5144.1 Appendix C

______________ Public Schools

Protective Measures Procedures

Staff Training: A core group of educators within each school building have been trained in the principles and philosophy of Physical & Psychological Management Training. (PMT) These staff members are appropriately trained in de-escalation techniques as well as safe and effective protective measures.

_____________ Public Schools mandates that alternative strategies and techniques must be exhausted prior to implementation of a protective measure including but not limited to:

  Planned Ignoring

  Environmental manipulation

  Contingency/Choices

  Physical Redirection

If a student is not able to regain self-control following all attempts by the staff to deescalate the student’s behavior and the safety of the student and/or the safety of others is in question, the following procedures should be enacted:

STEP 1:

Immediately notify the office:

The office will notify the appropriate team members and the principal and send them to the room or environment in question. The student should remain under constant supervision to assure that he/she is safe. At least two TEAM members must be present during the intervention.

Pre-approved protective measures as indicated within the PMT training manual

Escort:

Protective Hold:

  Guide-a-long

  Limited Security Hold

  Lower Figure Four

  Full Security Hold

 

  Seated Full Security Hold

 

  Seated Full Security Hold (two person)

 

  Kneeling Full Security Hold

 

  PMT Floor Control

Protective measures lasting longer than 5 minutes must be approved by an administrator or designee. Holds must be approved each additional 5 minutes up to 20 minutes. Protective measures are not to exceed 20 minutes.

STEP 2:

Administrator will notify parent.

_________________ Public Schools may seek an individual waiver for students who present a high risk of frequent, dangerous behavior that may require the frequent use of protective measures. Parent(s)/guardian(s) may withdraw consent to such waiver at any time without penalty. Protective measures that result in serious injury to a student or program staff member must be reported as described above regardless of any individual waiver.

STEP 3:

Complete Paperwork

  Protective Measures Documentation Form

o  To be completed before the close of the school day

  Protective Measures Report Form

o  To be completed no later than the following school day

Reports of these incidents should be submitted to the principal no later than the following school day, with copies sent to the pupil services office.

The principal or his/her designee shall maintain an on-going record of all reported instances of protective measures, which shall be made available for review by the Department of Education, upon request.

The following documentation regarding individual waiver of reporting requirements will be maintained on-site in the student’s file and will be made available for inspection to the Department of Education upon request:

a. Informed written consent of parent(s)/guardian(s) to the waiver, which shall specify those reporting requirements listed above that the parent(s)/guardian(s) agrees to waive; and

b. Specific information regarding when and how the parent(s)/guardian(s) will be informed regarding the administration of all protective measures to the individual student.

______________________________ Public Schools Protective Measures Documentation

Date:_____________    Time:________________    Location:____________________

Student:_________________________     Parent Notification:______________________

Antecedents to the Incident:

Demand: ______

Environmental: ______

Denied Access: ______

See Attached: _______

Describe Environment or Activity:      

___________________________________      

___________________________________      

___________________________________      

Alternatives to Protective Measure:

Ignoring:

Environmental Manipulation:

Contingency: ____

Physical Redirection: ____

Severity of Behavior Prevents: ____

Other:

 

Justification for Protective Measure

______ Safety of Student

______ Safety of Others

Protective Hold/Escort Utilized:

Escort:                                         _____Guide-a-long

                                                _____Lower Figure Four

Protective Hold:                       _____Limited Security Hold (1)

                                               _____Full Security Hold (1)

                                               _____Seated Full Security Hold (1)

                                               _____Kneeling Full Security Hold (2)

                                               _____PMT Floor Control

Staff Implementing Protective Hold:

Staff 1 Signature: ___________________________ Init: ______

Staff 2 Signature: ___________________________ Init: ______

Staff 3 Signature: ___________________________ Init: ______

Immediate Notification:

Staff: ________

Time: ________

Admin: _______

_____________________

5-min. Notification

Staff: ________

Time: ________

Admin: _______

_____________________

20-min. Notification

Admin: _______

Total Duration: ______

Reason for Release:

Student Specific Criteria: __

Unsafe Protective Hold:   __

Physiological Factors:      __

Supervisor Directive:       __

Monitoring:

Staff____________________

Skin Color      ____

Breathing         ____

Body Position   ____

Reestablish

Therapeutic Rapport:

(follow up actions)

Classroom Teacher Review:                              __________________________        Date: _____

School Principal Review:                                   __________________________        Date: _____

Special Education Administrator Review:          __________________________        Date: _____

Nurse (if necessary)                                          __________________________        Date: _____