Updated August 2019

Physical Restraint, Transport and Seclusion Documentation Student: Date of Incident: School:

Grade: ☐Male ☐Female ☐ IEP ☐ 504 ☐ FIE ☐N/A

NCI= Nonviolent Crisis Intervention® CPI = Crisis Prevention Institute®Seclusion – Confinement of a student in a room from which the student’s egress is restricted

Location: Time In: Time Out: Duration:

NCI Physical Transport – Safely moving an individual who is beginning to regain control

☐CPI Transport ☐CPI Interim Control☐Other (Describe):

Time Started: Time Ended: Duration:

NCI Physical Restraint – Used to manage individuals who have become dangerous to themselves or others; used as a last resort

☐CPI Team Control ☐CPI Children’s Ctrl. ☐CPI Standing Hold ☐CPI Seated Hold☐ Other (Describe):

Time Started: Time Ended: Duration:

List All Staff Members Involved (minimum first initial and last name):

Before Seclusion/Restraint/Transport (Check implemented items and describe when indicated with a colon)Setting Events (Events indirectly impacting the behavioral outcome)

Antecedents (Immediate triggers or predictors of the problem behavior)

Student Behavior Immediately after Antecedent

Staff Response(Calm & nonjudgmental actions taken to de-escalate student behavior and avoid seclusion/restraint)

Location: ☐Given Verbal Direction ☐Anxious (Describe): ☐Gave RedirectionsSubject: ☐Given Work/Activity ☐Offered Coping Skill/Break, etc.Activity: ☐Unexpected Change in Routine ☐Planned Ignore☐Conflict Prior to School ☐Presented w/Social Interaction ☐Gave Time to De-escalate☐Conflict at School ☐Told “No” by: ☐Gave Encouragement/Praise☐Change in Routine ☐Denied Access to Item/Activity ☐Defensive (Describe): ☐Positive Reminders ☐Difficulty in Previous Class ☐ Preferred Activity Removed ☐Gave Support☐Homework Not Done ☐Teacher Attending to Others ☐Assignment Modified☐Missed Medication ☐Given Correction/Redirection ☐Changed Instruction☐Substitute Teacher ☐With Specific Peer(s) ☐Gave space☐Academic Failure ☐Work too Hard/Easy Behavior Leading to

Seclusion/Restraint/Transport☐Visual Cues Used

☐Hunger ☐Work Repetitive/too Long ☐Modeled Expected Behavior☐Fatigue ☐Independent Work ☐Physical Threats/Intimidation ☐Empathic Listening☐Illness ☐Sitting for Extended Time ☐Physical Aggression-Self ☐Gave Choices ☐ Pain ☐Approached by Adult ☐Physical Aggression-Others ☐Time Out (Where):☐Large Group Instruction ☐Scheduled Non-Preferred Activity ☐Physical Aggression-Property ☐Loss of Privilege/Reward ☐Small Group Instruction ☐Waiting ☐Weapon Possession ☐Set Limits (1st /Then, When/Then)☐Individual Instruction ☐Transition to: from: ☐Elopement ☐Called for Team Support☐Unstructured Time ☐Sensory: ☐Other (Describe): ☐Remove Other Students☐Other: ☐Other: ☐Other:

Additional Comments:

Possible Function/Purpose of Behavior (select at least one and describe when indicated with a colon)Student may have been trying to gain- Student may have been trying to avoid-☐Social Interaction- ☐Peer or ☐ Adult ☐Social Interaction- ☐Peer or ☐ Adult☐Sensory Stimulation: ☐Sensory Stimulation:☐Preferred Activity/Item: ☐Non-Preferred Activity/Task:

Staff Debriefing and Future Approaches to Decrease or Eliminate Behavior from Reoccurring: ☐Team Meeting (IEP, Learning Supports, etc.) Date:

☐Parent MeetingDate:

☐Complete Brief FBA &Competing Pathways Chart

☐Review FBA/BIP ☐Revise Social Skill Instruction ☐Review Positive Behavior Supports☐Collect ABC Data ☐Review Replacement Behavior ☐Access Community Supports☐Consider Student Strengths ☐Review IEP Goals & Data ☐Other (Describe):☐Revise Academic Support ☐Contact AEA Supports

Injuries/Property DamageInjuries to student/employees/others: ☐No ☐Yes (Describe; do not use names):

Property damage: ☐No ☐Yes (Describe): Communication Documentation

Parent/guardian MUST be contacted ON DAY OF INCIDENT. *3 SEPARATE CONTACT ATTEMPTS SHOULD BE MADE ON DAY OF INCIDENT*Name of person contacted: Relationship:Date: Contacted by:*List attempts to notify parents/guardians on day of incident (when contact is made, record in “Time of Parent Response” below)* -Contact method: Time: Contact method: Time: Contact method: Time:Time of Parent Response: Response method - ☐ Phone Call ☐ In-Person ☐ Text Message ☐ Email Parent Response to Notification:

