Policy Details

5144.1 FORM 2 Incident Report of Physical Restraint

5144.1
Form 2

Connecticut State Department of Education

Incident Report of Physical Restraint (revised July 2018)

Note: 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. An Incident Report of Physical Restraint 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.

Physical Restraint means any mechanical or personal restriction that immobilizes or reduces the free movement of a child's arms, legs, or head, including, but not limited to, carrying or forcibly moving a person from one location to another.


Physical Restraint does not include: (1) briefly holding a child in order to calm or comfort the child; (2) restraint involving the minimum contact necessary to safely escort a child from one area to another; (3) medication devices, including supports prescribed by a health care provider to achieve proper body position or balance; (4) helmets or other protective gear used to protect a child from injuries due to a fall; or (5) helmets, mitts, and similar devices used to prevent self- injury when the device is part of a documented treatment plan or IEP and is the least restrictive means available to prevent self-injury.

District Information

School District: School: Date of Restraint:


Address: Phone: Address: Phone:

Date of Report:


Person preparing the report:


Time restraint initiated


Time restraint ended


Total time of restraint


*If the total length of the restraint exceeds 15 minutes, attach the documentation of the required Administrator's (or designee) determination of the need for continuation of the restraint 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.

Restraint was initiated in response to an "emergency".



Staff Information

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


Title _ Title


Student activity/behavior precipitating use of restraint

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




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


_


Staff activity/response

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


Describe the nature of the physical restraint: (Include the type of hold/restraint and the number of persons required. Was it used as an emergency procedure to prevent immediate or imminent injury to the student or others?):


Did the student demonstrate physical distress during the restraint? 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 restraint:


Was the student injured during the emergency use of restraint? 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 restraint within a 20 school-day period.

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


Public Act 18-51 continues to require 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 30 minutes thereafter regarding whether such physical restraint or seclusion is necessary to prevent immediate or imminent injury to the student or to others.

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

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


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

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


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

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


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

30 minute determination of the necessity of continued restraint: 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 physical restraint.

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