i. Student: it E. 4n!" ?u Physical Restraintand Seclusion Documentation Date of Incident: I School: Grade: I Seclusion - Location: Time In: Time Out: Duration: Con?nement ofa student in a room from I . which the student?s egressis restricted goal/V} 5? Student Entered Seclusion by: UWaIked on their own CPI Transport DCPI Interim Control Physical Transport: Safety moving an Bether ?grease Describe): individual who is beginningto regain conlml Time Startedz/l; l7 Time Endedi/y? Duration: /?wq Physical Restraint? DCPI Team Control Time Started: Time Ended: Duration: Used to manage individuals who have Children?s Control 358:3?fadglfiggitm themsewes Growers El Other (Please Describe): Staff Members Involved: ort (Check implemented Items) Setting Events Antecedents Student Behavior Staff Response {Event impacting the (Immediate trigger or predictors of Immediately after (Calm 8: Noniudgmental actions taken to behavioral outcome) the problem behavior.) Antecedent 2:21:35 bEhaWDr and ?Did Location RG/iven Verbal Direction monous (Dacribe): max/e Redirections DSubject: EIGiven Work/Activity m3, 5,25 1 gee; gathered Coping Skill/ break, etc. DActivity: UUnexpected Change in Routine qt D?e?g I Jill? DPlanned Ignore Con?ict Prior to School DPresented w/Sociai Interaction a I DGave Time to Deescalate DCon?ict at School ?No? by: I EIGave Encouragem ent/ Praise DChange in Routine ElDenied Access to Item/Activity DDefensive DPositive Reminders (When/Then} UDi??TcuItyin Previous Class Preferred Activity DGave Support DHomework Not Done Bleacher Attending to Others UAssignment Modi?ed DMissed Medication When Correction/Redirection CIChanged Instruction Small Group instruction, Eilndependent Work DSubstitute Teacher DPeople too Close El Used ProxemicsiKinesics DAGademic Failure DLoud Noises/Room Behavior Leading to DPara Verbal Communication DHunger Lights Seclusion/ Restraint DUsed CPI Supportive Stance DFatigue a Speci?c Peerls) EIVerbaiI Aggression DWSUBI Cues Used Dillness DWork too Hard/Easy EIVerbal Threats/Intimidation DModeled Expected Behavior {juggle Group instruction DWork Repetitive/too Long Threat/Intimidation UEmpathic Listening El Physical Aggression/Self DGave Choices - More Out(Wherje): ?00.44 Ulndividuai Instruction 'Clln Pain UPhysital Aggression/Others EIUnstructured Time EISitting For Extended Time UPhysicai Aggression/Property DLoss of P?viIegefReward DApproached By Adult U_Weapon Possession [Set Limits (1st [Then-r, When/Then) DScheduled Non Preferred Activity - DCalled for Team Support DWaiting @ther (Please Describe}: DRemove Other Stu de nu - DTlansition to: from: r,hW Gig-135 DOther: DOther: - wank}! Ago} 5&5? Cl Additional Comments: Jamaal . Possible Function/Purpose of Behavior Student may have been trying to gain: Student may have been trying to avoid: eer or ?dual; DSocial Interaction Peer or 5-d- ljSensory Stimulation DSensory Stimulation CI Preferred Activity/ Item on?P referre Activity/T as DAdujt i i Physical Restraint and Seduslon; Documentation .1 Etudent: I Date orfincident' During Record actions of the student and during physical restraint, transport, and/or seclusion. Students must be monitored constantiy and documentation completed at a minimum of every two minutes. NOTE: For restraints and seclusians to exceed beyond each class period or every 60 minutes, obtain signature of administration indicating authorization. .. . Staff initials" "estratnt- 13ft ?rsponse to Obse Ned Actions Time I I 9 bserved Actions of the Student During SeclusionIR .. (ea Administrator Signature (to go beyond every 60 minutes or eacii class period) Time I Date I . ?thsma; Restraint and SEClusIe-n Documentatron Date of Incident: Student: Staff Actions After Incident DSupportive/ Undivided Attention Student Actions and Debrie?ng After incident Student Actions A Student Debrie?n'g ing - DProcessi?ng Aetivities'mesm'be} IDErnp'athic Listening . . . Calm I I I I U'Used Restatements for Understanding/Clari?cation ERa?onal tE?i?fave Wait Time I - . UTalk'ative - . DAliowed for Silence [tenant - . Scoping Skill Activity ibeso?ibe) oer-amt to Monitor 3 . DAccepting Support UAssisted Student with Work Completion - [:l?iired; DWalk?ed Student to Class DSIeeping I DSupported Student in Class . gallowing Directions gapected Behavior Ac?ytty, DAssisted Student with Task Completion [cleaning up, etc-) CIRetur?ned to Class i ?be? ji?fhr?g I I UCornrnunicated with Caregiver Name: 1:1 Visited Nurse .- DFolio'vvedThrough on Prior EXpectation I UApologited for Actions I EASsisted with Processing Activity DCornmunic'at'ed with Accepted Responsibility for UMaintained Awareness of ProXernics, Kinesics, Caregiver Name: Actions [cleans up, etc.) Para verbal Communication DPacing - If DAssisted with Coping Skill Activity BWorked Independently - DSwitched Staff Roles I II DRestroom/Bodily'hieeds UOther {Describe} masters: with Expected Behavior Activity - I mother (Describe) - I DOther - . Staff Debrie?ng and Future Approaches to Decrease" or Eiiminate Behavior from Reoccurring: Cl Collect ABC Data Diearn Meeting HEP, Learning Supports, UParent Meeting Date: etc.) Date: 1 -. 1:1 Review FBNBIP WeviSe sociai Skill Instruction UComplete Competing Pathways Chart- Etonduct Functional Behavioral Assessment {Review Replacement Behavior Review Positive Behavior Supports DConsider Student DReview IEP Goals 8L Data DAccess Community supports, DRevise Academic Support UContact AEA Supports DDther: - Describe any injuries to student, employees, others, or property damage: NW KWEIQA. Communication Documentation Parent] guardian mtg; Entacted on day?of incident Name of person contacted: Relationship: Date: I Time: Methodgin 05%} By: Describe attempts to notify the parentfgua'rdian ifcontact cannot be mdde on (day of incident. Written documentation must be sent to parent/guardian within 3 school days- Date sent: I Sent by: @Mail (postmatked within 3 days otthemoccurrence)" Eiriail'npon written request or re" guardian Fax upon written request ofparent/guardian Hand Delivered in Person Dial-me 0f Parent/guardian the documentation was sent to! .. ,?ir {l at"? 5353333353 . .i a - - -: "95 and Seclusron Documentation 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 at a minimum of every two minutes. NOTE: For restraints and sec/asions to exceed beyond each class period or every 60 minutes, obtain signatare of administration indicating authorizationTim Observed Actions of the Student During Seclusmn/Restramt Staff Response to Observed Actions [1:215 Administrator Signature (to go beyond every 50 minutes or each class period) Tima Date ,a 5 (If Cedar Rapids {piT?mLmitVSd?W?Di??it?d Physical Restraintand Seclusion Documentation Con?nement ofa student in a room from which the student's egress is restricted Til/5e 2:23 72wl?iimag Student: Date oflncident: School: Grade: l? Seclusion Location: Time in: Time Out: Duration: Student Entered Seclusion by: DWalked on their own DCPI Interim Control NCI Safely moving an mther Phase Describe). Egg? (5W a individual who is beginhing to regain control - ?2c; ?it/M mash: 0% 01 Time Stia ['iZEerQ: Time Endedz'z? Duration: Physical Restraint? UCPI Team Contrdi Time Started: Time Ended: Duration: Used to manage individuals who have children?s Cont?); become dangerous to themselves or others; . used as a last resort El Dther(Please Describe)". Staff Members involved: (Check implemented items) Setting Events Antecedents Student Behavior Staff Response (Events i_ndirectly impacting the behavioral outcome) (Immediate triggers or predictors of the problem behavior.) Immediately after Antecedent (Calm Sr Noniudgrnenta] actions taken to de?esaliate student behavior and avoid seclusion} restraint) ?gven Verbal Direction DAnxious (Describe): Wave Redirections ocatio: gsiibject: Ll?' ?siven Work/Activity {DOffered Coping Skiil/ break, etc- DActivitv: DUnexpec?ted Change in Routine DPIanned Ignore Con?ict Prior to School El Presented w/Sociai interaction CIGave Time to De?escalate DConflict at School CIToid ?No? by: EIGave Encouragement/Praise DCha age in Routine DDenied Access to itemfActivity ?Defensive (Describe): DPositiVe Reminders (When/Then) El Difficulty in Previous Class El Preferred Activity Removed Ara? leg? am CIGave SUpport Homework Not Done RDIeacher Attending to Others 99 if I avg DAssignment Modi?ed DMissed Medication ?Given CorrectionfRedirection UChanged Instruction DSubstitute Teach er DPeople too Close Used Proxemics/Kinesics DAcademic Failure El Loud Noises] Room Behavior Leading to El Para Verbal Commu nication El Hunger DBright tights Seclusio n/ Restraint Used CPI Supportive Stance DFatigue DWith a Speci?c Feeds) DVerba'l Aggression DVisual Cues Used Dillness DWork too HardIEasv DVerbal Threats] Intimidation DModeled Expected Behavior DLarge Group Instruction DWork Repetitive/too Long UthsiCBI Threats/intimidation DEmpathic Listening El mall Group Instruction. El Independent Work El Physical Aggression/Self DGave Choices El Individual Instruction 'Uln Pain Aggression/Others D'?rne Dut (Where): Unstructured Time DSitting For Extended Time El Physical Aggression} Property :lLoss of Privilege/Rewa rd DApproached By Adult ElWeapon Possession DSet limits (its1 [Them When??hen] DSEheduled Non Preferred Activity ?Elopement DCalled for Team Support DWaiting Ebther (Please Describe); DRemove Other Students EITransition to: from: 5,1 A DOther: DOther: g: Mm Cl Additional Comments: ab . Possible Function/Purpose of Behavior Student mayr have been trying to gain: Student may have een trying to avoid: [Social Interaction UPeer 'or Cl Adult DSocial Interaction UPeer UAdult or DSensory Stimulation (:ISenSory Stimulation El Preferred Activity/Item mid?Preferred Activity ask Jae. .. Restraint and Seclusron Datumen?tatwn rStudent: I I I Date aflncident'_ I During Record actions of the student and staff during physical restraint, transport, andfor seclusion. Students must be monitored constantly and documentation compieted at a minimum of every two minutes. NOTE: For restraints and sealusions to exceed beyond each class period or every 60 minutes, obtain signature of administration indicating authorization. Staff Initials Time Observed Actions of the Student During Seciusion/Restraint Staff Re?sponse to Observed Actions Administrator Signature (to go beyond every 60 minutes ar each class period) Time I Date CGW Physical Restminf anti Seclusion . I d1 L4 1 Siudmt; IDateo In Elem. I I ?hm ?ring-w Record actions of the Studeni: aod SEEM physicaf remint, tt'ansoorf, and or secluSED-n- Smdonis nuts? [39. monitored consian?y and documentation minimum {5vava two NOTE: For raqromt: and .. . gedosfons to Exceed beyond eoch CIHSS period or every 60 minute; obtain Signofure 3? Time Closet-?ed Actions of theStLIdEnt During Sedusion [Restraint SEE Hesponso to Observed Ac?uns 3713?: F14 A .44 . 5?1. . 1 x. a - .?gg??4Wax/M a . esm?ledv?o m6 istrator Signature [to go oeyuud [mom or Each c1355 period} . Time Data? . Admin free? Germ-am Restraan anzf Sedusmn Documentation I Sindent: I Date. of Ind?ent: . - uring? Reeo rd ac?ons of the student arid Stuff during physicaf rem-int, transport and/or seclusio n- Studen?cs must be mo?itnred co ns'tan?y and trio cumenta?on completed?Erie minimum of mew two.an urea?NOTE For raman and SE dosions to exceed beyond each dogs period oreven/ 60 minutes, obiofn Sign ofure of administration Indfco?ng ou'ihorizo?on- Time thenred Actions of t?e'Studenf During SedusionfRestrai?t ff Response ?to Observed Ac?nns . Adminmt?r Signature (tn 3? bEY?nd minutes or each class Period) . Time - - Date ii . . ?ya-Ml physicai Restraint and Secluszon Documentation Student: Date of Incident: During Racord actions ofthe student and staff during physical restraint, transport, and/or sedusion. Students must be monitored constantly and documentation completed at a minimum of every two minutes. NOTE: For restraints and seclusians to eXCeed beyond each ciass period or every 60 minutes, obtain signature of administration indicating authorization. Staff Time Observed Actions of the Student Dun'ng Seciusian/Restraint Staff Re5ponse to Obserued Actions Initials Administrator Signature (to go beyond ewery SD minutes or each class period) Time Date v: - - - - Restraint and Seclusmn Documentation 1? 1 Student: . Date ofincident: - Student Actions and Debrie?'ng After incident Staff Actions After Incident Student Actions Student Debrie?ng . I ?opport?ive/ Undivided Attention I DCrying' . I DProcessing Activities (Describe) DEn-ipathic Listening I I I gile DUsed Restatement for Under?anding/Clari?cation [:IlRational DGave Wait Time - I I DTalkative - . I UAllowed for Silence DSilent' I ESQCopi?ng Skill Activity {De The) ?Continued to Monitor I - . . UAcCepting Support flank, 3,9 DAssisted Student with Work Completion - 4M D'lired I (Await-5, ?Walked Student to Class - . DSleeping ?m DSupported Stddentin Class . QFollowing Directions DExpected Behavior Activity DAssisted Student w'rd1 Task Compietion (cleaning up, etc.) ??eturhe?d to Class (W133) I UCo'mmunicated with Caregiver Name: Cl Visited Nurse - DFolloWed Through on Prior EXpectation DApologiged for Actions I DAssisted with Processing Activity DCommunicated with Cl Accepted Responsibility for DMaintained Awareness of Proxernics, Kinesics, 8: Caregiver Nam e: Actions (cleans up, etc.) Pala verbal Communication DPacing DAssisted with Coping Skill Activity DWorked Independently - USwitched Staff Roles URestroom/Bodily Needs Bother (Describe) DAssisted with Expected Behavior Activity DOther {Describe} . DOther - Staff Debrie?ng and Future Approaches to Decrease'or Eliminate Behavior from Reoccurring: Meeting Learning Supporu, Meeting Date: DCollect ABC Data etc.) Date: - 1 . . I milievise Social Skill Instruction [Ecomplete Competing Pathways Chart I I DConduct Functional Behavioral Assessment DReview Replacement Behavior I DReview Positive Behavior Supports DConsider Student DReview 1 EP Goals Data DAccess Community Supports?- ElRevise Academic Support UConlact AEA Supports I I DDther: - - Describe any injuries to student, employees, others, or property damage: Mm Communication Documentation Parent/guardian plug; be contacted on day of incident. . Name of person contacted: Relationship: Date: I Time: I By: Describe attempts to notify the parent/guardian if contact cannot be lnade on day of incident: Written documentation _r_n__ust be sent to pare nt/gua rdian within 3 school daysSent by . a Mail (postmarked/(within 3 days of the occurrence) [3"Er?a?ii??pdn written tEquesi a. pm; El Fax upon Written request of parent/guardian Hand Delivered ln Person a- Name of parent/guardian the documentation was sent to: i I 6' Cir-3"- If- Cedar RapidS Student: Grade: adornmug?ty Sid-incl Physical Restraint__and Seclusion Documentation te of Incident: Schook Seclusion Con?nement ofa student in a room from which the student?s egress is restricted Student Entered Seclusion by: PhysiaiTaanspor-t Safer moving an I togatio n: c~ ml media?" DOther (Please De BWalked on their oiwn Time In: tff? dad M??l Transport his: scribe): Time Out: 2 3 I0 Duration: ?Edema CPI Interim Co ntrol (Vila leiw?; (EvenE i_ndirectly impacting the (Immediate triggers or predictors of Immediately after Indmdual who is regain control Tune Started: .I?lme Ended: In?ation: MCI Physical Restraint? DCPI Team Control Time Started: Time Ended: Duration: Used to manage individualsth have DCPI childrenls CD ntm] be120me dangerous to themselves or others; . used as a Eastman? Other (Please Staff Members involved: Befo (Check Implemented Items) Setting Events Antecedents Student Behavior Staff Response (Calm 8v. Noniudgmentai actions taken to demiate student behavior and avoid behavmral outcome} the problem behavior.) Antecedent sedus?onlrmint} Location: h??iven Verbal Direc?on DAnxious (Describe): DGave Redirections EEGiven Work/Activity Do?ered Coping Skill/ break, etc. DActivity: EIUnexpected Change in Routine DPianned ignore El Con?ict Prior to School DPresented w/Sodal Interaction DGave Time to De?escalate El Conflict at School EITold ?No? by: Gave Encouragement/Praise DChange in Routine DDenied Access to Item/Activity Positive Reminders (When/Then) [JDefensive (Describe): Cl Dif?culty in Previous Class Cl Preferred Activity Removed Gave SUpport Homework Not Done MTeacher Attending to Others UAssignment Modi?ed DMissed Medication UGivan Correction/ Redirection DChanged Instruotion DSubs?tute Teacher DPeople too Close Used ProxemiG/Kinesics CIAcademic Failure DLoud Noises/Room Behavior Leading to Para Verbal Communication Cl Hunger [:lBright Lights Seclusion/ Restraint D'Used CPI Supportive Stance CIFatigue a Speci?c Feeds) DVerbai Aggression . DWsuaI Cues Used Diliness DWork too Hard/Easy DVerbal Threats/ Intimidation [:llv'lodeled Expected Behavior Charge Group instruction DWork Repetitiveftoo Long Threats/Intimidation Empathic Listening Additional Comments: DSmall Group Instruction, Ulndependent Work UPhysical Aggression/Self Gave Choices El Individual Instruction ?Dln Pain Aggression/Others D'?me Dut (Where): El UnstrUctured Time . DSitting For Exten Dthsical Aggressioanropel-ty Loss of Privilege/Reward DApproached By Adult I]_Weapon Possession DSet Limits fThen, When/men) UScheduled Non Prefen?ed Activity DElopement Called forTeam Support DWaiting ROther (Please Describe): DRemove Other Students - UTransition to: from: (?Vip?iw IQDFQEA @Dther: DomePossible FunctionIPurpose of Behavior Student may have been trying to gain: Student mayr have been trying to avoid: ctiotL. UPeer or Cl Adult IZISocial Interaction Cl Peer or DAdult USensory Stimulation USensorv Stimulation Cl Preferred Activity/Item ?lm?P referred Activity ask Restraint and Seclusrar?t Documentation rStudent: I Date of incident I .. . I During Record actions of the student and staffdu?ng physical restraint, tranSport, andlor seclusio n. Students must be monitored constantiy and documentation compieted at a minimum of every two minutes. NOTE: For restraints and seclusions to exceed beyond each class period or every 60 minutes, obtain sign ature ofadministratian indicating authorization- . Staff ['nitiafs Staff ReSponse to Obse Ned Actions Time Ob'semed Actions of the Student During Seclusio anestIaint Administrator Signature [to go beyond every 50 minutes or each class period] Time - Date - .vr?r x? a Physical Restraint and Seclusion Documentation Date of Incident During - Record actions of the student and staff during physical restraint, transport, and/arseclusiom Students must be mon'rtored constantly and documentation completed at a minimum ofeuery two minutes. NOTE: For restraints and seclusions to exceed beyond each class period or every 60 minutes, obtain signature of administration indicating authorization. me Observed Actions of the Student During Seclusioanestraint Initials Administrator Signature (to go beyond every 50 minutes or each class period) Time Date - it sittcg? g' a I . 5 Physical Restraint and Seclusmn Documentation . . i . \g i Student: Date oflncident: Student Actions and Debrie?ng After Incident Staff Actions After Incident Student Actions Student Debrie?ng I ijppor?ve/ Undivide'd Attention I - DCrying DProcessing Activities (Describe) El Empathic Listening 1 grain: I I DUsed RestatemEnts for Understanding/Clari?ation URational ?fiave Wait Time - DTalk'ative rE??tllowed for Silence DSilent' DCoping Skiil Activity (Describe) UCDntinued to Monitor UAccepting Support I DASsisted Student with Work Completion 'U??red DWalked Student to Class [:lSleeping DSupported Student in Class . @Followihg Directions DExpected Behavior Activity Dessisted Student with Task Completion (cleaning up, etc!) mama's to Class . (mm) ECO-mmunicated with Caregiver Name: El Visited INUrse I I I [Cl Followed Through on Prior Expectation UApoiogited for Actions DAssisted with Processirig Activity DCommu'nicated with Accepted Rspo'nsibility for - -- DMaint-ained Aware'nESs of Proxemics, Kinesics, Caregiver Name: ?ctions (cleans: ,ketc) Para Verbal communication [leasing I {it igm?l MW: [Riggs DAssisted wi?1 Coping'Skill Activity Dworked independently l?gg?gg? avgavg? DSwitched Staff Roles . DRestroom/Bodily Needs FDOther (Denise) UAssisted with Expected Behavior Activity DOther {Describe} . I . .. DOther Staff Debrie?ng and Future Approaches to Decrease or Eliminate Behavior from Reoccurring: Clieam Learning Supports, etc.) Date: ElParent Meeting Date: Collect AB Data littevise Sociai Skill Instruction DComplete Competing Pathways Chart I DConduct Functional Behavioral DReview Replacement Behavior El Review Positive Behavior Supports- ClConsider' Stu dent UBeview IEP Goals Data DAccess Community Supports: DContact AEA Supports DOther: CIRevise demic Support Describe ariv injuries to student, employees?others; or property damage: NW Communication Documentation Parent/guardian must be contacted on dav of incident. Name of person gontacted: Date: Time: Relationship: . Method: (ieli Describe afteng to notify the parent/guardian ifcontact cannot be made On day ofincident: Mm By: Written documentation must be sent to parent/guardian within 3 school davst .. .. .. . Mail [postmarxeo WW.an .3 days ofthe occurrence) El Fax upon Written request of parent/guardian wa?e? 