Parent requested Further Follow-up: ☐No ☐Yes (Describe):

Written documentation must be provided to parent/guardian within 3 school days (CANNOT BE SENT HOME WITH STUDENT).Name of parents/guardians the documentation was provided to:

Final outcome of incident: ☐Returned to Prior Setting ☐Sent to office ☐Sent home by admin ☐Sent home by parent choice ☐Other (Describe):

Student: Date of Incident:

Student Actions and Debriefing After Incident Staff Actions After IncidentStudent Actions Student Debriefing ☐Empathic Listening (Supportive/Undivided Attention)

☐Crying ☐Processing Activities (Describe): ☐Used Restatements for Understanding/Clarification☐Calm ☐Gave Wait Time☐Talkative ☐Allowed for Silence☐Silent ☐Coping Skill Activity (Describe): ☐Continued to Monitor☐Accepting Support ☐Assisted Student with Work Completion☐Sleeping ☐Supported Student in Class☐Following Directions ☐Expected Behavior Activity (Describe): ☐Assisted Student with Task Completion (cleaning up,

etc.)☐ Visited Nurse ☐Assisted with Coping Skill Activity☐Apologized for Actions ☐Followed Through on Prior Expectation☐Worked Independently ☐ Accepted Responsibility for Actions

(cleans up, etc.) (Describe):☐Assisted with Processing Activity

☐Communicated with Caregiver ☐Switched Staff Roles☐Restroom/Bodily Needs ☐Assisted with Expected Behavior Activity☐Other (Describe): ☐Other (Describe): ☐Other (Describe):

Updated August 2019

Date sent/provided: Sent/provided by:☐ Mail (postmarked within 3 days of the occurrence) ☐ Email (upon written request of parent/guardian)☐ Hand Delivered In-Person ☐ Text message (upon written request of parent/guardian)

During – Record actions of the student and staff during physical restraint, transport, and/or seclusion.*Students must be monitored constantly and documentation completed (all 4 columns) a minimum of every two minutes*

NOTE: For restraints and seclusions to exceed beyond each class period or every 45 minutes (consecutive OR non-consecutive), obtain signature of administration indicating authorization.

Time Observed Actions of Student During Transport/Restraint/Seclusion Staff Response to Observed Actions Staff Initials

Updated August 2019

☐ I have reviewed this form. ☐ This form was entered in Infinite Campus. Administrator Signature: ___________________________________

Administrator Signature (to go beyond every 45 minutes (consecutive or non-consecutive) or each class period)

☐In-person ☐Phone ☐Other (Describe): Method of Approval Time of Approval Date of Approval

Student: Date of Incident:

During – Record actions of the student and staff during physical restraint, transport, and/or seclusion.*Students must be monitored constantly and documentation completed (all 4 columns) a minimum of every two minutes*

NOTE: For restraints and seclusions to exceed beyond each class period or every 45 minutes (consecutive OR non-consecutive), obtain signature of administration indicating authorization.

Time Observed Actions of Student During Transport/Restraint/Seclusion Staff Response to Observed Actions Staff Initials

Student: Date of Incident:

District Policy on Student Restraint and Confinement/DetentionStudent Restraint and Confinement/DetentionThe Board of Education realizes that restraint and confinement/detention are, in some circumstances, appropriate as a means to maintaining a safe and orderly school environment. They also expect that such measures comply with the Iowa Administrative Code 281 – Chapter 103.

Use of Reasonable ForceAny staff member may, within the scope of his/her employment, use and apply such force as is reasonable and necessary for self-defense, to protect the safety of another person, to restrain a student from self-inflicted injury, to stop a fight between students, for the protection of property, to obtain possession of weapons or other dangerous objects upon the person or within the control of a student; and to use reasonable force in other circumstances as defined in 704.1 of the Code of Iowa.

Corporal PunishmentCorporal punishment is defined as the intentional physical punishment of a student. No employee shall inflict corporal punishment upon a student. Code of Iowa: 280.21 Iowa Administrative Code: Chapter 103, Section 281 704.1

Physical Restraint, Transport and Seclusion Parent Information

This packet provides information on physical restraint, physical transport, and seclusion as utilized in the Cedar Rapids Community School District (CRCSD). The following information is provided:

District Policy on Student Restraint and Confinement/Detention (Regulation 604.7) State of Iowa “Top 10 Points about Chapter 103: Amended Administrative Rules on Corporal Punishment, Restraint,

and Physical Confinement and Detention” Glossary of terms appearing in Physical Restraint, Transport and Seclusion Documentation Visual depictions of physical interventions

Top 10 Points about Chapter 103: Amended Administrative Rules on Corporal Punishment, Restraint, and Physical Confinement and Detention (Effective Nov. 12, 2008)

1. Add a training requirement Understand the law – Chapter 103 and Employers policies Positive behavior interventions and supports Disciplinary options to seclusion and restraint Crisis prevention, crisis intervention, crisis de-escalation techniques Student and staff debriefing

o Everyone who might need to implement seclusion or restraint should have the professional development described above. With supplemental information added regarding your district policies, the accompanying PPT presentation will serve the needs of this group.

