5144.1 Form 1

_______________ Public Schools

Physical Restraint Report Form

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

Physical Restraint: Any mechanical or personal restriction that immobilizes or reduces the free movement of a person's arms, legs or head. The term DOES NOT INCLUDE: (A) Briefly holding a person in order to calm or comfort the person; (B) restraint involving the minimum contact necessary to safely escort a person from one area to another; (C) medical devices, including, but not limited to, supports prescribed by a health care provider to achieve proper body position or balance; (D) helmets or other protective gear used to protect a person from injuries due to a fall; or (E) helmets, mitts and similar devices used to prevent self-injury when the device is part of an individualized education program pursuant to state special education statutes or an exclusionary time out.

STUDENT INFORMATION:

Name of Student: ___________________________________ Date of Restraint: _____________

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 physical restraint: ______________________

This report prepared by: __________________________________ Position: ________________

Staff administering restraint:

Name: ___________________________________ Title: _______________________________

Staff monitoring restraint:

Name: ___________________________________ Title: _______________________________

Administrator who was verbally informed following the restraint:

Name: ___________________________________ Title: _______________________________

Reported by: ______________________________ Title: _______________________________

PRECIPITATING ACTIVITY:

Description of activity in which the restrained or other students were engaged immediately preceding emergency use of physical restraint:

Description of the risk of immediate or imminent injury to the student restrained or others that required use of physical restraint:

Description of other steps, including attempts at verbal de-escalation, to prevent the emergency necessitating use of restraint:

DESCRIPTION OF PHYSICAL RESTRAINT:

Justification for initiating physical restraint (check all that apply):

___ Non-Physical interventions were not effective

___ To protect student from immediate or imminent injury

___ To protect other student/staff from immediate or imminent injury

Type of Protective Hold Used:

___ Side by side parallel hold

___ Lifted and carried (full security hold)

___ Held in chair (reverse cradle transport)

___ Floor control

___ Other (describe)

Regular evaluation of the student being restrained for signs of physical distress:

Time: _______ Evaluation:____________________________________________

Time restraint began:_______________________ Time restraint ended:____________________

Total time (in minutes): ____________________

CESSATION OF RESTRAINT:

How restraint 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 de-escalation

___ Law enforcement personnel arrived

___ Staff sought in-house assistance

___ Community emergency personnel arrived

___ Other (describe):

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

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 restraint

___ 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 restraints):

Parent who was verbally informed of this restraint:

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 physical restraint report

___ Reviewed behavior plan, if applicable

___ In considering the effect of the restraint on the student's established behavioral support of educational plan, I find the following: __________________________________________________

____________________________________________________________________________________________________________________________________________________