'z?equeSL a. Pale-neg; Cl Hand Delivered in Person l5; [Fame of parent/guardian the documentation was sent to: Jade ER Cedar Rapids Student: Grade: Seciusion Physical Restraint used as allast resort Staff Members Involved: Confinement of a student in a roomfrom which the student?s egress is restricted Student Entered Seciusion by: Physical Transport Safely moving an individual who is be ginning to regain control Used to manage individuals who have become dangerous to themselves or others; Physicai Restraint: and Sect Date of incident: Location: DWalked on their own DCPiTeam Control DCPI Children?s Control Before Seclusion/Restraint/Transport (Check implemented Items) Setting Events Antecedents Student Behavior Staff Response I (Events i_ndirectly impacting the (immediate triggers or predictors of Immediately after {Calm El Nonii-Idgmental a?io'?s taker)?: behavioral outcome) the problem behavior.) Antecedent g?gz?e?t??g behavior and aVDld 1 Location: DGiven Verbal Direction (Describe): . Redirections USubject: DGiven Work/Activity - 1 [ZIOffered Coping Skill] break, etc. ?lActivity: ingg El Unexpected Change in Routine DPlanned i DCon?ict Prior to School CIPresented w/Social Interaction EIGave Time to De-escalate DConflict at School ETold "No" by: aclu?? UGav?? EncouragemEnt/ Praise DChange in Routine UDenied Access to Item/Activity l?Defensive (Describe): UPositive Reminders (When/Then) [:lDif?cuity in Previous Class Preferred Activity Removed DGave SUpp'ort - . Cll-lomework Not Done DTeacher Attending to Others DAssignment M?odi?ed DMissed Medication DGiven CorrectionfRedirection CIChanged Instruction DSubstitute Teacher ClPeople too Ciose I Cl Used Proxemics/Kinesics DAcademic Failure El Loud Noises/Room Behavior Leading to UPara Verbal Communication Ell-lunger ClBright Lights Seclusion/ Restraint CIUsed CPI Supportive Stance UFatigue DWith a Speci?c Peer(s) DVerbal Aggression ENisual Cues Used DWork too Hard/Easy ., EVerbal Threats/intimidation UModeIed Expected Behavior @Large Group Instruction DWork Repetitive/too Long W, ?ths'lcal Threats! intimidation ClEm pathic Listening DSmall Group Cl Independent Work Cl Physical Aggressi on/Self Cl Gave Choices instruction Din Pain Physical Aggression/Others Out (Where): DUnstructured Time DSitting For Extended Time Cl Physical Aggression/ Property ClLoss of Privilege] Reward DApproached By Adult DWeapon Possession [Set Limits [Then, Whenrr hen) USchedUIed Non Preferred ActiVitY Eiopement iePi to Cl Called for Team Support ElWaiting (El Other (Please Describe): ClRemove Other Students UT'ransition to: from: DOther: DOther: Additional Comments: prnpety pollCe call School? Time In: 12.1332: f/fl" DCPI Transport DOther (Please Describe): Time Started: Tlme Started: 3] Other (Please Describe): Ponce leggy? - Time Ended: Time Ended: osion Documentation ime Out: Duration: Interim Control Duration: Duration: Behavior DSocial interaction Student may have been trying to gain: DPeer or Cl Adult Possible Functio Purpose of (a Student may DSocial Interaction have been trying to ClSensory Stimulation UNon USensory Stimulation ME: UPeer or DAdult ?Preferred Activity/T ask . Cedcu'R?qpiciE . . Phyeteei Restreint and See?ee?on Doeoote I Beteo?ooidentte I Daring R?ecord actions of the student and staff during physical restraint, transport, and/or seclusion. Students In ust be monitored constantly and documentation completed at aminimum of every two minutes. NQTE: For restraints and seclusions to exceed beyond each class period or every 60 minutes, obtain signature of administration indicating authorization. I Staff Initials Time Goseraed Actions of the Student Du ring Seclusion/ Restraint Staff Response to Qosemed Actions Administrator Signature (to go beyond every 63 minutes or each class period) Time Date scat: EA Cedar Rapids Student: a. Student Actions [3 Crying Cl Calm Cl Rational UTalkative USilent DAccepting Support U'l'lred El Sleeping gig Following Directions Returned to Class Visited Nurse 3 DApoiogized for Actions Communicated with CaregiVer Name: Pacing DWorked independently El Restroom/Bodily Needs DOther (Describe) Staff Debriefing and Future Approaches to DTeam Meeting Learning etc.) Date: Review El Consider Student Student Actions and Debrief?ing Conduct Functional Behavioral Assessment Cl Revise Academic Support Describe any injuries to student, Physical Restraint and Seclusion Documented After incident Student Debrie?ng [3 Processing Activities (Describe) Coping Skill Activity (Describe) Expected Behavior Activity _{Describe) Ma '9 Accepted Responsibility for Actions (cleans up, etc.) WM DAssisted Student with Task Completion (cleaning up, etc.) upportsp Revise Social Skill Instruction El employees, Communication Documentation Pa rent] guardian must be contacted on day of inident. Name of person contacted: Date: Date sent: Mail (postrh arkled within 3 Cl Fax upon written nm?i' Describe httei?n to notify the parent! guardian if request of parent/guardian Relationship: Method: i ontact cannot be made on day of incident: Written documentation must be sent to pa rentlguardian within 3 school days. Sent by: days of the occurrence) .3 .mnn-i-n?nn ?rs-U: to: DOther {Describe} - ClAssisted with Behavior Activity Other Decrease or Eliminate DParent Meeting Date: Review Replacement Review Goals 31 Data Cl Contact AEA Supports ill others, or property damage: on Staff Actions After incident DSupportive/ Undivided Attention Empathic Listening ElUsed Restatem ents for Understanding/Clari?cati on El Gave Wait Tlrne EAiloWed for Silence DContinued to Monitor EAssisted Student with Work Completion ClWalked Student to Class DSupported Stu dent in Class Date of incident: ClCommunicated with Caregiver Name: El Followed Through on Prior Expectation I CIAssisted with Processing Activity DMaintained Awareness of Proxemics, Para verbal Communication DAssisted with Coping Skill Activity ClSwitched Staff Roles Kinesics, El Behavior from Reoccurring: Cl Collect ABC Data ClComplete Competing Pathways Chart Review Positive Behavior Supports DAccess Community Supports ElOther: Behavior By: EI Email upon written?reiwest of parent/gu ardian El Hand Delivered in Person ?ake Cedar Rapids Student: Grade: a. Confinement of a student in a room from which the student's egress is restricted Student Entered Seclusion by: Community School District: Ca Sedudonw NCI Physical Transport Safely moving an Date of Incident: School: IEP. . . as -.- Location: "lime In: Time Out: DurationDWalked on their own EJCPI Transport DCPI interim Control i Restraint and Seclusion ecumentation MCI Physical Restraint used as a last resort Staff Members involved: individual who is beginning to regain control Used to manage individuals who have become dangerous to themselves or others; DCPI Team Control EICPI Children?s Control Other (Please Describe): . DOther (Please Describe): Time Sta?edz?f Time Started: Time Endedz?illg Duration: Time Ended: Duration: Before (Check lmpie mented Items) . Student Behavior Setting Events Antecedents Staff Response (Events indirectly impacting the (immediate triggers or predictors of immediately after behavioral outcome) the problem behavior.) Antecedent secijsioafesmini) KlLocation: UGiven Verbal Direction DAnxious (Describe): CIGave Redirections DSubject: EIGiven Work/Activity glo?ered Ceping Skiil/ break, etc. Electivity: DUnexpected Change in Routine DPlanned Ignore DCon?ict Prior to School DPresented vii/Social Interaction ElGave Time to e-escalate DCon?ict at School DToid ?No? by: Gave Encouragement] Praise ClChange in Routine ClDenied Access to Item/Activity EIDefensive (Describe): Positive Reminders (When/Then) DDif?cuity in Previous Class El Preferred Activity Removed - - - DGave Support DHomEWork Not Done DTeach er Attending to Others - EIAssignment Modi?ed UMissed Medication CIGiven Correction/Redirection ClChanged instru ction DSubstitute Teacher ClPeople too Close Used Proxemics/Kinesics DAcademic Failure l:lLoud Noises/Room Behavior Leading to DPara Verbal Communication ClHunger DBright lights Seclusion/ Restraint DUsed CPI Supportive Stance I ElFatigue DWith a Speci?c Peer(s) EVerbal Aggression DVisual Cues Used Ellilness ClWork too Hard/Easy EVerbal Threats/Intimidation ClModeled Expected Behavior EJLarge Group InstrUction DWork Repetitiveftoo Long Physical Threats} intimidation DEmpathic Listening DSmall Group instrUction Work UPhysical Aggression/Self Gave Choices Clindividual instruction Din Pain Physical Aggression/Others Time Out (Where): UUnstructured Time DSitting For Extended Time Aggression] Property ULoss of Privilege] Reward BApproached By Adult DWeapon Possession DSet Limits fThen, When? hen) DScheduied Non Preferred Activity E?Eiopement ECalled for Team Support ClWaiting El Other (Please Describe): Cl Remove Other Students . UT?ransition to: from: DOther: . Either: didn?t like ?lint they Additional Comments: L, had yggun adays inu? row Par- bxealgfg?i? Student may have been trying DSocial interaction 1 USensory Stimulation DPeer to gain: Possible Function] Purpose of Behavior Student may have been trying to avoid: or Cl Adult DSocial Interaction DSensory Stimulation Non?Preferred Activity/T ask Cl Peer or DAdult Cede Wen-Ids . . - . Phyeteel Reetrefnt and Secfueien ?eeumentettan lemme ?aring - Record actions 'of the student and staff during physical restraint, transport, and/or seclusion. Students must be monitored constantly and documentation completed at aminim um of every two minutes? NGTE: For restraints and seciusions to exceed beyond each ciass period or every 60 minutes, obtain signature of administration indicating authorizationTime Ghsewed Acttans of the Student Durtng SecluSIenIRestrelnt a Staff Respense te ?hserued Aetians 00! initials '45 if I - (1 ?ner 1 08 if ?15 Adrninfistretdr Signature (ta go beyond event 6-0 minutes or each class period) Time Date \c 133 (Cedar?gpids . Communriyschoom?m Physical Restraint and Seciusion Documentation Student: Date of incident: Student Actions DSupportive/ Undivided Attention earring Hinge-renaming w, DUsed Restatem ents for Understanding/Clari?cati on DRational "leave Wait Time DTalkatiVe UAllOWed for Silence DSilent DCoping Skill Activity (Describe) EContinued to Monitor DAccepting Support DAssisted Student with Work Completion Tired Walked Student to Class Sleeping DSupported Student in Class Cl Following Directions Student with Task Completion (cleaning up, etc.) Returned to Class HECommunicated with Caregiver Name: Visited Nurse 3 ~11 Followed Through on Prior Expectation ~105an with Processing Activity Kinesics, 8r. ll DApoiogizedforAC?E'lonS [l Accepted Responsibility for DMaintained Awareness of Proxemics, CaregiVer Name: Actions {cleans up, etc.) Para verbal Communication Bracing Switched Staff Roles UAssisted with Expected Behavior Activity Dower {Describe} Staff Debriefing and Future Approaches to Decrease or Eliminate Behavior from Reoccurring: ElTeam Meeting liEP, Learning Supports, UParent Meeting Date: DCollect ABC Data etc.) Date: UCon duct Functional Behavioral Assessment ?3 Consider Student lClAccess Community Supports H3 Revise Academic Support Cl Contact AEA Supports Describe any injuries to student, employees, others, or property Communication Documentation Parent] guardian must be contacted ?1131? incident. Name of person contacted: Date: Time Describe attem to notify the parent] Written docu Date sent: Mail within 3 days of the occurrence] :11] Fax upon written request of parent/guardian mn+ guardiz- 5 limit \r Cedar Rgpids f? Communm?Sd?W?D?m Physical Restraint and Seciusion Documentation Student Date of incident; School: Grade: i . Seclusion Location: Time In: Time Out: Duration: Confinement of a student in a room from - g. .0 digit ,1 '2 1"?l which the student's egress is restricted a A: mm Student Entered Secluslon bv: ElWaIked on their own Transport EICPI Interim Control Physical Restraint used as a last resort Staff Members involved: Physical Transport Safer moving an individual who is beginning to regain control Used to manage individuals who have become dangerous to themselves or others; DCPI Team Control EICPI Children?s Control LEOther (Please Describe): ElOther (Please Describe): Time Startedzi?ll'n Tlme Ended:lZiZ?Duration: got Before (Check implemented Setting Events (Events indirectly impacting the behavioral outcome) [3 Location: I EISubject: CIActivity: ClConflict Prior to School DConflict at School UChange in Routine Dif?culty in Previous Class ClHomework Not Done DMissed edication DSubstitute Teacher ElAcadernic Failure Ell-lunger Cl FatigUB illness ElLarge Group Instruction EISmall Group instruction Elindividual Instruction @Unstructured Time ClWith a Speci?c Feeds) Additional Comments: Behavior Antecedents (immediate triggers or predictors of the problem behavior.) 'EGiven Verbal Direction - [IlGiven Work/Activity DUnexpected Change in Routine CI Presented w/Social interaction [:ITold ?No? by: Cl Denied Access to item/Activity El Preferred Activity Removed ClTeach er Attending to Others Given Correction/Redirection DPeOpie too Close CI Loud Noisesy?Room DBright Lights DWork too Hard/Easy CIWork Repetitive/too Long Elindependent Work In Pain DSitting For Extended Time Time Started: Time Ended: Duration: items) . Student Behavior Staff Response Immediate? after (Calm 8: Nonjudgmental actions taken to Antecedent de-escalate student behavior and avoid sedusronlrestraint) DAnxious (Describe): . Gave Redirections EIOffered Coping Skiilf break, etc. DPIanned Ignore Gave Time to De?escaiate CIGave Encouragement/ Praise MDefensive (Describe): Positive Reminders (When/T hen) . 'sM-c I DAssignment Modified I, DChanged Instruction El Used Proxemics/Kinesics Behavior Leading to Para Verbal Communication SeciusionI Restraint DUsed Supportive Stance erbai Aggression EIVisual Cues Used DVerbal Threats/intimidation Cl Modeled Expected Behavior Ethsicai Threats/intimidation El Em pathic Listening Physical Aggression/Self Gave Choices DApproached By Adult DScheduied Non Preferred Activity UWaiting Sinansitio DOther: to: DWeapon Possession ElEiopernent Possible Function] Purpose of Student may have been ing to gain: MSociaI interaction ?eer or Adult DSensorv Stimulation [HSocial interaction Whysi cal Aggressi on/ Others Cl Physical Aggression! Property Cl Other (Please Describe): Student may haVe been trying to avoid: El Peer or CIAdult DSensory Stimulation nn?Preferred ActivityfTask Out (Where): 1. ElLoss of Privilege/ Reward ESet Limits [Then, When/Then) DCaIled for Team Support I - Cl Remove Other Students Cl Other: - f? Physical Restraint and; Seciusien D'ocan?tentetien I I I IM 4. During Record actions of the student and staff during physical restraint, transport, and/or seclusion. Students must be monitored constantly and documentation completed at eminimum of every two minutes. NOTE: For restraints and seclusions to exceed beyond each class period or every 60 minutes, obtain signature of administration indicating authorization. Time Observed Actions of the Student During Seclusio n/ Restraint Staff Response to Observed Actions :3:ng 2: (in! IKE) V744 ?i @600 369; ASPEJQ Administrator Signature [to go beyond every 60 minutes or each class period) Time Date it <1 CeciCIngpicls If" Restraint and Seciusion Documentation Student: Date of incident: Student Actions and Debrie?ng After incident Staff Actions After incident Student Actions Student Debrie?ng DSupportive/ Undivided Attention El Crying glProcessing Activities (Describe) DEmpathic Listening Cl Calm Used Restatem ents for nderstanding/Clari?cation Rational ClGave Wait 'i'ime EITaikative [ZlAllowed for Silence DSilent UCoping Skill Activity (Describe) lZlCont'inued to Monitor DAccepting Support [:IAssisted Student with Work Completion [:ITired Walked Student to Class Sleeping Supported Student in Class Following Directions Expected Behavior Activity CIAssisted Student with Task Completion (cleaning up, etc.) Returned to Class 995mm} ClCommunicated with Caregiver Name: El Visited Nurse ClFolloWed ThrOUgh on Prior Expectation UApologized for Actions CIAssisted with Processing Activity DCommunicated with Cl Accepted Responsibility for DMaintained Awareness of Proxemics, Kinesics, Caregiver Name: Actions (cleans up, etc.) Para verbal Communication DPacing ClAssiSted with Coping Skill Activity ClSwitched Staff Roles Assisted with Expected Behavior A DWorked independently Cl Restroomeodily Needs UOther {Describe} El Other (Describe) Staff Debriefing and Future Approaches to Decrease or Eliminate Behavior from Reoccurring: Cl Parent Meeting Date: Cl Collect ABC Data etc.) Date: [:IReview ElRevise Social Skill instruction [3Com plete Competing Pathways Chart El Conduct Functional Behavioral Assessm ent ClReview Replacement Behavior [:lTeam Meeting Learning Supports, Review Positive Behavior Supports Consider Student El Review IEP Goals Data [:IAccess Community Supports El Revise Academic Support El Contact AEA Supports Describe any injuries to student, employees, others, or property damage: Communication Documentation Parent/guardian gigs]; be contacted on day of incident. Name of person contacted: Date: Time: . Describe'attempts to notify the parent] guardian if contact cannot be mad Relationship: m0 By: ncident: J- day ofi nu. :1 within 3 school days. Sent by: El Em ail upon written request of parent/guardian [1 Hand Delivered in Person - Written documentation sent to parent/guardia Date sent: Mail (postmarked within 3 day Fax upon written request of parent/guardian of the occurrence) -ni-n?nn \iim': sent to: {Cedar Rgpids f? Physical Restraint and Seclusion ?ncumdntation Student: Date of Incident: School: Grade: Seclusion Location: Time in: Time Out: Duration: Confinement of a student in a room from which the student?s egress is restricted Student Entered Seclusion by: Physical TranSport Safely moving an individual who is beginning to regain control ClWalked on their own : Other (Please Describe): rave Transport Tlme Started: (Zihivg?l?lme ?in id DCPI interim Control DCPI Team Control Physical Restraint Time Started: Time Ended: Duration: Used to manage individuals who have children?s Contra) - become dangerous to themselves or others; . . used as a iastresort Cl Other (Please Describe). Staff Members Involved: Before Seclusion/Restraint/Transport (Check Implemented items) Setting Events Antecedents Student Behavior Staff Response {Events i_ndirectly impacting the (Immediate triggers or predictors of immediately after (Calm 3! Noniudgmental actions taken to behavioral outcome) the problem behavior.) Antecedent dw?late Snider? bEhaVl?" and ?Old seclusionlrestraint) Location: DGiven Verbal Direction EIAnxious (Describe): mGave Redirections DSubject: El Given Work/Activity DOffered Coping Skill! break, etc. UActivity: EIUnexpected Change in Routine DPlanned I gnore DCon?ict Prior to School EIPresented w/Social Interaction DGave Time to De-escalate I El Con?ict at School Droid ?No? by: ElGave-Encouragement/PraiSe I ClChange in Routine El Denied Access to item/Activity El Positive Remind ers (When/T hen) DDif?cultyin Previous Class Preferred Activity Removed El Defensive (Describe):- Gave Support - DHomework Not Done DTeacher Attending to Others BAssignment Modi?ed DMissed Medication Given Correction] Redirection UChanged Instruction . EISubstitute Teacher People too Close Used Proxemics/Kinesics DAcademic Failure Loud Noises/Room Behavior Leading to 'XlPara Verbal Communication El Hunger DBright Lights Seclusion/ Restraint El Used Supportive Stance [JFatigue mWith a Speci?c Feeds) DVerbaI Aggression ElVisual Cues Used Ulliness too Hard/ Easy EIVerbal Threats/intimidation DModeled Expected Behavior ElLarge instrUction DWork Repetitiveftoo Long El Physical Threats/Intimidation CI Empathic listening EISmall Group InstrUction Elindepend?ent Work El Physical Aggression/Self ElGave Choices Elindividual Instruction El In Pain Aggression/Others E?me Out (Where): El Unstructured Time DSitting For Extended "lime Physical Aggression/Property Eltoss 0f Privilege/ Reward DApproached By Adult El Weapon Possession ElSet Limits hen, When/T hen) USCheduled Non Preferred Activity EIElopement ?Called for Team Support DWaiting Other (Please Describe): DRemove Other Students . DT'ransition to: from: [JOtherz DOthe?r: El Additional Comments: Hifaw 3 Guild kicked Possible Fu nctio n/ Purpose of Behavior Student may have been trying to gain: Student may have been trying to amid: modal interaction ?Peer or Adult EISocial Interaction [3 Peer or DAdult DSensory Stimulation EISensory Stimulation -. I . . ?esh. w? . CedarR?fripids . - . Physissi Restraint: and: Seaiasion Documentation [mm . W??aido?n?dentDuring ?4 Record actions of the student and staff during physical restraint, transport, end/or seclusion. Students. must be monitored constantly and documentation completed at sminimum of every two minutes. NQTE: For restraints and seclusions to exceed beyond each class period or every 60 minutes, obtain signature of administration indicating authorization, Staff lnitiais bse reed Actions of the Student During Seclusia nIRestraint Min-4 a 44? Lu gf/ celMs? f, . o? l' 1/ tot? Response to absewed Actions [on ?rm haunan nunm so minutes nr each class period} Time I Date SAL CedarRGpids Jar-a Community School District i Student: i i - Student Actions and Debrie?ng After incident Staff Actions After incident Student Actions Student Debrie?ng DSupportive/ Undivided Attention DCrying H3 Empathic Listening Used Restatements for Understanding/Clari?cai?on CIRational ?3 Gave Wait Time DTaikative DAliowed for Silence DContinued to Monitor DAccepting Support DAssisted Student with Work Completion Minted Student to class DSleeping DSupported Student in Class ClAssisted Student with Task Completion (cleaning up, etc.) (Describe) Write, an {bet UCommunicated with Caregiver Name: El ViSlted Nurse EiFollowed Through on Prior Expectation UApoiogized for Actions DAssisted with Processing Activity DCommunicated with El Accepted Resp El Maintained Awareness of Proxemics, Kinesics, Caregiver Name: Actions [cleans up, Para verbal Communication [3 Switched Staff Roles DAssisted with Expected Behavior Activity Gatherioescrebe: Staff Debriefing and Future Approaches to Decrease or Eliminate Behavior from Reoccurring: l, i Restraint and Seciusion Document etion Date of incident: ll for etc.) DTeam Meeting UEP, Lear. DParent Meeting Date: DCollect ABC Data etc.) Date: ning Supports, CIReview URevise Social Skill instruction DCompiete Competing Pathways Cha DConduct Functional Behavioral Assessment DReview Replacement Behavior EReview Positive Behavior Supports El Consider Student DReview Goals El Data DAccess Community Sopports Cl Revise Academic Support UContact AEA Supports Describe any injuries to student, employees, others, or property damage: Communication Documentation Pa rent] guardian Mbe contacted on day ojjncident. Name of person contacted: Date: Time: Describe'attempts to notify the parent/guardi guardian within 3 schoo Sent by: El Email upon written request of parent/guardian Date sent: Mail (postindrked within request \i Cedar Rapids; Commnitv School District Physicai Restraint and Seciusion Do cumetntatien Physical Transport Safer used as a last resort Staff Members