5144.1 Form 2

Seclusion Report Form

Note: This report is required to be submitted to the Director of Special Education as soon as practicable after an incident involving the seclusion of a student, but in no event later than 24 hours after the incident. Any use of seclusion is to be documented in the child's educational record, and, if appropriate, in the child's school health record.

Seclusion: The involuntary confinement of a student in a room, whether alone or with supervision by a Board of Education employee, in a manner that prevents the student from leaving. (A student may not be placed in seclusion except as an emergency intervention to prevent immediate or imminent injury to the student or others. Seclusion may not be used to discipline a student, because it is convenient or instead of a less restrictive environment.)

STUDENT INFORMATION:

Name of Student: ___________________________________Date of seclusion:________________________

Date of Birth: ___________ Age: ___________ Gender: M/F ______________ Grade Level:______________

Does student currently receive special education services or is the student being evaluated for eligibility for special education services? Yes: _____ No:_____ School: _______________________________________________

Date of this report:______________________________ Site of seclusion: ____________________________

This report prepared by: __________________________________ Position: _________________________

Staff placing student in seclusion:

Name: ____________________________________ Title: ________________________________________
Name: ____________________________________ Title: ________________________________________
Name: ____________________________________ Title: ________________________________________

Staff monitoring seclusion:

Name:_____________________________                 Title: ________________________________________

Name:_____________________________                 Title: ________________________________________

Administrator who was verbally informed following the seclusion:

Name:____________________________________   Title:  ________________________________________

PRECIPITATING ACTIVITY/DESCRIPTION OF SECLUSION:

Does the student have an IEP which includes the use of seclusion? Yes     No

If No: Description of the risk of immediate or imminent injury to the student secluded or others that required use of seclusion.

If Yes or No: Description of other steps, including attempts at verbal deescalation, to prevent the use of seclusion:

MONITORING OF SECLUSION

Evaluate the student being secluded for signs of physical distress:

Time: ______________  Evaluation: __________________________________
Time: ______________  Evaluation: __________________________________
Time: ______________  Evaluation: __________________________________
Time: ______________  Evaluation: __________________________________
Time: ______________  Evaluation: __________________________________
Time: ______________  Evaluation: __________________________________
Time: ______________  Evaluation: __________________________________
Time: ______________  Evaluation: __________________________________

Time seclusion began: ___________________ Time seclusion ended:

Total time (in minutes):  ___________________

CESSATION OF SECLUSION:

How seclusion ended (check all that apply):

•  Determination by staff member that student was no longer a risk to himself/herself or others

•  Intervention by administrator(s) to facilitate deescalation

•  Law enforcement personnel arrived

•  Staff sought in-house assistance

•  Community emergency personnel arrived

•  Termination per instruction in IEP/behavior plan

•  Other (describe):

Description of any injury to student and/or staff and any medical or first aid care:

Time medical staff checked injured person:____________________________________

Medical staff actions:_____________________________________________________

Medical staff name:_______________________________________________________

Incident report was filed with the following school district official:__________________

Date:_________________

FURTHER ACTION TO BE TAKEN: (Attach separate page if necessary)
The school will take the following actions (check all that apply)

•  Review incident with student to address behavior that precipitated the seclusion

•  Debrief staff regarding incident

•  Consider whether follow-up is necessary for students who witnessed the incident (Further contact with parents (describe):

•  Convene Crisis Team Meeting

•  Convene PPT to review/revise behavior intervention plan and/or IEP

•  Convene PPT to discuss functional behavior assessment

PARENT/GUARDIAN NOTIFICATION (required for all seclusions):

Parent who was verbally informed of this seclusion:

Name: _______________________________________ Telephone Number:___________________________

Date: ________________________________________ Time: _____________________________________

Called by:  ____________________________________  Title: _____________________________________

Notice mailed to Parent: Yes ______ No________

Mailed by: ____________________________________ Title:______________________________________

Reviewed by: _____________________________________________________ Date: __________________
                                  (Program Administrator/ Team Leader)

Reviewed by: _____________________________________________________ Date: __________________
                                   (Director of Special Education)

FOR DIRECTOR OR DESIGNEE USE ONLY

Reviewed seclusion report

Reviewed behavior plan, if applicable

In considering the effect of the seclusion on the student's established behavioral support of educational plan, I find the following:___________

_______________________________________________________________________

_______________________________________________________________________

Report of Seclusion or Restraint
Incident Report

School District: __________________________________ School: __________________________________

Address: _______________________________________ Address:_________________________________

Phone: _________________________________________ Phone:__________________________________

Name and Title of Person Preparing the report: ___________________________________________________

Incident: Seclusion ________________________________ Restraint__________________________________

Name of Student: _________________________________Student Disability: __________________________

Birth Date of Student: ______________________________ Male/Female Race: _________________________

Describe the nature and use of seclusion: (Identify the emergency that necessitated the use of

seclusion and how long the student was in seclusion.) _______________________________________________

Describe the nature and use of restraint: (Identify the emergency that necessitated the use of restraint, time in restraint and type of restraint used.)     

Was the parent contacted within twenty-four hours of the use seclusion or restraint as an emergency intervention to prevent immediate or imminent injury to the person or others?

Yes _____ No _____ f "No", did the parent receive a copy of the incident report no later than five days from the date of the incident? Yes _____  No _____

Was the student injured during the emergency use of restraint or seclusion? Yes _____________________No           If "Yes", complete and attach a Report of Injury.