NOTE:

For official copies of board policies and procedures please contact the superintendent's office at (253) 583-5190 or email supt@cloverpark.k2.wa.us

Physical Restraint/Isolation Incident Report

3246-F1
3248-F1
A. Student Information
Name
School
Date of Birth
Grade



Race/Ethnicity:




English Language Learner:
Level:

Gender:


 

B. Incident Description
Date incident occurred
Time restraint began: Time isolation began: Location of incident

Time restraint ended: Time isolation ended:
Behavior(s) directed at:

Other:
Behavior(s) the student exhibited prior to incident:


Aggressive behavior(s) the student exhibited prior to incident:






Intervention(s)/effort attempted to de-escalate student prior to physical restraint/isolation





Restraint methodology used:

Other:
Restraint hold used:











Student’s behavior during restraint:
Student’s behavior after restraint:

Physical Restraint: physical intervention or force used to control a student, including the use of a restraint device.

Restraint Device: device used to assist in controlling a student, including but not limited to metal handcuffs, plastic ties, ankle restraints, leather cuffs, other hospital type restraints, pepper sprays, tasers or batons

Isolation: excluding a student from his/her regular instructional area and restricting the student alone within a room or any other form of enclosure, from which the student may not leave.

Does include room clears if student is not permitted to leave the room. Does NOT include time out, study carrel, hallway, etc., or any area that student goes to voluntarily calm down. Student must be under constant visual and auditory supervision of staff.

C. Staff administering the physical restraint/isolation
Name (print name) Position Restraint
Certified
Restraint
Methodology
Received training
prior to restraint/
isoloation















 

D. Staff/student observing the incident
Staff/Student (print name) Position Was there any injury to staff and/or student(s)?
Staff:
If yes, what: (fill in district incident report)
Student:

 

E. Principal Notification (as soon as reasonably possible)
Date
Time

 

F. Parent Notification (Parents must be verbally notified by the end of the day, or as soon as reasonably possible. Written notification must be given within five days)
Name of parent(s)/guardian(s) contacted:
Time of verbal contact:

Date:

Date of written contact:
Staff contact:
Staff contact:

 

Report prepared by:


Employee

Date

Administrator

Date

 

Send completed pages one and two to parent within three business days


G. Debriefing Information (to be completed by staff members involved in the restraint/isolation as well as any other appropriate personnel)
Date of debriefing
Time of debriefing meeting
Location
Debriefing notes for restraint: Debriefing notes for isolation:
Who was involved:
Who was involved:
Where did it happen:
Where did it happen:
What were the identified triggers:
What were the identified triggers:
What happened:
What happened:
What de-escalation techniques were used:
What de-escalation techniques were used:
What worked and what didn’t work:
What worked and what didn’t work:
What would you do differently next time:
What would you do differently next time:
Was a tiered level of support used? Was a tiered level of support used?
Was the BIP followed? Was the BIP followed?
Position Printed name of those attending the debriefing meeting Signature of those attending the debriefing meeting

Report prepared by:


Employee

Date

Administrator

Date

 

Send all completed pages to risk management, with a copy to the special education office (if student has an IEP), at the Student Services Center no later than two days after incident.