involved: individual who is beginning to regain controi Physical Restraint - . Used to manage individuals who have become dangerous to the mseives or others; Student: _-.Date of incident: School .7 Grade: Seciusion Location: Time In: Time Out Duration: Confinement of a student in a room from r? 1 ii which the student's egress is restricted QR 2! ?its?? Vi *5 Student Entered Seciusion by: DWaiked on their own Transport DCPI interim Control moving an [:lOther (Please Describe): TimeStarted: Time Endedztiigg Duration: Team Control [:lCPi Children?s Control Other (Please Describe): Time Started: Time Ended: Duration: I Before SeclusionfRestraint/Transimrt (Check implemented items) *1 Student Behavior Staff Response UDif?culty in Previous Class Setting Events Antecedents (Events i_rrdirectly impacting the (immediate triggers or predictors of Immediately after [Calm 31 Nonludsmenwl a?iions 1-3ka behavrorai outcome) the problem behavior.) Antecedent 3:125:22}: behavior and avord Location: Raven Verbal Direction DAnxious (Describe): @Gave Redirections EiSubject: Mm gGiven Work/Activity DOffered Coping Skill} break, etc. ClActivity: EiUnexpected Change in Routine ?amed ignore Cl Con?ict Prior to School Cl Presented vii/Social interaction DGave Time to De-escalate UConflict at School _l;l_Toid "No" by: ave Encouragement/Praise DChange in Routine Denied Access to item/Activity Defensive (Describe): El Positive Reminders (When/Then) DHomework Not Done Preferred Activity Removed DTeacher Attending to Others DGave Support DAssignment Modi?ed DMissed Medication B?iven Correctioanedirection DChanged instruction DSubstitute Teacher DPeople too Close 1 El Used Proxemicstinesics UAcademic Failure EILoud Noises/Room Behavior Leading to DPara Verbal Communication Dillinger El Bright Lights Seclusionf Restraint DUsed CPI Supportive Stance ClFatigue UWith a Speci?c Feeds) rbal Aggression DVisual Cues Used Ulliness [:IWork too Hard/Easy DVerbai T_h-r_ea_ts/ Intimidation ElModeied Expected Behavior [large Group instruction [:IWork Repetitive/too Long Threat?SI intimidation pathic Listening USmall Group Instruction [:llndependent Work El Physical Aggression/Self ??ave Choices ?E?individual instruction [:lin Pain Aggression/Others Elime Out (Where): DUnstructured Time [:ISitting For Extended Time El Physical Aggression/ Property ULoss of Priviiege/Reward UApproached By Adult DWeapon Possession [Set Limits hen, When/T 11er USCheduled Non Preferred Activity ?Elopement DCalled for Team Support CiWaiting DOther (Please Describe): DRernove Other Students DT'ransition to: from: DOther: Cl Other: Additional Comments: Possible Functio n/ Purpose of Behavior *7 Student may have been trying to gain: Student may have been trying to avoid: EISocial interaction DPeer or Adult DSocial Interaction El Peer or DAdult USensory Stimulation DSensory Stimulation 4 ?Non?Preferred Activitle ask I Ceaeregptde . Pittreicai Reetraiat and Becamentetion I J?ratea?lncideatzw Eating Record actions of the student and staff during physical restraint, transport, l'andior seclusion. Students must be monitored constantly and documentation completed at aminimum of every two minutes. NGTE: For restraints and seclusions to exceed beyond each class period or every 60 minutes, obtain signature of administration indicating authorization. - Staff Staff Response ta easemea Actmne initials Time absentee Actiens at the Student Daring Seclasian?teetraint ll ll ?1 . ,v-glaf? minnistrator Signatu FE (ta ge beyond every 60 minutes or each class parted) Time Date v-x adults. a? Ceer Rapids fer-k Community School District. CE I Student: i Restraint and Seciusion Documentation Date of incident: l? Student Actions and Debrief?ing After incident Staff Actions. After incident Student Actions Student Debrie?ng DSupportive/ Undivided Attention UCrying [3 Processing Activities (Describe) Cl Empathic Listening Cl Calm El Used Restatements for Understanding/Ciari?cati on CIRational CIGave Wait Time DTaikative DAiiowed for Silence DSilent UCoping Skill Activity (Describe) El Continued to Monitor EAccepti ng Support I CIAssisted Student with Work Completion D'lired @Walked Student to Class DSleeping ?Supported Student in Class .I ESFollowing Directions CIExpected Behavior Activity Assisted Student with Task Completion (cleaning p, etc.) ElReturned to Class inescribel DCommunicated with Caregiver Name: Cl Visited Nurse ElFoliowed Through on Prior Expectation DApologized for Actions CIAssisted with Processing Activity DCommunicated with Accepted Responsibility for UMaintained Awareness of PrDXernics, Kinesics, Caregiver Name: Actions [cleans up, etc.) Para verbal Communication DPacing cemetete mm [JAssisted with Coping Skill Activity DWorked independently DSwitched Staff Roles El Restroom/Bodily Needs UOther (Describe) CIAssisted with Expected Behavior Activity Other (Describe) Cl Other Staff Dehriefing and Future Approaches to Decrease or Eliminate-Behavior from Reoccurring: DTearn Meeting Learning Supports, I DParent Meeting Date: DCoilect ABC Data etc.) Date: El Review [:lRevise Social Skill instruction DComplete Competing Pathways Chart UConduct Functional Behavioral Assessment UReview Replacement Behavior Review Positive Behavior Supports Consider Student DRevievv Goals 81 Data CIAccess Community Supports Cl Revise Academic Support DContact AEA Supports Describe any injuries to student, employees, others, or property damage: Communication Documentation Pa rentlgua rdian must be contacted on day of incident. Name_of person contacted: Relationship mom 1 Date:_ 1 Time: 9 .- By: Describe ttempts to notify the parent/guardian if contact cannot be ade on day of incident: mentation must be sent to parent] guardian wi Written docu thin 3 school days. Date sent: Sent by: Mail (postr'narke'd within 3 days of the occurrence) Email upon written request of parentlguardian itten request of parentfguardian Hand Delivered in Person 1:1 Fax upon wr .manrntinn was sent to: . i See?s: \f Cedar Rgpicis thsicai Restraint and Seclusien Documentatien Student' Date of Incident: School: Grade: I IEP: - I Seclumon - Location: Time In: Time Out: Duration: Confinement of a student in a room from - which the student?s egress is restricted 2 0? a $3 <3 2 Student Entered Seclusion by: EIWaIked on their own ECPI Transport DCPI interim Control MCI Physical Transport Safer moving an 0th er (Pl ease ascribe): individual who is beginning to regain control Time Started_ $.00 Time Ended. an, Duratiow . - l' Physical Restraint EICPI Team Control Time Started: I Time Ended: Duration: Used to manage individuals who have [:ICpl Child re Control become dangerous to themselves or others; I . used as a last resort . El Other (Please Describe). Staff Members Involved: Before (Check Implemented items) Setting Events Antecedents Student Behavior Staff Response (Events Lndirectly impacting the (Immediate triggers or predictors of Immediately after (Calm 3* Nonludgmental actions takerrto behavioral outcome) the problem behavior.) Antecedent - S?ggr??f bahBViPV and ?Old Location UGiVen Verbal Direction UAnxious (Describe): ?GaveRedirections? DSubject: - EIGiven Work/Activity I 'ElOffered Coping Skill] break, etc; DActivity: DUnexpected Change in Routine . EIPlanned Ignore DConflict Prior to School El Presented w/Social Interaction [:lGav'eTlrne to De-escalate DConflict at School DTold__?_No? by: . DGave Encouragement/Praise DChange in Routine Imbenied Access to Item/Activity Defensive (Describe): DPo?sitiVe Reminders (When/Then)- [IIDif?culty in Previous Class l3 Preferred Activity Removed cmwiim' our)" CIGave' Support - . - UHomeworlLN_dc_Done DTeacher Attending to Others (1 i?jb Kicking? rag)" DAssign?mentModi?ed UMissed Medication CIGiven Correction/Redirection ?rm in [ogm DChanged Instruction EISubstitute Teacher El People too Close Used Proxemics/Kinesics [:IAcademic Failure I EILoud Noises] Room Behavior Leading to Era Verbal Communication Eunger I DBright Lights Seclusionl Restraint ?Used CPI Supportive Stance - Fatigue DWith a Speci?c Peer(s) UVerbaI Aggression DVisual Cues Used DWork too Hard/Easy DVerbalThreats/Intimidation DModeled Expected Behavior ElLarge Group Instruction DWork Repetitive/too Long UPhYSical ThmatS/ Intimidation UEmpathic Listening USmall Group Independent Work Physical Aggression/Self El Gave Choices Clindividual Instruction Elln Pain EPhysical Aggression/Others ElTime Out (Where): Unstructured Time DSitting For Extended Time El Physical Aggression/Property El Loss Of Priviiege Reward DApproached By Adult DWeapon Possession Ester Limits nhen, When/Then} UScheduled Non Preferred Activity Elopement ECalled for Team Support [:lWaiting Other (Please Describe): ERemove Other Stu dents . CIT'ransition to: from: ClOther: El Other: Cl Additional Comments: (arm add 1 . .11.. Gilli}! I gl' Possible Function] Purpose of Behavior 3 Student may have been trying to gal? Student may have been trying to am: [Social Interaction UPeer or Cl Adult DSocial interaction [:IPeer or CIAdult DSensory Stimulation DSensorv Stimulation mNon-Preferred Activity/T ask A Cedar Resp-idg . Restraint and Becamentatian Student: ?aring Record actions of the student and stafiduring physical restraint, transport, and/or seclusion. Students must be monitored constantiy and documentation completed at aminimum of every two minutes. NGTE: For restraints and seclusions to exceed beyond each class period or every 60 minutes, obtain signature of administration indicating authorization. - Staff initials 69:0 4" . . Time absereed Actions of the Student Baring Seaiusian/Restraint Staff Response ta Gbsenred Actions . Administrator Signature (ta go beyond every 50 minutes or each class period} Time Date ?if; (CedangpidS . - fa. Commnaysehoosousvft Physicai Restraint and Seeiusien Becumentatien Student: Date of incident: C: Student Actie ns and Debrie?ng After Incident Staff Actions After Incident Student Actions Student Debrie?ng ESupporti-ve/ Undivided Attention CI Crying [:lProcessing Activities {Describe} Empathic Listening El Caim [3 Used Restatements for Understanding/Ciari?cati on DRational DGa?ve Wait Time DTalkative ElAllowed for Silence DSilent El Coping Skill Activity (Describe) Continued to Monitor Assisted Student wi DAccepting Support I th Work Completion [Hired ClWalked Student to Class USleeping DSupported Stu dent in Class UFoliowing Directions DExpected Behavior Activity DAssisted Student with Task Completion {cleaning up, etc.) DReturned to Class (Describe) UCommu nicated with Caregiver Name: El Visited Nurse ElFollowed Through on Prior Expectation DApoiogized for Actions ElAssisted with Processing Activity DCommunicated with Accepted Responsibility for DMaintained Awareness of Proxernics, Kinesics, 8: CaregiVer Name: Actions (deans up, etc.) Para verbal Communication DPacinB . .. .. . mark, ElAssisted with Coping Skill Activity EWorked - I DSwitched Staff Roles DRestroom/Bodily Needs LJOtner {Describe} - DAssisted with Expected Behavior Activity DOther {Describe} UOther Staff Debriefing and Future Approaches to Decrease or Eliminate Behavior from Reoccurring: DTeam Meeting Learning Supports, UParent Meeting Date: ClCollect ABC Data Cl Review Revise Social Skill on DComplete Competing Pathways Chart El Conduct FUnctionai Behavioral Assessment EReview Positive Behavior Supports Cl Consider Student UAccess Community Supports Cl Revise Academic Support DOth er: damage: Describe any injuries to student, employees, others, or prOperty Communication Documentation Pa rent/guardian must be co_ntact_ed on day of incident. Name pipersoncontacted: Date: Time: Describ?a empts to notify the parent/guardian if contact cannot be Relationship: om 41:5" on day of incident: a Written documentation must be sent to parentlguardian within 3 schooi days. Date sent: Sent by: Mail (postmarked within 3 days of the occurrence] El Email upon written request of parent/guardian El Fax upon written request of parent/guardian El Hand Delivered in Person - nm rian .mpntation was sent to: \k Respide I Wenet?dm?'witm P??hysieai Restraint and Secitrsien Docenteh?tdtien rStudent.? Date of Incident: School: Grade: A Seclusion Location: Time In: Time Out: Duration: Confinement of a student in a r00m from i2 1 I5 which the stude nt's egress is restricted Student Entered Seclusion by: Physical Transport Safely moving an DWalked on their own DOther (Please Describe): DCPI Transport DCPI Interim Control individual who is beginning to regain control Time Started. Time Ended. Duratiow Physical Restraint EICPI Team Control Time Started: Time Ended: Duration: Used to manage individuals who haVe childrenrs Contmi become dangerous to themselves or others; . used a? iastresm El Other (Please Describe). Staff Members Involved: Before Seclusion/Restraint/Transport (Check implemented Items) Antecedents Student Behavior Staff Response Setting Events (Events i_ndirectly impacting the be haviorai outcome) (immediate triggers or predictors of the problem behavior.) immediately after Antecedent {Cairn 8: Nonjudgmental actions taken to de-escalate student behavior and avoid seclusion/restraint) Wiven Verbal Direction ClAnxious (Describe): mayo Redirections Location: ESUbiect c?i?ve rec? El Given Work/Activity Hottered Coping Skill/ break, etc. BActivity: Change in Routine UPianned ignore DConflict Prior to School Eli'resented w/Social interaction EIGave Time to De?escalate DConflict at School ?No? by: EIGave Encouragement/Praise UChange in Routine IZIDenied Access to Item/Activity ?Defensive (Describe): DPositive Reminders (when/T hen) EIDifficulty in Previous Class Preferred Activity Removed Punting Shw?ir EIGave Support DHomework Not Done ElTeacher Attending to Others Km,th DAssignment Modified [ZIMissed Medication EGiven Correction/Redirection Puwm?g DChanged Instruction DSubstitute Teacher ElPeople too Close El Used Proxemics/Kinesics ElAcademic Failure : Loud Noises/Room Behavior Leading to ClPara Verbal Communication DHunger EIBright Lights Seclusion/Restraint BUsed CPI Supportive Stance Cl Fatigue El With a Speci?c Peer(s) wVerbal Aggression CIVisuaI Cues Used too Hardeasy EIVerbal Threats/ Intimidation DModeled Expected Behavior EILarge Group instruction Repetitive/too Long CIPhysical Threats! Intimidation El Empathic Listening DSmall Group Instruction Work Physical Aggression/Self [:IGave Choices Clindividual Instruction Elln Pain EphvSical Aggression/Others EITime Out(Where): DUnstructured Time DSitting For Extended Time Aggression/Property [:lLoss of Privilege/Reward DApproached By Adult DWeapon Possession [:ISet Limits (1?t fihen, When/Then) CIScheduled Non Preferred Activity DEIopement ?cailed for Team Support DWaiting ClOther (Please Describe): El Remove Other Students ClTransition to: from: ClOther: ClOther: Cl Additional Comments: a??ul?i? kicked (Icicdi' tmuJ?i'iple timers Possible Function/Purpose of Behavior Student may have been trying to gain: Student may have been trying to avoid: [IISocial interaction Peer or Cl Adult DSocial Interaction DPeer or EIAdult DSensory Stimulation DSensory Stimulation Activity/T ask ?Preferred Activity/Item t??i?Res-tresnt end-Seeieston Doeamentetron I Student: ?-ete of incidentBoring Record actions of the student and staff during physical restraint, transport, and/or seclusion. Students must be monitored constantly and documentation completed eta minimum of every two minutes. MGTE: For restraints and seclusions to exceed beyond each class period or every 60 minutes, obtain signature of administration indicating authorization. ?i?ime absentee notions of the Student Eating Seciosion/Restreint Staff Response to Ghee-reed Actions e. Administrator Signature (to go beyond every minutes or each class period] Time Date P-Eavsicai Restraint and Seciosion Docomentation I Date of incident: I Student? it - Student Actions and D-eiarieiing After incident Staff Actions After incident Student Actions Student Debriefing DSupportive/ Undivided Attention Crying Cl Processing Activities (Describe) Em pathic Listening DCalm El Used Restatements for Understanding/Clari?cation Ll Rational DGave Wait Time DTalkative DAllowed for Silence [:lSiient Skill Activity {Describe} KIContinued to Monitor CIAccepting Support ClAssisted Student with Work Completion ClTired EWalked Student to Class DSIeeping ??Supported Student in Class ElFollowing Directions [??xpected Behavior Activity rDAssisted Student with Task Completion (cleaning up, etc.) EReturned to Class {Describe} DCommunicated with Caregiver Name: SET-TE To 1rEl Visited Nurse El Followed Through on Prior Expectation DApoiogized for Actions ElAssisted with Processing Activity El Accepted Responsibility for Actions (cleans up, etc.) ElCommunicated with Caregiver Name: DMaintained Awareness of Proxemics, Kinesics, Para verbal Communication DAssisted with Coping Skill Activity DPacing DWorked independently DSwitched Staff Roles DRestroom/Bodily Needs DOther (Describe) ElAssisted with Expected Behavior Activity DOther (Describe) DOther Staff Debriefing and Future Approaches to Decrease or Eliminate Behavior from Reoccurring: DTeam Meeting Learning Supports, Meeting Date: DCollect ABC Data etc.) Date: DReview DRevise Social Skill instruction DComplete Competing Pathways Chart [ZIConduct Functional Behavioral Assessment ClReview Replacement Behavior EReview Positive Behavior Supports Cl Consider Student Review IEP Goals Data DAccess Community Supports URevise Academic Support : Contact AEA Supports :l0ther: Describe any injuries to student, employees, others, or property damage: Communication Documentation Parent/guardian must be contacted on day of incident. Name of person contacted: Relationship: mom Date: Time: Method: Dianne, I By: Describe'attlampts to notify the parent/guardian if contact cannot be rhade on day of incident: Written documentation must be sent to pa rent/guardian within 3 school days. Date sent: Mail (postmarked within 3 days of the occurrence) Sent by: Email upon written request of parent/guardian l3 Fax upon written request of parent/guardian Hand Delivered in Person I Name of parent/guardian the documentation was sent to: e. a? Raga-ide? agmmaniw Same-I Sigh-let .., are 'i . Physical Restraint and Seeinsien Decementetien ?Student' Date of incident: School: Grade: IEP: Seclusien a Confinement of a student in a room from which the stude nt's egress is restricted Location: (QR Time In: THE Time Out: Duration: ?l Student Entered Seclusion by: NCI Physicai Transport Safely moving an individual who is beginning to regain control DWalked on their own DOther (Please Describe): DCPI Transport Time Started: Time Ended: Interim Control Duration: Physicai Restraint - Used to manage individuals who have become dangerous to themselves or others; EICPI Team Control BICPI Children?s Control [3 Other (Please Describe): Time Started: NIH, Time Ended: Duration:I used as a last resort Staff Members involved: Befere (Check Implemented Items) Setting Events (Events i_ndirectly impacting the Antecedents (Immediate triggers or predictors of Student Behavier immediately after Stat? Respense (Calm E: Nonjudgmentai actions taken to de-escalate student behavior and avoid be haviorai outcome) the problem behavior.) Antecedent seclusion/restraint) Location DGiVen Verbal Direction anious (Describe): Gave Redirections EISubject: Wm ?Given Work/Activity Fluvian {km/Pm) ?rearm DOffered Coping break, etc. CIActivity: EIUnexpected Change in Routine garage? EIPianned Ignore El Conflict Prior to School Presented w/Social Interaction ?Gave Time to De?escalate EICoanict at School EITold ?No? by: [ZlGave Encouragement/Praise DChange in Routine EDenied Access to Item/Activity Wefensive (Describe): EIPositive Reminders (When/T hen) DDifficulty in Previous Class Preferred Activity Removed Firm/161.. lamina, DGave Support EIHomework Not Done EITeacher Attending to Others nephew wran Whats DAssignment Modified UMissed Medication EIGiven Correction/Redirection Swim?nc, EIChanged instruction El Used Proxemics/Kinesics El Substitute Teacher El People too Close DAcademic Failure EILoud Noises] Room Behavior Leading to [:lPara Verbal Communication Hunger Lights Seclusion/ Restraint Used Supportive Stance El Fatigue DWith a Speci?c Peer(s) [:IVerbal Aggression EIVisual Cues Used Dillness DWork too Hard/Easy EIVerbai Threats/ Intimidation UModeled Expected Behavior El Large Group Instruction Work Repetitive/too Long Eli?hvsical ThreatSI intimidation [:IEmpathic Listening Group instruction Dindependent Work EIPhysical Aggression/Self ?Gave Choices Dlndividual Instruction Din Pain Whysical Aggression/Others [:lTime Out (Where): Unstructured Time DSitting For Extended Time [:IPhysical Aggressioanroperty DLoss of Privilege/ Reward DApproached By Adult EIWeapon Possession DSet Limits (1"t fThen, When/T hen) DScheduled Non Preferred Activitv CIElopem ent DCalIed for Team SUpport CiWaiting ClOther (Please Describe): DRemove Other Students nsition to: from: DOther: El Other: Additional Comments: Possible Function/Purpose of Behavior e?l Student may have been trying to gain: Student may have been trying to avoid: [Social Interaction - El Peer or Cl Adult DSociaI Interaction Peer or EIAduit I CISensory Stimulation DSensory Stimulation El Preferred Activity/Item Won?Preferred Activity/T ask ?tu. Writtede _r I Reg?j?sgmt ?acgme?ta?a? I gmde I Date etEnc?dent: - . - [During Record actions of the student and staff during physical restraint, transport, and/or seclusion. Students must be monitored constantly and documentation completed at a minimum of every two minutes. tea-re: For restraints and seclusions to eXceed beyond each class period or every 60 minutes, obtain signature of administration indicating authorization. - Staff initials Time absentee? tietiens at the Student During Seelasian/Restraint Stat? Response ta Streamed Aetiens Administrath Signature (ta ge beyond every 60 minutes er each class netted) Time Date Sod-ctr R?ioicte I Student: Physical Restraint and Seclesion Documentation I I Date of incident: Student Actions and Deorieting After incident Stat? Actions After incident Student Actions Student Debriefing DSupportive/ Undivided Attention DCrying DProcessing Activities (Describe) DEmpathic Listening EICalm DUsed Rest'atements for