionChange in environment (noise, light, temperature, etc)Unknown/no observable antecedentOther (describe):__________________________________________________________________________________________________________________________________________________________________ | ||
| Preventative efforts made to de-escalate and/or alternatives that were attempted prior to the use of safety intervention (check all that apply):Provided/offered breakProvide/offered alternativeProvided prompting to use functional communication strategiesProvided redirectionUsed first/then languageProvided regulation strategies/optionsRemoved excess stimuliOther (describe:__________________________________________________________________________________________________________________________________________________________________ | ||
| Cessation of Restrictive Intervention (check all that apply):☐ Determination by staff member that student was no longer a risk to self or others☐ Security arrived☐ Police arrived☐ Ambulance arrived☐ Staff sought medical assistance☐ Other (describe):_________________________________________________________________________________ | ||
| Description of any injury to student or staff (attach a copy of incident report) : | ||
| Parent/guardian notification (Parent/guardian must be verbally notified the same day as incident) | ||
| Name(s) of parent/guardian contacted: _________________________ _________________________ Date of contact:____________________ Time of contact: _____:_____ AM/PM | How was parent(s)/guardian(s) notified? In personSpoke with parent/guardian via phoneLeft voicemail | Name/position of school administrator (or designee) who verbally notified parent/guardian: |
This Hold Incident Report must be sent to parent/guardian within 1 student contact days of the incident.
Date report was sent: _______________________Report sent by: ____________________________
One copy each to the Parent/Guardian, Principal, District Office and Student’s confidential record.
RESTRICTIVE PHYSICAL INTERVENTION INCIDENT DEBRIEFING NOTES
Within two (2) school days of use of restrictive physical intervention (hold, restraint, seclusion) a debriefing meeting attended by appropriate staff, including staff involved in the incident and Crisis Prevention Intervention (CPI) trainer, must occur. The purpose of the meeting is to review the incident, ascertain whether appropriate procedures were followed, and minimize the future use of restrictive physical interventions. Those attending shall review the applicable Incident Report.
| Date of Debriefing: | ||
| Student Name: | Date of Incident: | |
| Type of Restrictive Physical Intervention:Children’s Control PositionStanding/SeatedMedium – levelHigh – levelTeam Control PositionSeclusion | ||
| Exact Duration of Restrictive Physical Intervention: ______ minutes ______ seconds | ||
| Debriefing Notes (address whether appropriate procedures were followed and alternative strategies were used): | ||
| Recommendations for adjustment of procedures, if appropriate: | ||
| Names/Positions of those attending the debriefing meeting: | ||
This report has been prepared by _________________________________________________________ Name Position
One copy each to the Parent/Guardian, Principal, District Office and Student’s confidential record.
Issued: July 2010
Reviewed: September 2020
Revised: June 2024
Lake County School District R-1, Leadville, Colorado