Policy Details

5144.1 FORM 1 Incident Report of Seclusion

5144.1
Form 1

Connecticut State Department of Education
Incident Report of Seclusion (revised July 2018)

Note: Any use of seclusion is to be documented in the child's educational record and, if appropriate, in the child's school health record. An Incident Report of Seclusion is required and should be completed as soon after the incident as possible or within 24 hours of the incident. Parents/guardians must be notified in writing within 24 hours of the incident. Notification should include the information documented on the incident report.

Seclusion means the involuntary confinement of a student in a room, from which the student is physically prevented from leaving. "Seclusion" does not include an exclusionary time out.

District Information

School District: School: Date of Seclusion:


Address: Phone: Address: Phone:

Date of Report:

Person preparing the report: Time seclusion initiated Time seclusion ended Total time of seclusion *


*If the total length of the seclusion exceeds 15 minutes, attach the documentation of the required Administrator's (or designee) determination of the need for continuation of the seclusion to prevent immediate or imminent injury to the student or to others.

Student Information

Student's Name:


SASID #:


Date of Birth:


Age:


Gender (M /F):


Grade:


Race:


Disability:


The student is a general education student.

The student currently receives special education services.

The student is being evaluated or considered for eligibility for special education services.

Seclusion was initiated in response to an "emergency".

Staff Information

Name of staff administering seclusion: Name of staff monitoring/witnessing seclusion:


Title _ Title

Student activity/behavior precipitating use of seclusion

Describe the location and activity in which the student was engaged just prior to the seclusion:



Describe the risk of immediate or imminent injury to the student secluded or to others that required the use of seclusion:



Staff activity/response

Describe other steps, including de-escalation strategies implemented to prevent the emergency, which necessitated the use of seclusion:


Describe the nature of the seclusion: (Was it used as an emergency procedure to prevent immediate or imminent injury to the student or others?):


Did the student demonstrate physical distress while in seclusion? Yes No Indicate times student was monitored for physical distress and if any signs of physical distress were noted:


Describe the disposition of the student following the use of seclusion:


Was the student injured during the emergency use of seclusion? Yes No

If "yes," complete and attach a report of injury.



Parent/Guardian Notification

Was parent/guardian notified within 24 hours of the incident?

Yes (indicate manner)

No

Was a copy of the incident report sent to parent/guardian within two business days?

Yes No

Is a *PPT meeting required to review/revise the IEP or discuss additional evaluation or the development/revision of an FBA and or BIP? Yes No

Is a PPT meeting recommended to modify the IEP? Yes No if "yes," indicate date

Is a *meeting required for this general education student? Yes No

If "yes," indicate date

*A PPT meeting or a meeting is required if this incident marks the 4th incident of seclusion within a 20 school-day period.


Please complete when a student is secluded for a period exceeding 15 minutes.


Public Act 15-141 requires that an administrator, as defined in Section 10-144e of the general statutes, or such administrator's designee, a school health or mental health personnel, or a board certified behavioral analyst, who has received training in the use of physical restraint and seclusion, shall determine whether continued physical restraint or seclusion is necessary to prevent immediate or imminent injury to the student or to others. Upon a determination that such continued physical restraint or seclusion is necessary, such individual shall make a new determination every thirty minutes thereafter regarding whether such physical restraint or seclusion is necessary to prevent immediate or imminent injury to the student or to others.

Time seclusion was initiated: a.m./p.m. Time seclusion was terminated: a.m./p.m.

15 minute determination of the necessity of continued seclusion: a.m./p.m.

Signature of *qualified administrator, designee, school health or mental health professional

30 minute determination of the necessity of continued seclusion: a.m./p.m.

Signature of *qualified administrator, designee, school health or mental health professional

30 minute determination of the necessity of continued seclusion: a.m./p.m.

Signature of *qualified administrator, designee, school health or mental health professional

30 minute determination of the necessity of continued seclusion: a.m./p.m.

Signature of *qualified administrator, designee, school health or mental health professional

*NOTE: "Qualified" is defined as having received required training in the use of seclusion.

Download a PDF of this Form