Understandirig/Clari?cation El Rational EIGave Wait Time ElTaikative CIAllowed for Silence EISilent DCoping Skill Activity (Describe) EIContinued to Monitor DAccepting Support EAssisted Student with Work Completion ElTi red EIWalked Student to Class Dsieeping DSupported Student in Class El Following Directions ?linpected Behavior Activity DAssisted Student with Task Completion (cleaning up, etc.) ??etumed to Class (Desc?it?e? (cm RBTE Warez. EICommunicated with Caregiver Name: El Visited Nurse EFoilowed Through on Prior Expectation DApologized for Actions ElAssisted with Processing Activity EICommunicated with Caregiver Name: El Accepted Responsibility for Actions (cleans up, etc.) DMaintained Awareness of Proxemics, Kinesics, Para verbal Communication DPacing ElAssisted with Coping Skili Activity DWorked Independently DSwitched Staff Roles CIRestroom/Bodily Needs C) Other (Describe) CIAssisted with Expected Behavior Activity DOther (Describe) DOther Staff Debrieting and Future Approaches to Decrease or Eliminate Behavior from Reoccurring: etc.) Date: EITeam Meeting (IEP, Learning Supports, DParent Meeting Date: EICoilect ABC Data El Review EIRevise Social Skill Instruction [JComplete Competing Pathways Chart EIConduct Functional Behaviorai Assessment DReview Replacement Behavior ?Review Positive Behavior Supports ElConsider Student El Review IEP Goais 84 Data ElAccess Community Supports EIRevise Academic Support EIConta ct AEA Supports DOther: Describe any injuries to student, employees, others, or property damage: Communication Documentation Parent/guardian must be contacted on day of incident. Name of persogcontacted: Relationship: mow?. Date: Time: Method: Chime; I By: Describe lattel'npts to notify the parent/guardian if contact cannot be rrlade on day of incident: Written documentation must be sent to parent/guardian within 3 school days. Date sent: Mail (postinark'ed within 3 days of the occurrence) Sent by: CI Email upon written request of parent/guardian Cl Fax upon written request of parent/guardian Hand Delivered in Person I Name of parent/guardian the documentation was sent to: 1.. I Cede?e metres; Physieai Restraint. anoi- Seciusien ntentetien Student: Date of Incident: School: Grade: Seciusien - Location: Time in: Time Out: Duration: Confinement of a student in a room from -- . ?72. as sea- Ciitly I0 which the student?s egress is restricted Student Entered Seciusien by: Physical Transport Safely moving an individuai who is beginning to regain control DWalked on their own DOther (Please Describe): DCPI Transport Time Started: Time Ended: interim Control Duration: Physical Restraint used as a last resort Used to manage individuals who have become dangerous to themselves or others; Team Control Children?s Control Cl Other (Please Describe): Time St_arted:q:3E 'Time Ended: Duration: ?tee .. Staff Members involved: Befere Seclusion/Restraint/T?ranspert (Check Implemented items) Setting Events (Events indirectly impacting the behavioral outcome) Antecedents (immediate triggers or predictors of the problem behavior.) Student ehavier immediately after Antecedent Staff Response (Cairn 8: Nonjudgmentai actions taken to de-escaiate student behavior and avoid seclusion/restraint) ?GaVe Redirections Location: Verbal Direction {BAnxious (Describe): DSubject: DGiven Work/Activity DOffered Coping Skill/ break, etc. lZIActivity: Unexpected Change in Routine El Planned Ignore ElConfiict Prior to School DPresented w/Sociai inter?action Gave Time to De-escalate El Conflict at School DTold ?No? by: ElGave Encouragement/Praise UChange in Routine DDenied Access to Item/Activity Defensive (Describe): El Positive Reminders (When/T hen) Cl Difficulty in Previous Class El Preferred Activity Removed (Vth Prism ?'tc?hl Gave Support ElHomework Not Done EITeacher Attending to Others h'r'ir?i?lr?t a DAssignment Modified Missed Medication Given Correction/Redirection DChanged instruction Teacher [3 Peopie too Close kmt?tdla a) Used Proxemics/Kinesics CIAcademic Failure Loud Noises/Room Behavior Leading to Para Verbal Comm unication Hunger Bright Lights seclusion] Restraint EUsed Supportive Stance ClFatigue DWith a Speci?c Peer(s) ?Verbal Aggression IZIVisual Cues Used Clillness ClWork too Hard/Easy lZIVerbal Threats/intimidation El Modeied Expected Behavior El Large Group Instruction Work Repetitive/too Long Uthsicai Threats/Intimidation DEmpathic Listening [:lSmall Group Instruction Independent Work [:IPhysical Aggression/Self [?Gave Choices [:llndividuai Instruction In Pain Aggression/Others ElTime Out (Where): ClUnstructured Time DSitting For Extended Time Aggression/ Property ElLoss of Priviiege/ Reward ClApproached By Adult DWeapon Possession Limits hen, When/T hen) DScheduled Non Preferred Activity ?Elopement ?lCalled for Team Support DWaiting EIOther (Please Describe): . [JRemove Other Students DTransition to: from: EIOther: DOther: El Additional Comments= hit? wi Kicle ed? a Fuh?incil around moments, Possible Function/Purpose of Behavior Student may have been trying to gain: Student may have been trying to avoid: NSociai Interaction : Peer or ?Aduit ElSocial interaction Peer or ElAduit ?El Sensory Stimulation ElSensory Stimulation El Preferred Activity/item DNon?Preferred Activity/T ask Phys-teal Restraint and Deaeaneentation Date at incident: I Etudent: During Record actions of the student and staff during physical restraint, transport, and/or seclusion. Students must be monitored constantly and documentation completed at a minimum of every two minutes. NQTE: For restraints and seclusions to exceed beyond each class period or every 60 min utes, obtain signature of administration indicating authorization. Staff initials Time Glaseraed Aeti?ens at the ?tadent Daring Seciusian/Restraint Stat? ?espense ta thewed Aetiens all ti . . I Adntinistra?tdr Signature (to go beyond every minutes or each ciass period) Time Date i Cleaer Wayside. [as grammar-rim! Edna-rel Phys-teat Restraint and: Secitrsien Elie-cementatien I Student: lDateniincident: i i Student Actiens and De?ne-ting After incident Sta-it Actions After incident ?tudent Actions Student Debriefing DSupportive/ Undivided Attention DCrying DProcessing Activities (Describe) DEmpathic Listening DCaim [:IUsed Restatements for Understanding/Clari?cation DRational DGave Wait Time DTalkative DAiiowed for Silence _l:l Silent DCoping Skill Activity {Describe} EContinued to Monitor EAccepting Support ?Assisted Student with Work Completion EITired DWalked Student to Class DSIeep?mg ESupported Student in ?nes: hat) DFoilowing Directions EXpected Behavior Activity DAssisted Student with Task Completion (cleaning up, etc.) EReturned to Class (Describe) DCommunicated with Caregiver Name: Visited Nurse Mm rm as DFoilowed Through on Prior Expectation ClApologized for Actions wt? DAssisted with Processing Activity DCommunicated with Accepted Responsibility for DMaintained Awareness of Proxemics, Kinesics, 8: Caregiver Name: Actions (cleans up, etc) Para verbal Communication DPacing DAssisted with Coping Skill Activity [:IWorked Independentiy DSwitched Staff Roies DRestroom/Bodily Needs DOther (Describe) DAssisted with EXpected Behavior Activity DOth er (Describe) DOther Staff Debriefing and Future Approaches in Decrease pr Eliminate Behavior from Redccurring: [:ITeam Meeting Learning Supports, etc.) Date: DParent Meeting Date: Coliect ABC Data El Review DRevise Social Skili instruction DCompiete Competing Pathways Chart DConduct Functional Behavioral Assessment DReview Repiacement Behavior EReview Positive Behavior Supports Consider Student [:IReview IEP Goals 81. Data DAccess Community Supports URevise Academic Support DContact AEA Supports DOther: Describe any injuries to student, employees, others, or property damage: Cemmunicatien Documentatien Parent/guardian must be contacted on day of incident. Name of person contacted: Reiationship: Mam Date: 1 Time: Method: ghom I By: Describe'atteiin to notify the parentiguardian if contact cannot be made on clay of incident: Date sent: Mail (postmarked within 3 days of the occurrence) Written documentation must be sent to parent/guardian within 3 school days. Sent by: El Email upon written request of parent/guardian El Fax upon written request of parent/guardian Hand Delivered in Person I Name of parent/guardian the documentation was sent to: (Events udirectly impacting the behavioral outcome) (immediate triggers or predictors of' the problem behavior.) immediately after Antecedent it is. Cedar Rgpids f? Physical Restraint and Seelusidn Documentation.- Student; Date oflncident: School: 1 4M Grade: Seclusion Location: Time in: Time Out: Duration: Confinement of a student in a roomfrom 20% i which the student?s egress is restricted ?2 ?9 In) Student Entered Seciusion by: DWalked on their ovvn Transport Interim Control Physicai Transport Safely moving an Other (please Describe): individual who is beginning?to regain control Time Started_ ?2.63 Tlme Endedamz Duration_ 2 N0 Physical Restraint DCPI Team Control Time Started: Time Ended: Duration: Used to manage individuals who have DCPI Childrenrs Conn?0i - become dangerous to themselves or others; . . med 3? last resort (Please Describe). Staff Members Involved: . . I Before SeclusronfRestramtITransport (Check implemented items) Setting Events Antecedents Student Behavior Staff Response (Cairn 8i Nonjudgmerital actions taken to de?escalate student behavior and aVoid seclusionlrestraint) a Location:( ?Given Verbal Direction EIAnxious (Describe): @Gave Redirections DSubiect: @Given Work/Activity [ZIOffered Coping Skiilf break, etc. DActivity: EUnexpected Change in Routine manned ignore El Con?ict Prior to School UPresented w/Social Interaction a. DGave Time to De?escalate El Conflict at School DTold by: I ElGave Encouragement] Praise UChange in Routine EDenied Access to itemIActivity [E'Defensive (Describe): ElPositive Reminders (When/T hen) DDif?culty in Previous Class El Preferred Activity Removed Via/(ting i y} CIGave Support Homework Not Done ElTeacher Attending to Others DAssignment Modi?ed CIMissed Medication ElGiven Correction/Redirection CIChanged Instruction [:lSubstitute Teacher UPeopie too Close I Cl Used Proxemic?s/Kinesics DAcademic Failure ElLoud Noises/Room Behavior Leading to @Para Verbal Communication [3 Hunger UBright Lights Seclusion/ Restraint DUsed CPI Supportive Stance DFatigue DWith a Speci?c Peer(s) DVerbal Aggression EIVisual Cues Used El Illness DWork too Hard/ Easy ?Verbai Threats/Intimidation UModeied EXpected Behavior ULarge Group ction DWork Repetitive/too Long Cl Physical ThmaB/ln?midatlon DEmpathic Listening EISmal! Group instruction [lindependent Work Aggression/Self @Gave Choices a El individual instruction Din Pain EPhysical Aggression/Others ElTlme Out (Where): [:lUnstrUCtured Time DSitting For Extended Time El Physical Aggression] Property Loss of PrivilegefReward UApproached By Adult DWeapon Possession ESet Limits (1?t fThen, When/Then) DScheduled Non Preferred Activity DElopement DCailed for Team Support ClWaiting El Other (Please Describe): CIRemove Other Students UT'ransition to: from: ElOther: EIOther: . El Additionai Comments: Student may have been trying to gain: Possible Function] Purpose of Behavior r? may have been trying to avoid: Student DSocial interaction? DPee'r or- El Adult- USOcial-lnteraction DPeer _o_r :ElAduit on ElSensory Stimulation 'l DSensory Stimulati . [given?Preferred Activity/T ask Cedachrpids . ?a Commun't?r?schc?c?m?? theicei Reetreint end Decomentetron [item Beieo?nciden?i .- -l During Record actions of the student and staff during physical restraint, transport, and/or seclusion. Stadents must be monitored constantly and documentation compieted at aminimum of ever?;? two minutes. NGTE: For restraints and seclusion: to exceed beyond each class period or every 60 minutes, obtain signature of administratioo indicating authorizationTime Qbserved Actions of the Student During Seciusron/Restrelnt Staff Response to Qbsewed Actions :15:ng . . i- II we? then returned to ciase whei'ii meow mi?nilstragtorSignature (to go beyond every 56 minutes or: each class period) Time Date "sf {Cedachiipids Physicai Restraint and Seclusion Documentation I Student: I I Date of incident: i Student Actions and Dehriefing After incident Staff Actions After incident Student Actions Student Debrie?ng ESupportive/ Undivlded Attention l3 Crying [3 Processing Activiti es {Describe} ClEmpathic Listening El Calm El Used Restatem ents for Understanding/ Clari?cati on ElRational UGave Wait Time CITalkative Silence ElSilent Cl Coping Skill Activity (Describe) EContinued to Monitor EAccepti rig SDpport Jr.ClAssisted Student with Work Completion Diired DWalked Student to Class USleeping DSupported Student in Class EFollowing Directions EIExpected Behavior Activity DAssisted Student with Task Completion (cleaning up, etc.) Returned to Class (Describe) DComrnunicated with CaregiVer Name: El Visited Nurse DFollowed Through on Prior Expectation DApoiogized for Actions DAssisted with Processing Activity El Communicated with El Accepted Responsibility for UMaintained Awareness of Proxernics, Kinesics, 8e Caregiver Name: Actions {cleans up, etc.) Para verbal Communication El Pacing ElAssisted with Coping Skill Activity [3 Worked independently DSwitched Staff Roles DRestroom/Bodtly Needs Ember (Describe) Fire DAssisted with Expected Behavior Activity LEOther (Describe) moi ewe? - man We UOther going bed; to (rides Staff Debriefing and Future Approaches to Decrease or Eliminate Behavior from Reoccurring: Meeting (IEP, Learning Supports, I DParent Meeting Date: UCollect ABC Data etc.) Date: ElReview ClRevise Sociai Skill on UComplete Competing Pathways Chart El Conduct Functional Behavioral Assessment El Review Replacement Behavior HReview Positive Behavior Supports El Consider Student El Review IEP Goals Data DAccess Community Supports Revise Academic Support El Contact AEA Supports ElOther: Describe any injuries to student, employees, others, or property damage: . Communication Documentation Parentlguardian mug; be contacted on dav of incident. Name of person contacted: Relationship: mom Date: I Time: Method: Ghana I Describe?mpts to notify the parent/guardian if contact cannot be rriade on day of incident: Written documentation must be sent to parentlguardian within 3 school days. Date sent: Sent by: Mail (postmarked within 3 days ofthe occurrence) El Email upon written request of parent/guardian El Fax upon written request of parent/guardian El Hand Delivered in Person . mum-m Hm impnfa?rion was sent to: a Cedachinds f? Physical Restraint and Seeiusion Documentation Student: Date oflncidentz. School?: .. . . Grade: Seciusion Location: Time In: Time Out: Duration: Confinement ofa student in a room from (11" ?2 T5 1pm,.? I I which the stu dent?s egress is restricted Student Entered Seciusion by: EIWaIked on their own Transport DCPI interim Control NCI PhysicalTransport: Safely moving an [lather (please Describe): individual who is beginning to regain control Time Started Time Ended_ Duratiow Physical Restraint Team Control Time Started:q;2b Time Ended:q;;3 Duration: Used to manage individuals who have DCPI Contro) . become dangerous to themselves or others; Lused as a last resort Staff Members Involved: El Other (Please Describe): Before Seclusion/Restraintfi?ranaport (Check Implemented items) Setting Events Antecedents Student Behavior Staff Response (Eve Editedly impacting the (Immediate triggers or predictors of Immediately after (Calm 3t Nonludgmental aftlons taker) to be havloral outcome) the problem behavror.) Antecedent Sirjilzifeitj?; bahawor and ?Old Location: Uleen Verbal Direction EIAnxious (Describe): - Gave Redirections lZlSubject: El Given Work/Activity El Offered Coping Skill/ break, etc. DActivity: Upnexpected Change in Routine DPlanned Ignore EIConflict Prior to School ?i?resented w/Social interaction DGave Time to De-escalate EIConflict at School : Told ?No? by: DGave Encouragement/Praise El Change in Routine Denied Access to Item/Activity El Defensive (Describe): Positive Reminders (Whe hen) DDif?culty in Previous Class El Preferred Activity Removed miav?m d1 Mm mm; EIGave Support Homework Not Done DTeacher Attending to Others (Ltdifm I DAssignment Modi?ed El Missed Medication ElGiven Correction/Redirection bi Ham [3 Changed Instruction CISubstitute Teacher El People too Close El Used Proxemics/Kinesics DAcademic Failure El Loud Noises] Room Behavior Leading to : Para Verbal Communication Hunger Upright Lights Seclusio n/ Restraint Used CPI Supportive Stance DFatigue EWith a Speci?c Peer(s) EIVerbal Aggression CIVisual Cues Used CIWork too Hard! Easy DVerbal Threats/ Intimidation EIModeled Expected Behavior EILarge Group Instruction DWork Repetitive/too Long Whysical Threats/ Intimidation EIEmpathic Listening ClSmall Group Instruction El Independent Work Physical Aggression/Self ElGave Choices Ellndividual instruction Elln Pain Aggression/Others ElTime Out (Where): Unstructured Time CISitting For Extended Time EPhysical Aggression/Property El Loss of Privilege/Reward ElApproached By Adult DWea pon DSet Limits fThen, When/T hen) DSChedUled Non Preferred Activity Elopement Called for Team Support CIWaiting EIOther (Please Describe): : Remove Other Students EIT'ransition to: from: El Other: - EIOther: (3 eat: ohm-r Additional Comments: billing eel? (. brim?j stall" Kid/de Poured mill: all owe!? Possible Function/Purpose of Behavior I Student may have been trying to gai_n: Student may have been trying to you: .t ClSocial Interaction ElPeer or Cl Adult ESocial Interaction EPeer or DAduit EISensory Stimulation CISensory Stimulation Dillon?Preferred Activity/T ask math. Cedar Rgpids . . I Physiaai Restraint and Seeiesian Qaeantentetten I student: I I I ?ate aftncident: i During Record actions of the student and staff during physical restraint, transport, and/or seclusion. Students must be monitored constantiy and documentation completed at a minimum of every two minutes. NGTE: Far restraints and seclusions to exceed beyond each class period or every 60 minutes, obtain signature of administration indicating authorization. Staff initials ?time Qbsewed Actiens of the Student During Seclusion/ Restraint Staff Response to Observed Actions Administrator Signature (to go beyond every 60 minutes or each class period) Time Date assets m? Cedar Rapids- Community School District Physica i Restraint and Seciusion Doeumentetien I Date of incident: ?Jr? 9 Student Actions and Debriefing After incident Staff Actions After Incident Student Actions Student Debrie?ng ESupportive/ Undivided Attention Crying El Processing Activities {Describe} El Em pathic Listening El Calm DUsed Restatements for Understanding/Ciari?cation El Rational KJGave Wait Time NTall-(ative DAilowed for Silence DSilent ECoping Skill Activity (Describe) mContinued to Monitor CIAccepting Support ?Assisted Student with Work Completion : Tired DWalked Student to Class Dsleeping ESupported Student in Class El Following Directions DExpected Behavior Activity DAssisted Student with Task Completion (cleaning up, etc.) El Returned to Class (Describe) DCommunicated with Caregiver Name: El Visited Nurse Through on Prior Expectation El Apologi zed for Actions DAssisted with Processing Activity El Communicated with Caregiver Name: Cl Accepted ReSponsibility for Actions (cleans up, etc.) KlMaintained Awareness of Proxemics, Kinesics, Para verbal Communication EIPacing CIAssisted with Coping Skill Activity ClWorked Independently . ESwitched Staff Roles DRestroom/Bodiiy Needs EIOther (Describe) ElAssisted with Expected Behavior Activity El Other (Describe) Staff Debriefing and Future Approaches to Decrease or Eliminate Behavior from Reoccurring: etc.) Date: DTeam Meeting Learning Supports, El Parent Meeting Date: Cl Collect ABC Data El Review El Revise ociai Skill Instruction DComplete Competing Pathways Chart DConduct Functionai Behavioral Assessment El Review Replacement Behavior Review Positive Behavior Supports El Consider Student Review Goais Data DAccess Community Supports El Revise Academic Support [:lContact AEA Supports El Other: Describe any injuries to student, employees, others, or property damage: Communication Documentation Parent/guardian must be contacted on dav of incident. Name of person contacted: Relationship: Mam Date: Time: . Method: 9mm I By: Describe?atte'm to notify the parent/g Iuardian if contact cannot be made on day of incident: Written documentation Date sent: must be sent to parent/guardian within 3 school days. Sent by: Mail (postmarked within 3 days of the occurrence) Email upon written?request of parent/guardian El Fax upon written request of parent/guardian Hand Delivered In Person ?ame of parent/guardian the documentation was sent to: Cedangpidt-a . Physical Restraint and Seciusion Documentation Student: I Date oflncident: School: IEP: c_ Seciusion - Location: Time In: Time Out: Duration: Confinement ofastudentin a momfrorn Lr 1 p? which the student's egress is restricted 1 Ll! (2 i L) ?5 Student Entered Seclusion by: Walked on their own DCPI Transport CICPI Interim Control NCI Physical Transport Safer moving an Dower (please Describe): individual who is beginning to regain control Time Started: Time Ended: Duration: Physical Restraint EICPI Team Control Time Started: Time Ended: Duration: Used to manage individuals who have Children's Control - adfa?irezgs?to themselves or Others: El Other (Please Describe): Staff Members Involved: Before (Check Implemented items) Setting Events Antecedents Student Behavior Staff Response Cl (Eve [its mdirectiy impacting the (immediate triggers or predictors of Immediately after gCalm 3330115 33kg? behavroral outcome) the problem behavior.) Antecedent sg?fjgizliestraiilh a a? a Location DGiven Verbal Direction DAnxious (Describe): ??Gave Redirections CISubject: ElGiven Work/Activity ID Offered Coping Skill/ break, etc. CIActivity: Unexpected Change in Routine El Planned Ignore Conflict Prior to School El Presented vii/Social Interaction El Gave Time to De?escalate DConfiict at School ClTold o? by: EGave Encouragement/ Praise Change in Routine El Denied Access to Item/Activity [?Defe nsive (Describe): El Positive Reminders (When/Then) El Difficulty