Safe, effective use of restraint and confinement and detentiono All staff who definitely use seclusion and/or restraint should be trained in depth regarding holds, restraint, and seclusion (e.g.

Mandt, CPI) 2. Corporal Punishment is banned in Iowa. The definition of corporal punishment is “The intentional physical punishment of a

student, “including “the use of unreasonable or necessary physical force, or physical contact made with the intent to harm or cause pain.”

3. No mechanical restraints may be used. This includes misusing physical devices that are meant for safety, therapy, or another purpose (E.g. you may not use Rifton chair to discipline a child)

4. You can still use necessary and reasonable force. Necessary and reasonable are defined by the context of the event. (E.g. restraining someone for tearing up a paper is unreasonable and unnecessary force)

5. If using seclusion (or physical confinement), the room must be of adequate size, sufficient light, adequate ventilation, and temperature similar to the rest of the building

6. Period of time for confinement should be reasonable and allow for bodily needs. 7. If confinement extends past 60 minutes or 1 period (whichever is shorter), an administrator must authorize the continued

confinement. 8. Adequate and continuous adult supervision is necessary. 9. Material restraints cannot be used to maintain confinement. Door latches must be nonlocking and allow for easy exit if pressure is

released. May not be disabled by duct tape or chairs. No keyed locks!10. Notice to parents: if restraint or seclusion is used with a student, parents must be notified that day and in writing within 3 days.

Share documentation with parents. Documentation includes: Name of student involved, Name of employees involved, including the administrator authorizing further confinement Date, time & duration of incident

Updated August 2019

☐ I have reviewed this form. ☐ This form was entered in Infinite Campus. Administrator Signature: ___________________________________

Administrator Signature (to go beyond every 45 minutes (consecutive or non-consecutive) or each class period)

☐In-person ☐Phone ☐Other (Describe): Method of Approval Time of Approval Date of Approval

NCI Physical RestraintSeated Hold

Standing Hold Team Control

Abbreviations Listed on the Seclusion and Restraint Documentation FormCPI Crisis Prevention Institute

More information can be found here: www.crisisprevention.com

NCI Nonviolent Crisis InterventionPractical skills for safely managing and preventing difficult behavior – proprietary language from CPI.

FBA Functional Behavior AssessmentA systemic way to figure out what triggers problem behavior. The information is used in designing a plan to address problem behaviors and prevent them from happening in the future.

BIP Behavior Intervention PlanA plan that includes positive strategies, program modifications and supplementary aids and supports that address a student’s disruptive behaviors.

IEP Individualized Education PlanThe IEP is written document that describes the educational plan for a student with a disability. The IEP talks about the student’s disability, what skills he/she need to learn, what the student is doing in school this year, what services the school will provide, and where learning will take place.

FIE

CPC

Full Individualized EvaluationAn initial evaluation to determine if a student is a child with a disability and the educational needs of the student. The FIE determines eligibility for special education.Competing Pathways ChartA chart utilized along with an FBA to help identify appropriate replacement behavior

504

BFBA

Individualized Plan of Accommodations A plan that lists the accommodations a school will provide, such as audiobooks, note-taking aids or extend time to complete tests, so that a student with a disability has equal access to the general education curriculum. (Accommodations are tools or procedures that provide equal access to instruction and assessment for students with disabilities.)Brief Functional Behavior AssessmentChecklists and questionnaires that help determine the function/purpose of problem behavior

PBS Positive Behavior SupportsSupports that reinforce appropriate behaviors and make challenging behavior less desirable to engage in.

RB Replacement BehaviorA replacement behavior is an alternative that allows a student to meet the same need or achieve a similar outcome as the undesired behavior they are currently using.

ABC ABC Data – Antecedent- Behavior- Consequence Data:ABC data is collected through direct observation to gather information about the events that are occurring within a student’s environment. “A” refers to the antecedent, or the event/activity that immediately precedes a problem behavior. “B” refers to observed

AEA Area Education AgencyEducational service agencies that ensure all students have access to high-quality educational opportunities and resources. AEA staff work

Updated August 2019Updated August 2019