Policy JKA-E Student Restraint Incident Report Form

File: JKA-E

Student Restraint Incident Report Form

Student: _________________________ School: __________________________

Date: ___________________________ Time: ____________________________

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:

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

Efforts/alternatives made prior to the use of restraint:

_____ Teaching interaction

_____ Offered self-control strategy

_____ Verbal de-escalation

_____ Other(s) (please describe): ______________________________________

___________________________________________________________________

Type of restraint used:

___________________________________________________________________

___________________________________________________________________

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 title of person writing report

______________________________________

Signature

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 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]

Issued: September 23, 2014

Huerfano School District Re-1, Walsenburg, Colorado