in Previous Class Preferred Activity Removed it, an .39 (Li ell/hearth 3 El Gave Support DHomework Not Done CITeacher Attending to Others Eggl Elma rg??gf DAssignment Modi?ed El Missed Medication P?Given Correction/Redirection Changed instru ction EISubstitute Teacher Cl People too Close Used Proxemics/ Kinesi cs ElAcademic Failure El Loud Noises/Room Behavior Leading to Para Verbal Communication Hunger ClBright Lights Seclusion/Restraint Used CPI Supportive Stance ElFatigue a Speci?c Peer(s) - DVerbaI Aggression EIVisual Cues Used Elillness EIWork too Hard/Easy EVerbal Threats/intimidation EIModeied Expected Behavior Large Group Instruction EIWork Repetitive/too Long ?thsical Threats/Intimidation Cl Empathic Listening Group Instruction Ellndependent Work EIPhysical Aggression/Self [:lGave Choices El Individual instruction El Pain El Physical Aggression/ Others MTime Out (Where): Ff DUnstructured Time EISitting For Extended Time EIPhysical Aggression/Property TD Loss of Privilege] Reward EIApproached By Adult ElWeapon Possession Limits hen, When?' hen) EIScheduled Non Preferred Activity Elopement )ZlCalled for Team Support ClWaiting EOther (Please Describe): [IIRemove Other Students from: Kicking wt [:IOther: DOther: Additional Comments: Eli rectal "l'o use, me: lo Otiicj wad lites; a?i/t waif sti?e-r?, owcptivwi Lugs on benches) Reincsecit Yelling +lnrelc-Jig cc U"I?ll shoal: yoga Fl? Rel/(H all? I 5% curbs. a Possible Function/Purpose of Behavior Student may have been trying to g?i_n: (H Student may have been trying to avoid: ?Social interaction E?Peer or Adult lnteracti on El Peer or CIAdult (ESensory Stimulation I I iZISensory Stimuiation "??l'tnm BIN on-Preferred Activity/T ask ?if Cedangapids . . I ?ts sicai Restraint and Seciasren Becamentatren Ea" LStudent: I Bate at incident: . Baring Record actions of the student and staff during monitored constantly and documentation completed at seclusions to exceed beyond each class period ar every 6 authorization. physicai restraint, transport, and/or seclusion. Students in ust be a minimum of every two minutes. MQTE: For restraints and 0 minutes, obtain signature of administration indicating . Staff Time Ghsenred Actions at the Student During Seciusian/?Restramt Staff Respanse ta @bserued Actions Initials i - Ir Administrator Signature (ta g0 beyond every 60 minutes or each class period) Time Date CedarRapids Comm?th Schc'o'D'smC" Physical Restraint and Seciusion Documentation Student: Date of incident: I Student Actions and De briefing After incident Staff Actions After incident Student Actions Student Debrie?ng DSupportive/ Undivided Attention Crying . Cl Processing Activities (Describe) ClEmpathic Listening )ZlCalm Egsed Restatements for nderstanding/Clari? cation ClRational EIGave Wait Time Ejalkative DAilowed for Silence El Silent - Cl Coping Skill Activity (Describe) DConti nu ed to Monitor DAccepting Support assisted Student with Work Completion EITired DWalked Student to Class ElSleeping ESupported Student in Class ?f?ollowing Directions EjExpected Behavior Activity ElAssisted Student with Task Completion (cleaning up, etc.) EReturned to Class (Describe) name Evil slats: DCommunicated with Caregiver Name: El Visited Nurse Cf; 5 p61,) EFollowed Through on Prior Expectation DApologized for Actions ClAssisted with Processing Activity El Communicated with Accepted Responsibility for DMaintained Awareness of Proxemics, Kineslcs, 8; Caregiver Name: Actions (cleans up, etc.) Para verbal Communication Pacing DAssisted with Coping Skill Activity Worked independently Ewitched Staff Roles DRestroom/Bodily Needs UOther {Describe} JEAssisted with Expected Behavior Activity [3 Other (Describe) DOther Staff Debriefing and Future Approaches to Decrease or Eliminate Behavior from Reoccurring: CJTeam Meeting Learning Supports, DParent Meeting Date: rClCollect ABC Data etc.) Date: Cl Review EIRevise Social Skill DCompiete Competing Pathways Chart DConduct Functional Behavioral Assessment DReview Replacement Behavior i?ZiReview Positive Behavior Supports DConsider Student CJReview IEP Goals 8; Data DAccess Community Supports Revise Academic Support ClContact AEA Supports EIOther: Describe any injuries to student, employees, others, or property damage: Communication Documentation Parent/guardian must be contactejl on clay of incident. Name of person contacted: Relationship: caddie/r Date: 1 Time: Method: an perso ii I By: ?a Describe attempts to notify the parentfguardian if contact cannot be made on day ofincident: Written documentation must be sent to parent/guardian within 3 school days. Date seni Sent by El Mail (postmarlied within 3 days of the occurrence) El Email upon written request of parent/guardian Lg Fax upon written request of parentfguardian $1 Hand Delivered in Person I i Name of parent/guardian the documentation was sent to: I c? Cedar Rapids Community Student: - Grade: Seclusion thsical Restraint - used as a iast nasort Staff Members involved: Before SeclusionIRestraint/Transport (Chec Setting Events (Events i_n_directiv impacting the behavioral outcome) @Location I ESubject: Mm DActivitv: - Confinement of a student in a momfrom which the student?s egress is restricted Student Entered Seclusion by: Physical Transport Safeiv moving an individual who is beginning to re gain control Used to manage individuals who have .. become dangerous to themseives or others; DConflict Prior to School UConflict at School UChange in Routine ClDifFiculty in Previous Class [:lHomework Not Done UMissed Medication DSUbstitute Teacher UAcademic Failure DHunger DFatigue Cliilness ULarge Group instruction DSmall Group instruction Dindividuai instruction Cl Unstructured Time [Social interaction DSensorv Stimulation ?ame Restraint: and Sesiusi?m 3% Date of incident: Location: ?Walked on their Antecedents I (immediate triggers?or predictors of the problem behavior.) EIGiven Verbal Direction - Given Work/Activity El Unexpected Change in Routine Ci Presented w/Sociai interaction [:lTold by: DDenied Access to item/Activity Preferred Activity Removed ch'er'Attending to Others CiGiven Correction/Redirection DPeople too Close ElLoud Noises/Room DBrigh't Lights - DWith a Speci?c Peeds) DWork too Hard] Easy DWork Repetitive/too Long [:lindependent Work Clin Pain USitting For Extended Time DApproached Bv Aduit DScheduied Non Preferred Activity DWaiting DTransition to: from: BOther: Possible Function/Purpose of Student may have been trying to gem: DPeer or Cl Adult Team Control . DCPIChiidren?s Control implemented items) DuratiOn: Time In: DOther (Please Describe): Time Out: i 135 a 2 ed ESQ own DCPI Transport interim Control fiirne Started: Time Ended: Duration: "Iii?me Started: Time-Ended? Duration: DOther(Please Describe): . Student Behavior immediately after Anteceden't DAnxious (Describe): . Staff Response . . (Cairn 81. Nonjudgmenial actions taken'to de?escalate student behavior and avoid seclusion! restraint) ?lGave Redirectio'ns DOi?fered COpin'g?Skill/ break, etc: WPlanned Ignore - EGave Time to De-escalate . Defensive (Describe): Behavior Leading to Seciusioanestraint UVerbal Aggression CiVerbal Threats/intimidation whvsical Threats! Intimidation Physical Aggression/Self ?thsical AggressionIOthers Aggression/Property DWeapon Possession Elopem ent DOther (Please Describe): Gave Encouragement/ Praise Positive Remind ers' (When/T hen) WM DAssignment Modi?ed . . UChanged Instruction -- . UUsed ProxemiCS/Kinesics Para Verbal-Communication - Used CPISupportive Stance, - CIVlsuai Cues Used DModeled Expected Behavior DEmpathic Listening [:lGave Choices E??me Out (Where): KLoss of Privilege] Reward ?sts: Limits [Them Whenrrhen) Called for Team Support 1:1 RemoVe Other Students UOther: Behavior Student may have been trying to avoid: DSocial interaction [3 Peer USensory Stimulation Additional Comm ents: or CIAduit If: 1 Non?Preferred Activity/T ask 1 Cadet-Testi?es . . - of? Physioei iteetretnt and Seolosion Docementetron Ismaane ILBij?il?cid??iL. During Record actions of the student and staff during physical restraint, transpart, ?and/or seclusion. Students must be monitored constantly and documentation completed at aminimum of every two minutes. For restraints and seclusions to exceed beyond each class period or every 60 minutes, obtain signature of administration indicating authorization" i - - Staff Ti Gbserved Actions of the Student Du ring Seclusion! Restraint Staff Response to Gheenred Actions Initials a A . Administrator Signature (to go beyond every 59 minutes or each class period) Time Date "if. Cedar RcipiclS I "if commun?t?fschoom?md Physicai Restraint and Seciusion Documentation I Student: Date e'f incident: Student Actions and Debrie?ng After incident Staff Actions After incident Student Actions Student Debrie?ng DSupportive/ Undivided Attention Crying Cl Processing Activities (Describe) Cl Empathic Listening El Calm Cl Used Restatements for Understanding/Ciari?caij on [JRational DGave Wait Time CITalkative DAllowed for Silence CISilent Cl Coping Skiil Activity {Describe} ClContinued to Monitor DAccepting Support CIAssisted Student with Work Completion Cliired Ewialked Student to eiass USleeping DSupported Student in Class Following Directions DExpected Behavior Activity DAssisted Student with Task Completion (cleaning up, etc.) El Returned to Class in?ame) [:ICommunicated with Caregiver Name: \?si?ted Nurse ElFollowed Through on Prior Expectation CIApologized for Actions CIAssisted with Processing Activity DCom mu nicated with Cl Accepted Responsibility for DMaintained Awareness of PrDXemics, Kinesics, 8; Caregiver Name: Actions (cleans up, etc.) Para verbal Communication El Pacing [:IAssisted with Coping Skill Activity DWorked independently [:lSwitched Staff Roles [Restroom/Bodily Needs ?gther {Describe} {Qua DAssisted with Expected Behavior Activity Other (Describe) I Other Staff Debriefing and Future Approaches to Decrease or Eliminate Behavior from Reoccurring: CITeam Meeting Le arning Supports, DParent Meeting Date: DCollect ABC Data etc.) Date: Review 'Revise Social Skill Instruction DCompiete Competing Pathways Chart Review Replacement Behavior Positive Behavior Supports DReview Goals EV. Data CIAccess Community Supports ClContact AEA Supports Cl Other: Cl Conduct Functional Behavioral Assessment Consider Student Cl Revise Academic Support ll Describe any injuries to student, employees, others, or property damage: Communication Documentation Parentlguardian must be contacted'on clay of incident. Name of person contacted: Relationship: Date: Time: Method: Describe attempts to notify the pa rent] guardian if contact cannot be i] ade on day ofincident: Written documentation must be sent to parent/guardia within 3 school days. Date sent: Sent by: Mail (postmarked within 3 days of the occurrence) El Emaii Upon written request of parent/guardian El Fax upon written reqUest of parentfguardian El Hand Delivered In Person - Cedar Rgpid? . 7 Phosioal Restraint and Seclosion Documentation Student: Date of Incident: School: Grade: lEPz' Seclusion Location: Time In: Time Out: Duration: Confinement of a student in a room from which the stu dent?s egress is restricted Student Entered Seclusion bv: EIWalked on their own Transport [:lCPl Interim Control NCI Physical Transport Safely moving an Dome]. (Please Describe): ,1 individual is beginning to regain control Time Startedf?f: 3% Time Endedzq; Physical Restraint - Team Control I I used as a last resort Used to manage individuals who have become dangerous to themselves or others; I CPI Children?s Control Other (Please Describe): TimeStarted: Ti'me. Ended: Duration: Staff Members Involved: Before'SeclusionIBestraint/T tans?port (Check Implemented Items) Setting Events (Events indirectly impacting the behavioral outcome) Antecedents (Immediate triggers or predictors of the problem behavior.) Student Behavior immediater after Staff Response (Calm 8t Nonjudgmental actions taken to de?escalate student behavior and avoid [3 Change in Routine El Denied Access to item/Activity I UDefens'ive (Describe): A Ptececient secIUsion/restralnt) Location DGiVen Verbal Direction @Anxious (Describe): a DGave Redirections ?Subject: DGiven Work/Activity [017m] me, in (5)95 GEL-J EIOffered Coping Skill] break, etc. DActivity: DUnexpected Change in Routine Jag!) Hour: I IE?Planned ignore DConflict Prior to School DPresented w/Social interaction (Off a" lifp? {[340 EGave Time to De?escalate EConflict at School EITold ?No? by: I. p731"; .. EIGave Encouragement/Praise El Positive Reminders (When/Then) DDif?culty in Previous Class El Preferred Activity Removed ElGave Support DHomework Not Done DTeacher Attending to Others DAssignment Modi?ed El Missed Medication El Given Correction/ Redirection DChanged instruction Additional Comments: Possible Function/Purpose of Behavior Student may have been trying to gain: Student may have been trying to avoid: DSocial interattion UPeer El Adult or [Social Interaction El Peer or DAdult - .c (ESensory Stimulation I - _Lt. . DSensorv Stimulation on?P referred Activity/T ask EISubstitute Teacher DPeople too Close Cl Used Proxemics/Kinesics DAcademic Failure EILoud Noises! Room Behavior Leading to DPara Verbal Communication El Hunger El Bright Lights Seciusio n/ Restraint UhUsed Supportive Stance ClFatigue EIWith a Speci?c Peerls) DVerbal Aggression EVisual Cues Used 591$- Ell?llness EIWork too HardIEasy DVerbaI Threats/Intimidation DModeled Expected Behavior ?arge Group Instruction UWork Repetitive/too Long Threats/Intimidation DEmpathic Listening Small Group El Independent Work Aggressi on/Self El Gava Choices Elndividual Instruction [:lln Pain a? Physical Aggression/ Others E?Tirne Out (Where): EIUnstructured Time ClSitting For Extended Tlme Aggression! Property El Loss of Privilege/Reward DApproached By Adult DWeapon Possession Limits (1'st fThen, Whenfrhen) DScheduled Non Preferred ActivityF El Elopement El Called for Team Support DIWaiting EIOther (Please Describe): CIRernove Other Students ET'ransition fromzjs?fa [q 34 It"; ,1 r. 9 . EIOther: DOther: 1" El ll . i f? Physieoi Restraint end Seciosion documentation [studene .3?l13iaiteotlncidentgu - 1 During Record actions of the student and staff during physical restraint, transport, and/or seclusion. Students must be monitored constantly and documentation completed at a minimum of every two minutes. For restraints and seclusions to exceed beyond each class period ar every 60 minutes, obtain signature of administration indicating authorization. =1 1 Staff Initials Time Observed Actions of the Student During Seclusion/ Restraint Staff Response to Observed Actions 3 a I Administrator Signature (to go beyond every 60 minutes or each class period) Time Date '4?c ?r ft. I Student: - Cedar Rapids Community Domide Physical Restraint and glGave Wait Time Seciusion Documentation Date of incident: Staff Actions After incident DSupportive/ Undivided Attention Em pathic Listening DUsed Restatements for Understanding/Ciarification CIAllowed for Silence EIContinued to Monitor Assisted Student with Work Completion Walked Student to Class DSupported Student in Class DAssisted Student with Task Completion {cleaning up, etc.) EICommunicated with Caregiver Name: DFollowed Through on Prior Expectation DAssisted with Processing Activity El Maintained Awareness of Proxe mics, Kinesics, Para verbal Communication CIAssisted with Coping Skill Activity DSwitched Staff Roles CIAssisted with Expected Behavior Activity 81 Student Actions and Debriefing After incident Student Actions Student Debrie?ng DCrying Cl Processing Activities (Describe) Cl Calm Cl Rational DTalkative ElSilent ElCoping Skill Activity (Describe) gAccepting Support DTired El Sleeping @Following Directions @Expected Behavior Activity Returned to Class (DP-Scribe} El Visited Nurse UApologized for Actions El Communicated with El Accepted Responsibility for Caregiver Name: Actions [cleans up, etc.) Cl Pacing ClWorked independently Cl Restroom Bodily Needs DOther (Describe) El Other (Describe) Staff Debriefing and Future Ap ETeam Meeting Learning Supports, etc.) Date: ClReview DConduct Functional Behavioral Assessment Cl Consider Student El Revise Academic Support Cl Revise Social Skill ClOther proaches to Decrease or Eliminate Behavio ElParent Meeting Date: ElReview Replacement Behavior ClReview Goals Data DContact AEA Supports Describe any injuries to student, employees, others, or property damage: from Reoccurring: DCollect ABC Data El Complete Competing Pathways Chart El Review Positive Behavior Supports ElAccess Community Supports DOther: nstr-uction Communication Documentation fl/l?: 4/7 Parent/guardian must be contacted on day of incident. Name of person contacted: Relationship: h. Date: I Time: Method: By: Describe'atte to notify the parent/guardian if contact cannot be ade on day ofincident: Written docup'i_en_tation must be sent to parent/guardian within 3 school days. Date sent: Sent by: Mail (postmarked?within 3 days of the occurrence) El Email upon written request of parent/guardian El Fax upon written request of parent/guardian El Hand Delivered in Person i?mnmn NF narPnT/guardian the documentation was sent to: :3 Lat. CedachspidS . It? thsicai Restraint and Secidsren Deicprnentatien Student: 1' Date oflncident: School: *7 Grade: I I Seclusinn Location: Time In: Time Out: Duration: Confinement of a student in a room from a (9 which the stu dent?s egress is restricted Selma Student Entered Seclusion by: Physical Transport Safelv moving an individual who is beginning to regain control ClWalked on their own ClOther (Please Describe): Transport Time Started: DCPI Interim Control Time Ended: Duration: Physical Restraint used as a last resort Used to manage individuals who have become dangeroUS to themselves or others; ECPI Team Control DCPI Children?s Control Other (Please Describe): Time Started: 3: m?me Ended: 3'33Duration: 3 Staff Members Involved: Before (Check implemented Items) Setting Events (Events i_n_directlv impacting the Antecedents (Immediate triggers or predictors of Student Behavior Immediater after Staff Response (Calm E: Noniudgmental actions taken to de-escalate student behavior and avoid behavroral outcome)? the problem behavior.) Antecedent seclusion/restraint} Location Niven Verbal Direction [3 Anxious (Describe): EGave Redirections ClSubject: EIGiven Work/Activity IDOffered Coping Skill/ break, etc. DActivity: El Unexpected Change in Routine Planned ignore El Conflict Prior to School El Presented WISociaI Interaction El Gave Time to De-escalate El Conflict at School ?No? by: El Gave Encouragementf Praise Cl Change in Routine El Denied Access to item/Activity El Defensive (Describe): EIPositive Reminders (When/T hen) EDif?culty in Previous Class Cl Preferred Activity Removed whim I hi-H-Mi EIGave Support DHomework Not Done ElTeacher Attending to Others sin-335*) 5n 0y} 3 DAssignment Modi?ed El Missed Medication El Given Correction] Redirection gag-?; ElChanged Instruction bstitute Teacher ClPeople too Close Used Proxemics/Kinesics El Academic Failure EILoud Noises/ Room Behavior Leading to El Para Verbal Communication [3 Hunger EIBright Lights Seclusionl Restraint DUsed CPI Supportive Stance Eli?atigue EIWith a Speci?c Peer(s) DVerbal Aggression DVisual Cues Used DWork too Hard/Easy CIVerbal Threats/Intimidation ClModeled Expected Behavior El Large Group Instruction DWork RepetitiVe/too Long thsical Threats/intimidation Cl Em pathic Listening ElSmall Group instruction Ulndependent Work Aggression/Self El Gave Choices ?ndividual instruction Elln Pain Aggression/Others Out (Where): El Unstructured Time EISitting For Extended Time El Physical Aggression! Property Cl Loss of Privilege] Reward UApproached By Aduit - UWeapon Possession Limits (1st hen, When/T hen) DScheduled Non Preferred Activity El Elopement ?Kl'Called for Team Support UWaiting El Other (Please Describe): IljRemove Other Students [:lTransition to: from: El Other: E?Other: grandad, (4mg Additional Comments: net li?rQCM ml of. til/eel?) l. I ll Possible Function] Purpose of Behavior Student may have been trying to gain: p? Student may have been trying to avoid: EISocial Interaction EIPeer or Cl Adult DSocial Interaction DPeer or EIAdult EISensorv Stimulation DSensorv Stimulation ?rl-iui?hln-n?k Cedar?dpide . . r? Qmmunm?schm'mm emerges Restraint and Bocomentatton Igtooent: [Bate of incident: Daring Record actions of the student and staff during physical restraint, transport, and/or seclusion. Students must be monitored constantly and documentation completed. at a minimum of every two minutes. NGTE: Forrestraints and seclusions to exceed beyond each class period or every 60 rnin ates, obtain signature of administration indicating authorization. Staff mite? Time Qbser?ved Actions of the Student Bu ring ?eciusioni Restraint Staff Response to Gosemed Actions is? Administrator Signature (to go beyond every 53 minutes or each class period) Time Date Lot. if. I Student: Cedar Rapids Community School District Restraint and Seciusiort Documentation :l I Date of incident: Student Actions and Debriefirig After incident Staff Actions After incident Student Actions Student Debrie?ng DSupportive/ Undivided Attention El Crying El Processing Activiti es (Describe) Em pathic Listening I_l:l Cairn l3 Used Restatements for Understanding/Clarification DRational DGave Wait Time ElTalkative EIAIlowed for Silence El Silent DCoping Skill Activity (Describe) El Continued to Monitor CIAccepting Support DAssisted Student with Work Completion D'?red DWalked Student to Class DSleeping DSupported Student in Class El Following Directions DExpected Behavior Activity DAssisted Student with Task Completion (cleaning up, etc.) DReturned to Class (Describe) lSJCommunicated with Caregiver Name: El Visited Nurse l?Followed Through on Prior Expectation DApologized for Actions DAssisted with Processing Activity El Communicated with Caregiver Name: El Accepted Responsibility for Actions (cleans up, etc.) DMaintained Awareness of Proxemics, Kinesics, 8i. Para verbal Communication DPacing CIAssisted with Coping Skill Activity ?j El Worked independently l3 Switched Staff Roles ElRestroom/Bodily Needs MOther {Describe} DAssisted with Expected Behavior Activity L_l:l Other (Describe) I El Other Staff Debriefing and Future Approaches to Decrease or Eliminate Behavior from Reoccurring; EITeam Meeting Learning Supports,_ El Parent Meeting Date: El Collect ABC Data etc.) Date: Cl Review ClRevise Social Skill instruction DComplete Competing Pathways Chart EIConduct Functional Behavioral Assessment ClReview Replacement Behavior ?-Review Positive Behavior Supports El Consider Student El Review IEP Goals 8i. Data ElAccess Community Supports Revise Academic Support El Contact AEA Supports El Other: Describe any injuEe?s to student, employees, others, or property damage: Communication Documentation Parentfguardian must be contacted on day of incid_e_nt. Name of person contacted: Relationship: mm Date: Time: Method: Dina/,3 I By: I Describe attempts to notifyt he parent/guardian if contact cannot be m'ade on day of incident: Written documentation must be sent to Date sent: El Fax upon written request Mail (postmarked within 3 days of the occurrence) of parent/guardian parentlguardian within 3 school days. Sent by: El Email upon-written request of parent/guardian El Hand Delivered In Person .: "Mon". uni-dish the documentation was sent to: . 4 \y Cedar Rapids; gr? Community School District Physicai Restraint and Seciusion Documentation Student: Date of Incident: Schoof i Grade: IEP: Seciusion Location: Time in: Time Out: Duration: Confinement of a student in a room from (31 - '9 which the student?s egress is restricted Student Entered Seciusion by: DWaiked on their own ECPI Transport DCPI interim Control Physical Transport Safely moving an individual who is beginning to regain control ClOther (Please Describe): Time Started: CI 3% Time Endedzciio'? Duration: Physical Restraint EICPI Team Controi Time Started: Time Ended: Duration: Used to manage individuals who have Children's Contra} - themsewes Growers: El Other (Please Describe): Staff Members involved: Before (Chech implemented Items) Setting Events Antecedents Student Behavior Staff Response ?l (Events indirectly impacting the (immediate triggers pr predictors of immediately after (Cairn 3t No'niUdgmentai. aetions' taken to be haviorai outcome) the problem behavior.) I I Antecedent I Sifjgg?fe?rgiir?t behawor and aVOid Elocation: EIGiven Verbal Direction 1 EIAnxio?us (Describe): . EGave Redirection; fl] Subject: EIGiven Work/Activity UOffered Coping Skill! break,- etc. DActivity: El Unexpected Change in Routine EPianned Ignore ?Confiict Prior to School IZIPresented w/Social Interaction DGave Time to De?escalate DConfiict at School ClTold "No" by: DGave Encouragement/Praise El Change in Routine El Denied Access'to Item/Activity MDefensive (Describe): El Positive Reminders (When/T hen) El Dif?culty in Previous Class El Preferred Activity Removed EIGave Support - . 53 Homework Not Done EITeacher Attending to Others 4511035 (ha DAssignment Modified El Missed Medication Correction/Redirection ?1 "l - I DChanged instruction DSubstitute Teacher ElPeopie too Close Cl Used Proxe?tnics/Kinesics DACademic Failure ClLoud Noises/Room Be havior Leading to EPara Verbal Communication DHunger [:lBright Lights Seclusio n/ Restraint .. Used CPI supportive Stance DFatigue DWith a Speci?c Peer(s) I CIVerbal Aggression DVisual Cues Used . {Jiliness EIWork too Hard/Easy DVerbal Threats-I Intimidation Clisiiodeied Expected Behavior. CILarge Group Instruction Elka Repetitive/too Long UPhysical Threats] Intimidation Cl Em pathic Listening all Group Instruction El independent Work Cl Physical Aggression/Seif CI Gave Choices Elindividual Instruction Elln Pain EP hysical Aggression/ Others CITime Out (Where): DUnstructured Time CISitting For Extended Tlme UPhysical Aggression! Property EILoss of Priviiege/Reward mg?? 55m 13;) CIApproached By Adult DWea pon Possession El Set Limits hen, WhenfT hen) Droblme a) home i EIScheduled Non Preferred Activity El Elopement ECalled for Team Support Momrnq DWaiting CI Other (Please Describe): Remove Other Students 3 ET?ransition to: bug fromzhovne. DOther: El Other: El Additional Comments: Possible Function/Purpose of Behavior Student may have been trying to gain: Interaction DPeer or EISensory Stimulation DSociai interaction ClSensory Stimulation ?Adult Student may have been trying to avoid: DPeer or DAdult I A A El Non?Preferred Activity/T ask ?f - Cedar Rapids Communit?r?schm'mtmd Shesieei Restraint and Seeldsian ?esamentatian I Student:? I - I-Ijete atineident: 3 During Record actions of the student and staff during physicai restraint, transport, and/or seclusion. Students must be monitored constantly and documentation completed at a minimum of every two minutes. NOTE: For restraints and seclusions to exceed beyond each class period or every 60 minutes, obtain signature of administration indicating authorizationSta-ff Time Gbsewed Actions of the Student During Seclusm n/Restralnt initials Que I a I (liaq lit/1 c9 - El SEE 61:? i I Szi Staff Response ta Observed Actiens 'ell on iloor Administrator Signature (ta gd beyond every 60 minutes or each class periad) Time Date geeks . WI CedangpidS 1? ?if Physicai Restraint and Secidsien Dace-mentaticin I Student: I Date of Incident: I 5 I Student Actions and Debriefing After incident Staff Actie ns After incident 1 Student Actions Student Debrie?ng DSupportive/ Undivided Attention El Crying Processing Activities (Describe) Em pathic Listening Cairn EIUsed Restatements for Understanding/Clari?cation DRationai ElGave Wait Time DTaikative DAllowed for Silence Silent Coping Skill Activity (Describe) DContinued to Monitor UAccepting Support DAssisted Student with Work Completion _l:lTired EWalked Student to Class DSleeping DSupported Student in Ciass Following Directions Expected Behavior Activity DAssisted Student with Task Completion (clea ning up, etc.) EReturned to Class (Describe) DCommunicated with Caregiver Name: Visited Nurse [owl pm ElFollowed Through on Prior Expectation DApoiogized for Actions ?afm {1mg}; ElAssisted with Processing Activity Communicated with El Acce'pted Responsibility for DMaintained Awareness of Proxemics, Kinesics, 8t Caregiver Name: Actions (cleans up, etc.) Para verbal Communication DPacing DAssisted with Coping Skill Activity DWorked Independently DSwitched Staff Roles DRestroom/Bodily Needs ?Other {Describe) DAssisted with Expected Behavior Activity L_Other (Describe) brawl-flat? EOther - Staff Debriefing and Future Approaches to Decrease or Eliminate Behavior from Reoccurring: EITeam Meeting Learning Supports, UParent Meeting Date: DCollect ABC Data etc.) Date: El Review DRevise Social Skill instruction ElComplete Competing Pathways Chart DConduct Function ai Behavioral Assessment [Review Replacement Behavior ?Review Positive Behavior Supports [:lConsider Student DReview Goals 8i. Data DAccess Community Supports El Revise Academic Support El Contact AEA Supports Other: Describe any injuries to student, employees, others, or property damage: Communication Documentation Pa rent/gua rdian be contacted on day ofincident. Name of person contacted: Relationship: mum Date: I Time Method: I By:; Describe'attenipts to notify the parent/guardian if contact cannot be nlade on day of incident: Written dacumentation must be sent to pa rent/guardian within 3 school days. Date sent: Sent by! $1 Mail (postinark?d within 3 days of the occurrence) El Emaii upon Written sequest of parent/guardian El Fax upon written request of parent/guardian El Hand Delivered In Person l?Nnme nf narent/euardian the documentation was sent to: Emi? Student: Cedar Rapids Seciusion - Confinement of a student in a room from which the student?s egress is restricted Student Entered Seclusion by: Physical Transport Safely moving an individual who is beginning to regain control Physical Restraint Used as a last resort Staff Members Involved: Used to manage individuals who have become dangerous to themselves or others; Physicai Restraint and Sec Date of Incident: UCPI Team Control UCPI Children?s Control Cl Other {Please Describe): . WW IEP Location: Time In: Time Out: Duration: 01:54: (own 520 DWalked on their own Transport UCPI Interim Control UOther (Please Describe): Time Started: a?me Ended: Duration: Time Started: iusion Documentation School" Time Ended: Duration: (Events indirectly impacting the behaviorai outcome) Eitocation: ESubject: (Ed% I DActivity: [JConflict Prior to School DConflict at School [JChange in Routine DDif?culty in Previous Class DHomework Not Done DMissed Medication DSubstitute Teacher [:IAcademic Failure DHunger [JFatigue Ellilness ElLarge Group ction DSmall Group instruction Ellndividual instruction ClUnstructured Time [Social interaction ?Cnnan Stim ulati on I Student may have been trying to gain: Cl Peer the problem behavior.) UGiven Verbal Direction KGiven Work/Activity UUnexpected Change in Routine Eli?resented w/Social Interaction DTold ?No? by: CIDenied Access to ItemIActivity Cl Preferred Activity Removed ElTeacher Attending to Others El Given Correction! Redirection UPeople too Ciose EILoud Noises/Room UBright Lights UWith a Speci?c Peer(s) DWork too Hard/ Easy DWork Repetitive/too Long Elindependent Work Din Pain DSitting For Extended Time DApproached By Adult DScheduied Non Preferred Activity DWaiting UTransition to: El Other: from: Possible Function/Purpose of or Cl Adult efore SeclusionIRestraintITransport (Check impiemente 01 Items) Setting Events Antecedents Student Behavior Staff Response (Immediate triggers or predictors of immediately after I. e-iu Behavior Leading to Seclusion/ Restraint DVerbal Aggression [JVerbal Threats/intimidation Aggression/Self UWeapon Possession H?lopement Additionai Comments: Behavior Student may DSocial interaction USensory Stimulation ('71 Dresanan Adivitvaask AntBCEdent seclusionlrestraint) E?nxious (Describe): ave Redirections QQ Lg} 5503,] gi?lanned Ignore magi-p Gave Time to De?escalate Defensive (Describe): it) Cl Physical Aggression] Others Physical Aggression] Property DOther (Please Describe): Other: (Calm EL Noniudgmeniai actions taken to deescalate student behavior and avoid E?O?ered Coping Skiil/ break, etc. DGave Encouragement] Praise Wositive Reminders (When/T hen) DGave Support DAssignment Modi?ed UChanged Instruction Proxemics/Kinesics DPara Verbal Communication DUsed CPI Supportive Stance [JVisual Cues Used DModeled Expected Behavior ClEmpathic Listening ?Gave Choices Time Out (Where) HLoss Of Privilege] Reward Ego Limits fThen,WhenfThen) DCalled for Team Support Cl Remove Other Students El have been trying to avoid: ClPeer or DAduit xF {Cedangpi_ng I . . Commun?tys?i?mm?m Phirstcel?estretnt end SecEusEen Beeumentet?en l?i?de? "In .. During Record actions of the student and staff during physical restraint, transport, and/or seclusion. Students. must be monitored constantly and documentation completed at eminimum of every two minutes. NQTE: For restraints and seclusions to exceed beyond each class period or every 60 minutes, obtain signature of administration indicating authorization. .. . . Qbsewec? Actaens of the Student During Eeclusla [fa/Restraint. Staff Reseonse to Observed Actions Emails a I meet? t? ?tt' 3t a 1 "i Administrator Signetu re [to go beyond even; $0 minutes or each class eeriadl Tin-m Clark. (53er A I a f" Physical Restraint and Deco; mentation I Student: Date of Incident: Student Actions and Deitrie?iing After incident Staff Actions After incident Student Actions Student Debrie? ng ESUpportive/ Undivided Attention Cl Crying DProcessing Activities (Describe) El Empathic Listening DCalrn DUsed Restatements for Understanding/Clari?cation El Rational ave Wait Time DTalkative DAiloWed for Silence DSilent lECoping Skill Activity (Describe) Continued to Monitor DTlred DWalked Student to Class DSleeping DSupported Stu dent in Class Following Directions DExpected Behavior Activity ted Student with Task Completion (cleaning up, etc.) UAssis DReturned to Class Commu nicated with Caregiver Name: Cl Visited Nurse 5 ?3 Followed Through on Prior Expectation DApologized for Actions "likened with Processing Activity 84. DCommunicated with E1 Accepted Responsibility for DMaintained Awareness of Proxe mits, Kinesics, CaregiVer Name: Actions (cleans up, etc.) Para verbal Communication DPacing Assisted with Coping Skill Activity ClWorked independently Clswitched Staff Roles DAssisted with Expected Behavior Activity Def-cent? ng Support WW a; Assisted Student with Work Completion El Restroom/Bodily Needs ClOther {Describe} . Other (Describe) - - a, Staff Debriefing and Future Approaches to Decrease or Eliminate Behavior from Reoccurring: El Parent Meeting Date: CI Collect ABC Data etc.) Date: CIRevise Social Skill instruction DComplete Competing PathWays Ch art DReview El Conduct Functional Behavioral Assessment Cl Review Replacement Behavior eview Positive Behavior Supports Cl Consider Student Cl Review Goals Data DAccess Community Supports Cl Revise Academic Support El Contact AEA Supports or prOperty damage: ElTeam Meeting Learning Supports, I Describe any injuries to student, employees, others, Communication Documentation Pa rent] gua rdian _rp_y_s_t_ be contacted on day of incident. Name of person contacted: Date. ?lime: Describe'attem to notify the parent/ guardian if contact cannot be ade 0 Relationship: Method: ho day of incident: Written documentation must be sent to parent] guardian within 3 school days. Date sent' Sent by. Mail (postmarked within 3 days of the occurrence] Em ail upon written request of parent! guardian El Fax upon written request of parent/guardian El Hand Delivered in Person '5 I ?(Zealot Res-totem as" ?4 School Diem phygicag (an Restraint and Seciesion Documentation Confinement of a student in a room from which the stude nt's egress is restricted lizog Student Entered Seciusion by: NCI Physical Transport: Safely moving an individual who is beginning to regain control DWaIked on their own ClOther (Please Describe): Transport interim Control Time Time Duration: I r_Studenir Date of Incident: School: 1 Grade: I IEP: Seclusion Location: Time In: Time Out: Duration: Physical Restraint - Team Control Time Started: Time Ended: DuratIOn: Used to manage individuals who have Children?s Contm; become dangerous to themselves or others; . . used as a last resort El Other (Please Describe). Staff Members involved: Before (Check implemented items) Setting Events Antecedents Student Behavior Stati Reseonse (Events indirectly impacting the (immediate triggers or predictors of Immediately after (Calm 3* Nonludgmental actions taken to behavioral outcome the robiem behavior.) . die-escalate ?Udem bahaVior ?05d Antece?ient seclusion/restraint) Gave Redirections Mocation: DGiven Verbai Direction DAnxious (Describe): USubject: E?Given Work/Activity DOffered Coping Skill/ break, etc. DActivity: El Unexpected Change in Routine DPlanned Ignore Conflict Prior to School El Presented w/Social interaction ElGave Time to De?escalate Conflict at School DTold ?No? by: ElGave Encouragement/Praise ClChange in Routine Denied Access to Item/Activity KiDefensive Positive Reminders (When/Then) ClDifficulty in Previous Ciass Cl Preferred Activity Removed Kl?dc'm a DGave Support DHomework Not Done DTeacher Attending to Others orouo Karla be.? DAssignment Modified El Missed Medication Given Correction/Redirection Lag?)3 qj 4(an ElChanged instruction EISubstitute Teach er CJPeople too Close Kaela?; M) 0w '1 El Used Proxemics/Kinesics DAcademic Failure Noises/Room Behaviorlieading to DPara Verbal Communication CI Hunger CiBright Lights Seclusion/ Restraint El Used CPI Supportive Stance ElFatigue DWith a Speci?c Peer(s) DVerbal Aggression DVisual Cues Used El illness DWork too Hard/Easy lZlVerbal Threats/Intimidation ElModeied Expected Behavior DLarge Group instruction EIWork Repetitive/too Long JZ?Physical Threats/Intimidation DEmpathic Listening EISmail Group Instruction El Independent Work Aggression/Self ElGave Choices Elindividual instruction Elln Pain Aggression/Others UTime Out (Where): EIUnstructured Time DSitting For Extended Time )Z'Physical Aggression/Property ElLoss of Privilege/Reward EIApproached By Adult DWeapon Possession DSet Limits fThen, When/T hen) UScheduled Non Preferred Activity DElopemen't ECalied for Team Support DWaiting DOther (Piease Describe): El Remove Other Students EITransition to: from: EOther: Susi-e, room Other: El Additional Comments: Possible Function/Purpose of Behavior Student may have been trying to gain: Student may have been trying to avoid: DSocial Interaction EIPeer or Adult DSocial interaction DPeer Ol' DSensory Stimulation USensory Stimulation Preferred Activity/Item Milton-Preferred Activity/T ask Cedaerpicls . . f? Commn'tVSd?OO'D?m Physical Restraint and Seciusion Documentation Student: Date ofincident: . . School: Grade: Seclusion Location: 3 Time In: Time Out: Duration: Confinement ofa student in a roomfrom ,0 -. . which the student?s egress is restricted alga Imm? Student Entered Seclusion by: EIWaIked on their own ECPI Transport EICPI Interim Control Physical Transport Safely moving an Dome]. (please DescribeMduai who is beginning to regain control Time Started: ?34, Time Endedjz'g? Duratlon: I MCI Physical Restraint - DCPI Team Control Time Started: Time Ended: Duration: Used to manage individuals who have Dcp] Children?s Control - become dangerous to themselves or others; . used as a last mm Other (Please Staff Members Involved: Before Seclusion/Restraint/Transport (Check implemented Items) - Setting Events Antecedents Student Behavior Staff Response (Events i_ndirectly impacting the (Immediate triggers or predictors of Immediately after actions taken to- behavioral outcome) the problem behavior.) Antecedent dw?late ?dent bEhBVimand ?Did seclusionlrestraint) Cl Location: UGiven Verbal Direction Anxious (Describe): [:lGave Redirections mSubject: EC 655 ClGiven Work/Activity E?O?ered Coping Skill! break, etc. DActivity: El Unexpected Change in Routine Planned Ignore DConflict Prior to School EIPresented w/Social Intgaction DConflict at School WTold o? by: Gave Time to De?escaiate UGave Encouragement/Praise ClChange in Routine El Denied Access to Item/Activity El Defensive (Describe): DPositive Reminders (When/Then) ElDif?culty in Previous Class Preferred Activity Removed scouring . poouokim DGave Support DHomework Not Done EITeacher Attending to Others CIAssignment Modi?ed UMissed Medication UGiven Correction/Redirection been: .. valuing-.mqu r. I I I EIChanged Instruction DSubstitute Teacher UPeople too Close Used Proxamics/Kinesics DAcademic Failure El Loud Noises/RoOm Behavior Leading to . EIPara Verbal Communication El Hunger DBright Lights Seclusio n/ Restraint DUsed CPI Supportive Stance UFatigue a Speci?c Peer(s) EIVerbal Aggression DVisual Cues Used Diliness DWork too Hard/Easy DVerbaI Threats/ Intimidation EIModeled Expected Behavior EILarge Group Instruction DWork Repetitive/too Long Cl Physical Threats/ln?midation Em pathic Listening Group Instruction Dindependent Work El Physical Aggression/Self ,Z'Gave Choices Ellndividuai Instruction Din Pain Physical Aggression/ Others Out (Where): DUnstructured Tlme DSitting For Extended Time ?er hysical Aggression/Property DLoss of Privilege/Reward DApproached By Adult DWeapon Possession USet Limits (1?t IT hen, When/T hen) DScheduIed Non Preferred Activity )Zi'Elopement JZEailed for Team Sopport DWaiting Other (Please Describe): Cl RemOVe Other Students EIT'ransition to: from: EIOther: DOther: [j Additional Comments: wan-Pedal, uNew? Leqa sot a, but o-F-Fered [.3405 we. 1n GLASSWOM. inn cam menu 41: races MA screw-1&3 Alla-elm.) +Men +?er in Possible Function] Purpose of Behavior ?Ln moldna dpmuik. Student may have been trying to gain: Student may have been trying to ME: [Social Interaction DPeer or Cl Adult DSocial Interaction DPeer or DAdult DSensory Stimulation DSensory Stimulation Preferred Activity/Item Non-Preferred Activity/T ask Mr and anL' 04411:? Eleni-"LP 444 class room- glacier Rapids . NStuder Pam Crumbs) Physical Restraint and seetoeion Document: L. Date ofincident: I School: .. Grade: I I Seclusion - Location: Time In: Time Out: Duration: Confinement of a student in a room from 3 ~52 ?35: 237:; nun-"r Vat 1 which the student?s egress is restricted Student Entered Seclusion by: NCI Physical Transport Safer moving an individual who is beginning to regain control EIWalked on their own DOther (Please Describe): EtPi Transport DCPI lnte rim Control (Events i_ndirectly impacting the behavioral outcome) (immediate triggers or predictors of the problem behavior.) Immediately after Antecedent Time Started: Time Ended: Duration: Physical Restraint Team Control Time Started: Time Ended: Duration: Used to manage individuals who have Children?s Control become dangerous to themselves or others; . used as a last resort Other (Riggipescnbey Staff Members involved: Before Seclusion/Restraint/Transport (Check Implemented items) Setting Events Antecedents Student Behavior Staff Response (Calm 8r Nonjudgmental actions taken to de-escalate student behavior and avoid seclusion/restraint) DGiven Verbal Direction IZIAnxious (Describe): DGave Redirections Elocation CISubject: Given Work/Activity EIOffered Coping Skill! break, etc. E?ctivitvr?m host EUnexpected Change in Routine EIPIanned Ignore DConfiict ??ii?br tolSchool .HPresented w/Social Interaction Gave Time to De-escalate onfiict at EITold "No" by: Ef?ave Encouragement/Praise EChange in Routine El Denied Access to item/Activity Defensive (Describe): EQositive Reminders (When/Then) Difficulty in Previous Class Preferred Activity Removed Support DHomework Not Done Teacher Attending to Others CIAssignment Modi?ed DMissed Medication EIGiven Correction/Redirection [:iChanged Instruction DSubstitute Teacher El People too Close El Used Proxemics/Kinesics ElAcademic Failure El Loud Noises/Room I Behavior Leading to ?aw Verbal Communication EIHunger Bright Lights Seclusion/ Restraint EUsed CPI Supportive Stance DFatigue El With a Specific Peer(s) EIVerbaI Aggression . *QVisual Cues Used too Hard/Easy EIVerbai Threatsl?lntimidation D?Modeled Expected Behavior Large Group Instruction Repetitive/too Long Threats/ Intimidation ElEmpathic Listening Group instruction Independent Work '?j?hysical Aggression/Self CiGave Choices Ellndividual Instruction Din Pain Whysical Aggression/Others Out (Where): EIUnstructured Time EISitting For Extended Time Aggression/ Property El Loss of Privilege/Reward mpproached By Adult DWeapon Possession : Set Limits (1st J(Then, When/Then) UScheduied Non Preferred Activity ?iopement EEalied for Team Support EIWaiting EIOther (Please Describe): Other Students CITransition to: from: EIOther: Additional Comments: (E: ?aked; Possible Function/Purpose of Behavior Student may have been trying to gain: Student may have been trying to avoid: Modal Interaction EIPeer or EAdult Interaction Peer or EIAdult EISensory Stimulation CISensory Stimulation Preferred EINon?Preferred Activity/Task Werneect?i Piniecei Restraint and Seciasten'ijiescainentetion - Student: I Date of incident: {Eating Record actions of the student and staff during physical restraint, transport, and/0r seclusion. Students must be monitored constantly and documentation completed at a minimum of every two minutes. NGTE: For restraints and seclusions to exceed beyond each class period or every 60 minutes, obtain signature of administration indicating authorization. Staff initials Time absentee Actions of the Student During Seciasion/Restraint Staff Response to Gbserued Actions . if; Fit/Vin 6331/. 4: ft}; .K: (in/?t {id/14:? Mitt/Vi W'pia?dmingr pf Administrator Signature (to go beyond every 60 minutes or each class period) Time Date g?C-Iecicxr?jopide Cpm'ihuniwsmmoiDistrict Student" Date of incident: Physical Restraint and; Seciusien Decumentetinn Student Actions and Debriefing After incident Staff Actions After incident Student Actions Student Debriefing CISupportive/ Undivided Attention [JCrying CI Processing Activities (Describe) ClEmpathic Listening DCaim DUsed Restatements for Understanding/Clarification DRationai ClGave Wait Time DTalkative IZIAliovved for Silence ?gilent CICoping Skill Activity (Describe) ClContinued to Monitor EJAccepting Support ElAssisted Student with Work Completion CITired CIWalked Student to Class DSleeping DSupported Student in Class _ :lFollowing Directions CI Expected Behavior Activity DAssisted Student with Task Completion (cleaning up, etc.) DReturned to Class (Describe) UCommunicated with Caregiver Name: CI Visited Nurse CIFollowed Through on Prior Expectation BApologized for Actions IZIAssisted with Processing Activity CICommunicated with Caregiver Name: Actions (cleans up, etc.) Cl Accepted Responsibility for CIMaintained Awareness of Proxemics, Kinesics, Para verbal Communication EIPacing CIAssisted with Coping Skill Activity independently DSwitched Staff Roies L?JRestroom/Bodily Needs CIAssisted with Expected Behavior Activity El Other (Describe) ?bther (Describe) ?3 {a (EL cii?v'iia Di Mc? Echer at i {:61 . Staff Debriefing and Future Approaches to Decrease or Eliminate Behavior from Reoccurring: CITeam Meeting Learning Supports, etc.) Date: Parent Meeting Date: CICoilect ABC Data DReview CIRevise Social Skill instruction DCompiete Competing Pathways Chart DConduct Functional Behavioral Assessment Review Replacement Behavior If.) Review Positive Behavior Supports CIConsider Student ClRevievv IEP Goals 8: Data DAccess Community Supports Cl Revise Academic Support Woman AEA Supports DOther: Describe any injuriec in student. employees, others, or property damage(tattle-e33, 53m Communication Documentation Parent/guardian must be contacted on day of incident. Name of person contacted: Date A Time: Describe attempts to notify the parent/guardian if contact canno Relationship: Methodirx i?w?ll?w be made on day of incident: Written documentation must be sent to parent/guardian within 3 school days. Date sent: . Sent by: Mail (postmarked within 3 days of the occurrence) El Email upon written request of parent/guardian El Fax upon'written request of parent/guardian Cl Hand Delivered In Person I Name of parent/guardian the documentation was sent to: . Cedar Rciphds f? Physical Restraint and Seolusion Documentation Student I Date ofincidentr Schoo' Grade: i Seciusion Location: Time in: Time Out: Duration: Confinement of a student in a roomfrom .. . which the student?s egress is restricted 2 I Ll a (9 Student Entered Seciusion by: EWalked on their ovvn DCPI Transport interim Control Physical Transport Safely moving an Gather (Please Describe): Idwsdual who iS beginningto regain control I I Time-Started: Time Ended: Duration: Physical Restraint Team Control Time Started: I Time Ended: Dui?ation: Used to manageindividuals who have DCPI children?s Contra . - i become dangeroUs to themselves or others; . Used asa lastremrt Cl Other (PleaseDescribe). Staff Members Inmlved: Before SeclusionfRestraintITransport (Check implemented items) SettingEvents Antecedents I Student Behavior Staff Re'Sponse (Events indirectly impacting the .(immediate triggers or predictors of immediately after (Calm 31 Noniudgmental actions like? tO' behavioral outcome) the problem behavior.) Antecedent def-scat?? Simian" hEhaVlor and seclusionlrestraint} glLocation: DGiven Verbal Direction [:lAnxious (Descri be): DGave Redirections DSubject: DGiven Workactivity I ?Offered etc. DActivity: Citinexpected Change in Routine 'lZIPIanned Ignore I DConflict Prior to School Cl Presented vii/Social Interaction I ?Gave Time to De?escalate EIConflict at School CITold o? by: ?ClGave' Encouragement} Praise DChange in Routine El Denied Access to itemfActivity Cl Defensive (Describe): ElPositive Reminders (When/Then) DDif?cuity in Previous Class El Preferred Activity Removed I Cleave Support I Ell-iomevvork Not Done ClTeacher Attending to Others UAssignment Modified DMissed Medication EIGiven Correction/Redirection DChanged instruction DSubstitute Teacher DPeopie too Close Ki Used Proxemics/Kinesics DAcademic Failure [IiLoud Noises/Room Behavior Leading to ?Para Verbal Communication DHunger UBright Lights Seclusion/Rest?ra?int El Used CPI Supportive Stance UFatigue DWith a Speci?c Peer(s) DVerbai Aggression EIVisuai Cues Used Eliilness DWork too Hard/Easy DVerbai Threats/Intimidation Cl Modeled EXpected Behavior DLarge Group instruction DWork Repetitive/too Long Dthleal ThreaTS/ Intimidation DEmpathic Listening DSmaIl Group instruction Dindependent Work Aggression/Self UGave Choices Dindividual instruction Din Pain Aggression/Others Emma Out (Where): UUnstructured Time DSitting For Extended Time Physical Aggression/Property El Loss of Privilege/Reward CIApproached By Adult UWeapon Possession [Set Limits (1st fT hen, When/T hen) EIScheduied Non Preferred Activity EElopem ent El Called for Team Support UWaiting Cl Other (Please Describe): Remove Outer Students MTransition twang; from:qgm ?Other: El Other: . at?? Additional Comments: lap} {troperiy} Come back right W16 60 Pigli're call W08 Possible Function/Purpose of Behavior Etudent may have been trying to gain: Student may have been trying to avoid: - 1 [Social interaction ElPeer or E) Adult [JSocial interaction UPeer or DAdult ElSensory Stimulation [:lSensory Stimulation I??Inu Rb. . Cedar?opidss . - Physical Restraint and Sectasien ?esamentetten Etudent: I mtee?nctesst; - Eating E- Record actions of the student and staff during physical restraint, transport, and/or seclusion. Students must be monitored constantly and documentation completed at aminim um of every two minutes. For restraints and seclusions to exceed beyond each class period or every 60 minutes, obtain signature of administration indicating authorization. I Time absentee: ?ctions at the Student ?u ring Seciusioni Restraint gtaff Resnonse to Ghsenred Actions ?ags . . . i 5 Administrator Signature (to go beyond every 60 Ininutes or each class period} Time Date Cedar Rgpids? Physical Restraint and Seciusion Dependentation I Student: I Date of incident: Student Actions and Debriefing After incident Staff Actie ns After Incident Student Actions Student Debrie?ng KISUpportlve/ Undivided Attention DCrying BProcessing Activities (Describe) El Empathic Listening g} Calm DUsed Restatements for Understanding! Clari?cati on El Rational DGave Wait Time UTalkative [JAilowed for Silence DSilent Skill Activity (Describe) KICDntinued to Monitor @Accepting Support I DAssisted Student with Work Completion U?red 9mg? DWalked Student to Class DSleePinB Eegtiyio? bathtub ?r a DSupported Studentin Class Cl Followin Directions DExpected Behavior ctivity UAssisted Student with Task Completion (cleaning up, etc.) Returned to Class (Describe) g?g [JComrnunicated with Caregiver Name: El Visited Nurse 3 [JFollowed Throttgh on Prior Expectation DApolog?rzed for Actions UAssisted with Processing Activity [JCommunicated with [1 Accepted Responsibility for DMaintained Awareness of PrDXemics, Kinesics, Caregiver Name: Actions (cleans up, etc.) Para verbal Communication ClPacing ?Assisted with Coping Skill Activity DWorked independently @Switched Staff Roles DRestroom/Bodily Needs DOther (Describe) - [JAssisted with Behavior Activity DOther (Describe) [JOther Staff Debriefing and Future Approaches to Decrease or Eliminate Behavior from Reoccurring: DTeam Meeting Learning Supports, I DParent Meeting Date: UCollect ABC Data etc.) Date: DReview URevise Social Skill instruction DComplete Competing Pathways Chart El Conduct Functional Behavioral Assessment DReview Replacement Behavior Review Positive Behavior Supports Cl Consider Student El Review Goals 3r Data DAccess Community Supports Cl Revise Academic Support DContact AEA Supports BOther: Describe any injuries to student, employees, others, or property damage: Communication Documentation Parent/guardian must be contacted nn rinu n?F incident. Name of nersnn contacted: Relationship: Date: Time: Method: By: Describe att?mpts to notify the parent/guardian if contact cannot be ade on day of incident: Written documentation must be sent to pa rent/guardian within 3 school days. Sent by: Date sent: Mail (postmarKeo within 3 days of the occurrence) Email upon written request of parent/guardian - Fax upon written request of parent/guardian "'11 Hand Delivered In Person Impnf?tion was sent to: . - xi Cedar Rgpids f? D?sm?it Physicai Restraint and Seciusion Documentation Student' Date of incident: School: Grade - Seclusion Location: Time In: Time Out: Duration: Confinement of a student in a room from which the student's egress is restricted i I 3 I ?at, Student Entered Seclusion by: DWaiked on their own ECPI Transport interim Control Physical Transporte Safely moving an Bether (piease Describe): mdw'dua? who '5 regain comm! Time Started: (Ill Time Ended: liig Duration: Physical Restraint Team Control Tlme Started: Tlrne Ended: Duration: Used to manage individuals who have children?s Control . adEZEigzlto themsewes Growers: Other (Please Describe); Staff Members invoiwai:l Era-fore Seclusio I Restrainti?i?ransport (Check im piemented items) Setting Events Antecedents . Student Behavior ll Staff Response (Events indirectly impacting the (immediate triggers or predictors of Immediately after I: behavlo rai outcome) the problem behavior.) Antecedent SZIUSIoramrestmiin Eitocat?loni UGiVen Verbal Direction EIAnxious (Describe): DGave Redirections [:iSubject: ?lGiven Work/Activity EOffered Coping Skill! break, etc. DActivity: 'DUnexpected Change in Routine DPlanned ignore [:iConflict Prior to School El Presented interaction WGave Time to De?escaiate DConfiict at Schooi EITold ?No? by: DGave Encouragement/Praise DChange in Routine El Denied Access to item/Activity ?Defensive (Describe): DPositiVe Reminders (When/T hen) DDif?culty in Previous Class El Preferred Activity Removed EGave Support UHomework Not Done EITeach er Attending to Others DAssignment Modi?ed DMissed Medication EIGiven Correction/Redirection DChanged instruction DSubstitute Teacher EIPeople too Close Used Proxemicstinesics [:iAcademic Faiiure EiLoud Noises/Room Behavior Leading to EPara Verbal Communication [:li?lunger DBright Lights Seclusion/ Restraint XUsed CPI Supportive Stance ClFatigue CiWith a Speci?c Peer(s) DVerbal Aggression Visual Cues Used Cililness DWork too Hard] Easy mVerbai Threats/Intimidation El Modeled Expected Behavior ULarge Group instruction DWork Repetitive/too Long Wthsical Threats! Intimidation EEmpathic Listening USmaIl instruction [:ilndependent Work Aggression/Self ?Gave Choices Ulndividuai instruction [:iin Pain ?Physicai Aggression/Others ElTime Out (Where): DUnstructured Time [:iSitting For Extended Time ?Physicai Aggression/Property [31.055 of Privilege/ Reward BlApproached By Adult DWeapon Possession USet Limits fThen, When/T hen) DScheduied Non Preferred Activity EElopement (em but.)th EICailed for Team Support DWaiting DOther (Please Describe): CIRemove Other Students ElTransition to: from: DOther: EOther: hon- preibrmd admit - El Additional Comments: Owned (lacking stat?) tripod, to bite pipe on ambioimJ ship's shirt 911.10% and ?miter began gnaw? Possible Function/Purpose of Behavior Student may have been trying to gain: Student may have been trying to avoid: DSocial interacti on DSensory Stimulation DPeer or Cl Adult DSocial Interaction El Peer or DAduii' DSensory Stimulation j. etude. x? .CeerfEP-ids- .- . f. - Phaeter Restraint end Seotossoo I [gtode'ntr d, . [?ateo?octdeott Daring Record actions of the student and staff during physical restraint, transport, and/or seclusion. Students must be monitored constantly and documentation completed at aminimum of every two minutes. MUTE: For restraints and seclusions to exceed beyond each class period or every 60 minutes, obtain signature of administration indicating authorization. Staff memo ?E?ime Observed Actio no of the Student During SeclusionIRestreint gteft Response to Gosewed Actions 1 I- -. Ad niinistrator Signature (to go beyond every 60 minutes or each class period) Time Date at; {1 CedGrRapids ?n Community-Senate! District phvsica Student: i Restraint and Seciusien Decumentation Date of incident: Student Actions and Debriefing After incident Staff Actions After incident Student Actions Student Debrie?ng USupportive/ Undivided Attention UCrying Processing Activities (Describe) DEmpathic Listening ElCalm DUsed Restatem ents for Understanding/ Ciarificati on DRationa! El Gave Wait Time ClTalkative DAllowed for Silence DSiient El Coping Skill Activity (Describe) DContinued to Monitor ElAccepting Support CIAssisted Student with Work Completion ClTIred ElWalked Student to Class USleeping USupported Student in Class DFollowing Directions DExpected Behavior Activity DAssisted Student with Task Completion {cleaning up, etc.) DReturned to Class {Describel Communicated with Caregiver. Name I Visited Nurse CIFollowed Through on Prior Expectation DApologized for Actions DAssisted with Processing Activity ECommunicated with El Accepted Responsibility for ElMaintained Awareness of ProXemics, Kinesics, CaregiVer Name: Actions (cleans up, etc.) Para verbal Communication El Pacing CIAssisted with Coping Skill Activity ClWorked independently DSwitched Staff Roles DRestroom/Bodily Needs Other {Describe) lap) DAssisted with EXpected Behavior Activity ClOther (Describe) DOther Staff Debriefing and Future Approaches to Decrease or Eliminate Behavior from Reoccurring: DTeam Meeting Learning Supports, ClCollect ABC Data etc.) Date: [Review Revise Social Skill instruction DComplete Competing Pathways Chart El Conduct Functional Behavioral Assessment Cl Review Positive Behavior Supports Cl Consider Student ?4 Access Community Supports maevisemdemicsuppm eather_=__ I . . Describe any injuries to student, empioyees, others, or prOperty damage: . Communication Documentation Pa rent! guardian must be contacted ongav ofillcident. Name of person contacted: Relationship: . Date: Time: 1 Method: EEDEE By: tfguardian if contact cannot be ade on day of incident: Descnoe'atte'm to notify the paren Written documentation must be sent to pa rent/guardian within 3 school days. Sent by: Date sent: ostr'naiked within 3 days of the occurrence) mail upon written request of parent/guardian El Mail (p El Fax upon written request of parentlguardian Hand Delivered in Person - ra Louie. x? Cedar Rapids Com'mr?lt?i?schc?om?m Physical Restraint and Seciusien Decumentatien Student 1 Date of Incident' Schoc? Grade: 1 Seclusion Location: Time In: Time Out: Duration: Confinement of a student in a room from which the student?s egress is restricted QR path open Student Entered Seclusion by: Physical Transport Safely moving an DWalked on their own ECPI Transport DCPI Interim Control individual who is beginning to regain control DOther (Please Describe): Time Started: Time Ended: Duration: Physical Restraint Used as a last resort Staff Members Involved: Used to manage individuals who have become dangerous to themselves or others; ECPI Team Control Children?s Control El Other (Please Describe): Time Started: H327iime Ended: (1326} Duration: Before SeclusioniRestraint/Transport (Check lmplemente items) Setting Events Antecedents Student Behavior Staff Response 7 (Events i_ndirectly impacting the (immediate triggers or predictors of I Immediately after (iced: avqtl?rais 3:150 behav?ro ral outcome) the problem behavior.) Antecedem secmizli?li?) a tor Eltocation: Verbal Direction anious (Describe): ?Gave Redirections USubject: ElGiven Workactivity iq?bi?r} 01 ClOffered Coping Skillf break, etc. ElActivity: ClUnexpectecl Change in Routine I ClPlanned ignore UConflict Prior to School UPresented vii/Social Interaction mGave Time to De?escalate El Conflict at School DTold ?No? by: ?EGave Encouragement/Praise Echange in Routine EDenied Access to ltemlActivih/ EDefensiVe (Describe): EPositive Reminders (WhenfThen) DDif?cuity in Previous Class El Preferred Activity Removed ?(-hrealrenim ve?jqaj UGave Support DHomBWork Not Done DTeacher Attending to Others I DAssignment Modi?ed UMissed Medicati on ElGiven Correction/Redirection CIChanged instruction ClSubstitute Teacher [Cl People too Close I Used Proxemics/Kinesics DAcademic Failure :lLoud Noises/Room Behavior Leading to EPara Verbal Communication DHunger [ZiBright tights Seclusicln/ Restraint Used CPI supportive Stance DFatigue ClWith a Speci?c Peer(s) EIVerbal Aggression ClVisual Cues Used DWork too HardIEasy MVerbal Threats] intimidation Modeled Expected Behavior DLarge Group instruction DWork Repetitive/too Long Physical Threats! intimidation pathic listening DSmali Group Dindependent Work El Physical Aggression/Self ?Gave Choices Elindividual instruction Din Pain Aggression/Others Out (Where): ElUnstructured Time USitting For Extended Time EPhysical Aggression/Property ClLoss of Privilege Reward UApproached By Adult ElWeapon Possession ?Se?t Limits (1st [Them When/T hen) (3MB 1m Fibrin Preferred ElEiopement ClCalled for Team Support a} m_ - DWaiting El Other (Please Describe): El Remove Other Students DT'ransition to: from: DOther: lZlOther: - El Additional Comments: DSocial lnteraction Possible Function/Purpose of Behavior Student may have been trying to avoid: Student may have been trying to gain: EIPeer or Cl Adult EISocial interaction DPeer or ElAdult USensory Stimulation ClSensory Stimulation a I A r?Huihrn-ncl-C - J: l. ?t-c {Ceder?eeid? . . - @mWr?ft?m?D?m Physica??estraint and Sealasion Qacamentatian LStudent: - Dataa?nsident: During Record actions of the student and staff during physical restraint, transport, and/or seclusion. Students. must be monitored constantly and documentation completed at aminim urn of every two minutes. For restraints and seclusions to exceed beyond each class period or every 60 minutes, obtain signature of administration indicating authorization. Staff Initials Time Gbseraed Actions of the Student Du ring Seclusio n/ Restraint Staff Response to absented Actions Administrator Signature (to go beyond every 50 minutes or each class neriod) Time - Date to Cedar Rapids Communlt?r?sd?mm?smc? Restraint and Beside-ion Documentation Date of incident: I Student: Student Actions and Debrie?ng After incident Stat? Actions After incident Student Actions DSupportiue/ Undivided Attention DCrying I Processing Activi?es (Describe) El?mpathic Listening Calm Used Restatements for Understanding/Clari?cati on CIRational i UGave Wait Time lgTalkative CIAllowed for Silence USilent DCoping Skill Activity (Describe) DContinued to Monitor DAccepting Sopport CIAssisted Student with Work Completion Cl'lired ClWalked Student to Class [:lSleeping DSupported Student in Class UFollowing Directions El Expected Behavior Activity UAssisted Student with Task Completion (cleaning up, etc.) El Returned to Class {Describel gCommunicated with Caregiver Name: El Wsited Nurse I El Followed Through on Prior Expectation DApologized for Actions DAssisted with Processing Activity Communicated with El Accepted Responsibility for DMaintained Awareness of Proxemics, Kinesics, 81 Caregiver Name: Actions (cleans up, etc.) Para verbal Communication DPacing DAssisted with Coping Skill Activity DWorked independently Elswitched Staff Roles El Restroom/Bodily Needs DOther {Describe} DAssisted with Expected Behavior Activity Other (Describe) DOther Staff Debrie?ng and Future Approaches to Decrease or Eliminate Behavior from Reoccurring: DTeam Meeting Learning Supports, DParent Mee?ng Date: DCollect ABC Data etc.) Date: Cl Review URevise Social Skill instruction ClComplete Competing Pathways Chart DConduct Functional Behavioral Assessment DReview Replacement Behavior eview Positive Behavior Supports El Consider Student UReview Goals Data til Access Community Supports Revise Academic Support El Contact AEA Supports UOther: Describe any injuries to student, employees, others, or property damage: Communication Documentation Parent/guardian must be contacted on day of incident Name at contacted: I Date. I ?me. Method: 3 ., am: By: Describe'atte'm to notify the parent] guarotan if contact cannot be made on day of incident: Written docume_ng?gnmust be sent to pa rent/gua rdian within 3 school days. Date sent' Sent bl" ii! Mail (postnm. 3 days of the occurrence) mail upon written request of parent/guardian El El Hand Delivered in Person Fax upon written request of parent/guardian LL .mantntinn was sent to: ?5mm . ,Ced?r?apids i Physicai Restraint and Seciusion which the student?s egress is restricted 505% esters: Studen? Date of Incident Schoc' Grade: Seclusion Location: Time in: Time Out: Duration: Confinement of a student in a room from $Student Entered Seclusion by: NCI Physicai Transport Safely moving an DWaiked on their own ELM Transport DCPI interim Control d_ I I . I DOther (Please Describe): it): Q) (Q 1,03) 2 min; in Ni ua is regain contro . . . . Time Started: Tlme Ended: Duration. Physical Restraint Team Control Time Started: Time Ended: Duration: Used to manage individuais who have childrean Control become dangerous to themseIVes or others; . used as a CI Other (Please Describe). Staff Members Involved Before Seciusion/Restraint/Transport (Check Implemented Items) Setting Events Antecedents Student Behavior Staff Response (Eve j?directly im pacting the (immediate triggers or predictors of immediately after (Cairn 81 Noniudgmentai actions taken to de-escalate student behavior and avoid behavioral outcome) the problem behavror.) Antecedent mocation: DGiven Verbai Direction DAnxious (Describe): EiGave Redirections EISubject: moron Work/Activity EIOffered Coping Skill/ break, etc. DActivity: CIUnexpected Change in Routine Cliflanned Ignore EICon?ict Prior to School EIPresented w/Sociai Interaction Q?Gave Time to De-escaiate [EEonfiict at School ?No? by: EIGave Encouragement/Praise DChange in Routine El Denied Access to Item/'Activity Ci Defensive (Describe): Egositive Reminders (When/Then) El Difficulty in Previous Class El Preferred Activity Removed EiGave Support CIHomework Not Done EITeacher Attending to Others CIAssignment Modi?ed El Missed Medication EIGiven Correction/Redirection DChanged Instruction EISubstitute Teacher Ci People too Close IJsed Proxemics/Kinesics DAcademic Faiiure EILoud Noises/Room Behavior Leading to Eid?ara Verbal Communication C3 Hunger Bright Lights Seclusion/ Restraint ?Used CPI Supportive Stance [ZIFatigue EIWith a Specific Peer(s) Werbal Aggression EIVisuaI Cues Used Diliness Elka too Hard/Easy DVerbaI Threats/Intimidation Modeled Expected Behavior El Large Group instruction Cl Ivji'ork Repetitive/too Long El Physical Threats! Intimidation El Empathic Listening El Smail Group Instruction modependent Work Whysical Aggression/Self Gave Choices El Individual Instruction Elin Pain Physicai Aggression/Others ElTime Out (Where): Cl Unstructured Time CISitting For Extended Time Whysical Aggression/ Property EILoss of Privilege! Reward CIApproached By Adult pon Possession ClSet Limits (1st /Then, When/T hen) CIScheduied Non Preferred Activity {j?lo'pement IB/Called for Team Support EIWaiting EIOther (Please Describe): El Remove Other Students to: from: IZIOther: El Other: El Additional Comments: as g3 (tat aihg?i? (5 our In SenSom room . PrUrnPf-cd no 2, can?t in a e: use: if imue Jto (A: ?to ?as, ruf?ed reborn?! it! i we cwir wed ?as Soft room Possible Function/Purpose of Behavior Student may have been trying to gr}: Student may have been trying to avoid: IZISocial Interaction EIPeer or Ci Adult ClSocial interaction El Peer or CIAduit Eigensory Stimulation [Sensory Stimuiation Wreferred Activity/Item Won?Preferred Activity/Task .H. . . . . .Lm?l . . . 3.1We" ?tr-?i Restraint and Seeiusien Bowrnentetten Student: A I Date et incident: I 1 physical restraint, transport, and/or seclusion. Students must be fevery two minutes. MDTE: For restraints and ration indicating -- er Rapids Suiting Record actions of the student and staff during monitored constantly and documentation completed at a minimum 0 seclusions to exceed beyond each class period or every 60 minutes, obtain signature of administ outh orizotion. . taff tati Response to Observed etc-teens Ma?s bserved Actions of the Student During seclusion/Restraint Floor-n Time Date Administrator Signature (to go bevend every 60 minutes or each class period) 1' ($6er Rapids (sommun?rty School District thg?ca I Student: Student Actions and Debriefing After incident i Restraint and Seciusion Documentation Date of incidenT Staff Actions After incident Student Actions Student Debriefing ?siipportive/ Undivided Attention Efrying Cl Processing Activities (Describe) El Empathic Listening CICalm EIUsed Restatements for Uncierstanding/Ciarification CIRationai Wave Wait Time EITaikative milowed for Silence lZISiIent DCoping Skill Activity (Describe) ?Continued to Monitor BAccepting Support ElAssisted Student with Work Completion l: Tired E?Walked Student to Class BSleeping ESupported Student in Class ElFoliowing Directions Mxpected Behavior Activity EIAssisted Student with Task Completion (cleaning up, etc.) CIReturned to Class EICornrnunicated with Caregiver Name: Through on Prior Expectation DAssisted with Processing Activity aintained Awareness of Proxemics, Kinesics, 8: Para verbal Communication DAssisted with Coping Skill Activity CI Visited Nurse DApologized for Actions DCommunicated with Caregiver Name: ElPacing CI Accepted Responsibility for Actions (cleans up, etc.) ClWorked independently ElSwitched Staff Roles DRestroom/Bodlly Needs Cl Other (Describe) DAssisted with Expected Behavior Activity [El Other (Describe) El Other Staff Debriefing and Future Approaches to Decrease or Eliminate Behavior from Reoccurring: EITeam Meeting Learning Supports, IZIParent Meeting Date: ElCollect ABC Data etc.) Date: Meview [:lConduct Functional Behavioral Assessment EIConsider Student EIRevise Social Skill instruction EIReview Replacement Behavior El Review Goals Data DCompiete Competing Pathways Chart DReview Positive Behavior Supports DAccess Community Supports Cl Revise Academic Support ElContact AEA Supports IZIOther: Describe any injuries to student, employees, others, or property damage: Communication Documentation Parent/guardian must be contacted on ?aw of incident, Na me _of person con?de?d; Relationship: m. ather- Date: Time: Method: Phage Descrioe attempts to notify the parent/guardian if contact cannot be made on day of incident: Written documentation must be sent to parent/guardian within 3 school days. Date sent: Sent by Mail {postmarked within 3 days of the occurrence) El Email upon written request of parent/guardian El Fax upon'written request of parent/guardian El Hand Delivered in Person {Name of pa rent/guardian the documentation was sent to; it?: . a I a a vet-i Physical Restrarnt and Seclusion Documentath I Studr Date oflncident: I School: Grade: i Seclusion i Location: Con?nement of a student in a room from I which the student?s egress is restricted Time In: 92/7 Time Out: Duration: 62- 14/5? farm Student Entered Seclusion by: Physical Transport Safelv moving an individual who is beginning to regain control EIWalked on their own .ther (Please Describe): DCPI Transport EICPI interim Citintrol Time Started: Time Ended: _ration: NCI Physical Restraint - EICPI Team Control Time Started: Time Ended: Used to manage individuals who have Children?s mm? become dangerous to themselves or others; . - used as a last resort El Other??iease Describe). Staff Members involved: Before Seclusion/Restraint/Transport (Check Implemented items) Setting Events Antecedents Student Behavior Staff Response - (Events indirectly impacting the (immediate triggers or predictors of Immediately after gca'm 3" Noniuigmegtar: lactions Saken?o - 1 st behavroral outcome) I the/problem behavior.) Antecedent an own ?iocationz Kaiven Verbal Direction DAnxious (Describe): Gave Redirections Subject: EM DC, [tiGiven WorklActivity Dp?ered Coping Skill/ break, etc. EIActivity: EIUnexpected Change in Routine EPlanned Ignore DConflict Prior to School Dlyesented vii/Social Interaction DCon?ic?t at Schooi 5 - Gave Time to Deescalate ??roid ?No? by DGave Encou ragement/ Praise UChange in Routine DDenied Access to Item/Activity IXD efensive (Describe): UPositive Reminders (When/Then) DDiF?culty in Previous Class Preferred Activity Removed Qmei? UGave Support Homework Not Done DTeacher Attending to Others DAssignrnent Mod fied Missed Medication ?Given Correction/Redirection DChanged instruct on DSubstitute Teacher ti People too Close 42/ Used Proxemics/_Kinesics DAcademic Failure . EiLoud Noises/Room Behavior Leading to ??Para Verbal Communication ElHunger DBright Lights Seclusion/Restraint \Q'Used CPI Supportive Stance ElFatigue DWith a Speci?c Peer(s) [JVerbai Aggression 'IjVisual Cues Used} UWork too Hard/Easy DVerbal Threats/Intimidation UModeled Eitpecte'd Behavior EILarge Group Instruction DWork Repetitive/too Long CIEmpathic Listening - EISmall Group instruction Cilndependent Work hysicai Aggression/Self El/Gave Choices Dlndividual Instruction Cl In Pain Whysical Aggression/Others M?me Out (Where): Unstructured Time USitting For Extended Tlrne ?iPhysical Aggression] Property Ci Loss of Privilege/Reward DApproached By Adult DWeapon Possession DSet Limits (1?t [Th an, When/T hen) EIScheduied Non Preferred Activity DElopement DCalied for Team Support DWaiting ?Other (Please Describe): El Remove Other Siiudents 'DTransition to: from: UOther: UOther: (l Additional Comments: WU CI con/11mm Possible Function] Purpose of Behavior Student may have been trying to gain: Student may have been trying to avoid: DSocial interaction ElPeer or Adult DSocial Interaction DPeer or i - DSensor'v Stimulation ,[IISensory Stimulation Preferred Activi Item) referred Acthrityfj ask . 5 I $431k timestan Restraint and: geniusion Documentation Student: Sate of En'eident: - Sur?ng - Rec rd actions of the stUdent and staff during physics! restraint, tranSport, and/or seciusion. Students must be monitored co stantiy and documentation completed at a minimum of every two minutes. NQTE: For_restraint?s and seclusions to reed beyond each class period or every 60 minutes, obtain signature of administration indicating authorization. - Staff med Actions of the Student During Seciusion?testreint .mitials taff Response to therued?gc?tions ?he: . . 5e. Admin Signature (to go beyond every 60 minutes or each eiass period) i Wer?eeide . i . ., Cowmenity$chooim?tnct outpace-mi teaeemme wand gag?ugg?n I Student: 1 [him (if Ef?cient: Student Actions and Debriet?ing After Incident Sta-ii Actions After incident Student Actions Student Debrie?ng - ?opportive/ Undivided Attention QCWEGB Processing Activities {Describe} El Empathic Listening DCalrn Upsed Restatement: for Understanding/Ciari?catipn DRational ?Gave Wait Time DTaikative ?Allowed for SiIEnce CI Silent DCoping Skill Activity (Deseribe) ?ClContinued to Monitor IEAccmating Support DAssisted Student with Work Completion [Hired DWalked Student to Class Qsleeping I EJSupported Student in Ciass WFollowing Directions mEitpected Behavior Activity mssisted Student with Task Completion (cleaning, up, eta?? DReturned to Class I lo?i?lhel with Caregiver Name Visited Nurse I 2 8 {@Eollovved Through on Prior Expectation DApologized for Actions 1 ?DAssisted with Processing Activity DCommunicated with mAceepted Responsibility for DMaintained Awareness of Proxemits, Kinesics, Si Caregiver Name: Actions (cleans up, etc}. Para verbal Communication UPaci'ng I DAssisted with Coping Skill Activity ?Worke?d Independently - DSwitched Staff Roles . DRestroom/Bodiiy Needs DOther (Desoribe) ?Assisted with Expected Behavior Activity,r EIOther (Describe) - Bether Staff Debrie?ng and Future Approaches to Decrease or?Eliminate Behavior from Reoceurring: ElTeam Meeting (IEP, Learning Supports, MParent Meetin Date. DCollect ABC Data etc.) Date: - I Sum - DReview ?itevise Social Skill instruction UComplete Competing Pat 1ways Chart DConduct Functional Behavioral Assessment Review Replacement Behavior DReview Positive Behavior Supports El Consider Student El Review Goals Data DAccess Community Supports IClitevise Academic Support mContact-AEA Supports DOther: Describe any injuries to student, employees, others, or property damage: . s: It a est-z. . M, um 42%; AW .., Communication Documentation Parent/guardian must be contacted on dam afinrjdent, I Name of person contacted: REla?onSh'lpi MW Date: EI nrne: Methodzm lBi': Describe attempts to notify the parent/guardian if contact cannot be made on day of incident: Written must be sent to parent/ guardian within 3 school flew I Date sent: sent b?l: ?Kit/tail (postmarked within 3 days ofthe occurrence} Cl Email upon written a. pumuuguarolan El Fax upon written request of parentfguardian 1 Cl Hand Delivered in Person Eame of pa rent/ guardian the documentation was sent to: I . em ids 2 er Gem! We eiwsicai eestreier we metric? t? ?zemeotet?ed Studen -ete of Incident: School: Grade: . .. I - - Seciusion Location: Time In: Time Out: Duration: Con?nement of a student in a room from m? .. which the student?s egress is restricted ?0 I i A Strident Entered Seciusion by: DWalted on their own 1 Transport Physical Transport Safely moving an DCPI Interim control . DOther (Please Desc 1 Individual who is beginning to regain control I4 (Mi Time Started: Time Ended: mimetic n: Physicai Restraint DCPI Team Control I Time Started: Time Ended: Duration: Used to manage individuals Who have Dcpi Children's Contra] 3:321: 5:251:22: to themseives or others, 0th? [mam ?Humid. i I Staff Members Involved: (Check Implemented Items) Setting Events Antecedents Student Behavior Staff Response - (Events indirectly impacting the (Immediate triggers or predictors of immediately after (Cairn taken_t? behaworai outcome) the problem behavior.) Antecedent i??rgg?; b?h- Vii-if and ?Did a Location: Verbal Diraction QAnxious (Describe): DGave Redirection; i DSubject: DGiven Work?iictivitv - . DO?ered Coping Sliill/ break, etc, Wctivity: ClUnexpected Change in Routine DPianned Ignore DCon?ict Prio} to School DPresented 'ntmer?np - - I DGaveTime to Die?escalate UCon?ict at School ETold "No" by a DGave EncouragementIPraise UChange in Routine EJDenied Access to Item/Activity . ?Dlgfensive. (D,escribe)' Eli?ositive Reminders (WhenfThen) 'DDi?icuitv in Previous Class El Preferred Activity Removed V1.5 llama DGave Support UHomework Not Done DTeacher Attending to Others QM ?UAssignment Mod ?ed Missed Medication I EIGiven CorreCtioanedirection 7i DChanged Instruct on DSubstitute Teacher DPeople too close i Used Proxemicsjkinesics DAcadernic Failure DLoud Noiseisoom .. acting to El Para Verbal Communication Ell-longer - DBright Lights eclusio 'estraint DUsed CPI Supportive Stance DFatigue UWith a Speci?c Peer(s) We! Aggression . [linsual Cues Used! UWork too Hard/Easy Medial Threats/intimidation UModeied Eitpect?d Behavior DLarge Group Instruction DWork Repetitive/too Long- mhvsicalmreatsl intimidation UEmpatbic Listenin'gg - DSmail Group Instruction Dlndependent Work U?Physical Aggression/Self DGave Choices Ellndivid ual Instruction Din Pain UPhysical Aggression/Others ElTime Out (Where): Time DSitting For Extended Time Aggression} Property EILoss of PrivilegelReward DApproached By Adult - UWeapon Possession [ESet limits mien, When/Then) DScheduIed Non Preferred Activity DEiopement [Stalled for Team Support DWaiting DOther (Please Describe):- DRemove Other St'iudents 'DTransition to: from Ember: ,r when In 'woi mm ma. meek-eeth tease swisom ram ?lrb rug, Additional Comments: .- (ASIA 8 . PIM- 4 Possible FunctioniPurpose of Behavior I Student may have been trying to gain: Student may have been trying to avoid: DSocial Interaction UPeer or Adult USociai Interaction DPeer or DAdu DSensory Stimulation I Stimulation . referred Activity! Item Ewen-Preferred ask PEWEECEE Restratnt and Sectds?on ?acamentatton Student: Sate of Incident: Buf?ng Re rd actions of the student and staff during physical restraint, transport, andlor seclusion. Students must be - monitored co ntly and documentation completed at a minimum of every two minutes; For restraints and seclusions to ceed beyond each ciass period or every 60 minutes, obtain signature of admfnistration indicating authorization. Staff lnitiais - Time Staff Response to ?bsemed Actions rued Actions of the Student During: goal-usioni?estraint I LL Signature (to go beyond every 60 minutes or each class period) a? Rapids; ?t an?? Student: -raint and Seciusion Documentation I Date of incident: Student Actions and Debrie?ng After incident Stat? Actions After incident Student Actions Student Debrie?ng @Supportive/ Undivided Attention Stinging El Processing Activities (Describe) '?Empathic Listening gain} DUsed Restatements for Understanding/Clari?cation ??ational QGave Wait Trme' DTalkative @Ailowed for Silence @Silent. UCoping Skill Activity (Describe) mentioned to Monitor - QAccepting SUpport EIAssisted Student with Worl; Completion lj?lired Walked Student to Class i DSleeping . vElSupporteci Student in Class ?i?ollowing Directions Witpected Behavior Activity DAssisted Student with Task Completion (cleaning up, etci DReturned to Class - it? when rs. A ommunicated with Caregiver Name; Cl Visited Nurse (3?0 (3 iZIFollowed Through on Prior Expectation DApologized for Actions "@Assisted with Processing Activity UCommunicated with Caregiver Name: Cl Accepted Responsibility for Actions (cleans up, etc). UMaintained Awareness of Proxernics, Kinesics, 8. Para verbal Communication DPaci?ng El Assisted with Coping Skill Activity QWorked independently. I DSwitch'ed Staff Roles Needs UOther (Describe) mssisted with Expected Behavior Activity DOth-er (Describe) DOther Staff Dehrie?ng and Future Approaches to Decrease ortliminate Behavior from Reoccurring: CITeam Meeting REP, Learning upports, Parent Meeting Date: DCollect ABC Data etc.) Date: - - CIReview Revise Social Skill instruction [3Complete Competing Pat "sways Chart DConduct Functional Behavioral Assessment [Review Replacement Behavior 'E'Peeview Positive Behavior Supports DConsider Stu dent Review Goals Data CIAccess Community Supports DRevise Academic Support [JContact?AEA Supports DOther: Describe any injuylEs to student, employees, others; or property damage: ?f S?Ore Mm i i f? f4. Seaman? door? 4 Communication Documentation Parent/guardian must be cw? Name of Date: ident. Inn . Relationship;I Gil Mb? Time: Method: 4/ see i By: Describe to notify the parent! guard ian if contact cannot be made on day of incident: 9" i Date sent: -?Mail (postmarkgc?vithin 3 days of the occurrence) Written ?us; be sent to parent] guardian within 3 school Sent by El Email upon written request of parent/gu Cl Fax upon written request of parent/guardian "i Name of parentlguardian the documentation was sent tt El Hand Delivered in Person ardian':j . 2 a 1 Caren '1 Diegsieei Restraint Seciusion ?-ecemente Physicai Transport Safely moving an individual who is beginning to regain control DOther (Please Describe): i Date oflncident: SchoolSeciusion LoCation: Time in: Time Gut: . Ddretion: Con?nement of a student in a room from . I which the student?s egress is restricted 0 lg ?Dh? I an} ml?? Stddent Entered Seeiusion bv: DWalked on their own "Rim Transport DCPiinterim Control 6 I Time Startedzgc?gh?ime Ended: egg/Dilation: Physical Restraint DCPI Team Control Time Started: Time Ended: migration: Used to manage individuals who have DCP: Children's Comm} - themsewes or Others: Other (Please Describe): I I 5 Staff Members involvei? rm BefOre Seclusionj?esttaint?rensport (Check implemented Items) Setting Events Antecedents Student Behavior Staff Response i - [Events i_ndirectlv impacting the (Immediate triggers or predictors of immediateiy after (Calm 3t Noniudsmental. If?ons mitt-filo behavroral outcome) the problem behavior.) gntecedent ?55233]: behaimw tocatior CIGiven Verbal Direction CIAnxio us (Describe): ave Redirection? DSubject: ClGiven Work/?ctivity - bothered Coping 5 {ill/ break, etc. UActivity: ElUnexpected Change in Routine DPlanned Ignore I - ?ton?ict Prior to School DPresented w/Sociai Interaction ClGave Time to De?escalate n?ict at School . Droid "No" by: DGave Encouragement/Praise DChang?e in Routine DDenied Access to item/Activity [?befensive (Describe): Positive Reminders (Whennhen) iDDifficulty in Previous Class Preferred Activity Removed ii iEgiave Support UHomework Not Done CITeacher Attending to Others Est l? In all ri/ UAssignment Mod ?ed DMissed'Medication EIGiven CorreCtionIRedirection f) 93 (destiny-p CIChanged instruct on DSubstitute Teacher [JPeopie too Close ?tted Proxemics} DAcademic Failure DLoud Noises/Room Behavior Leading to Ware Verbal Communication DHunger [Bright Lights Seclusionl Restraint Wsed CPI Supportive Stance DFatigue UWith a Speci?c Feeds) DVerbal Aggression ?Wsual Cues Used) Dillness . ElWorktoo Hard/Easy "?ierbal 1hreatsfintimidation 'Ul?viodeled Eitpectdd Behavior ElLarge Group Instruction DWork Repetitive/too Long 1117831351 In?T?IdatiOH DErnpathic Listenirlag - [Small Group instruction Dindependent Work Aggression/Self Cleave Choices I Individual Instruction [:Hn Pain Whysical Aggression/Others Cl'?me Out (Where Time EJSitting For Extended Time Aggression! Property EILoss of Privilege} Reward 71;; (33? F) UApproached By Aduit UWeapon Possession et Limits [Th an, when/Then) 3 'EIScheduled Non Preferred Activity lied for Team Support Dwaiting ?Am - timber (Please Descrige): ClRernove Other Students ~?gl?ransition tawnjl?irom: I UOther: - UOther: - El Additional CommentsMots bi as a New; to Quit Mfsir a in: W- little-v s. . - sq (Mm, Possible of Behavior Student may have been trying to gai_n: Student may have been trying to avoid; ?i DSocial Interaction EIPeer or Cl Adult USocial interaction DPeer or DAdt?? - DSensow Stimulation .3359!?va Stimma?on 1i EEreferred Activity/item Briton-Preferred Adivity?' ask . ?zz-J: g?imx "i . Restreim end Eee?ee?on oeumee?e?on Student: Sate o? indolent: Due?ng rd actions of the student and staff during physical restraint, transport,_ andlor seefusion. Students must be - monitored co ntiy and documentation compieted et a minimum of every two minutes; Forfestroihts and s?edusfons to (reed beyond each class period or every 60 minutes, obtain signature of odministreiio? indicating aufhb?za?on. Staff Staff Resoo?se to ?bs'erued ?ctions . . Initlei? - Time reed Act??one of the Student ?uri?g? SEcEusionj Restraint a. ee 1 OW ?dminimtor Signature (to go be gone every 69 minutes or me}! class period} Time I -. -- . Dete' .- r. (Seeder Ringside islet Sal-1an I Student: REL. I E?Eiial??i: and Seclesion Documentation 1 Date oi incident: Student ?ctions and Dehriei?ing Alter incident Staff ?ctions After incident Student Actions Student Dehrie?ng tgi?upportivel Undivided Attention I Eli?tying DProcessing Activities {Describe} Dtmpathic listening DCalrn ?leed Restatements for Understanding/Clarification DRational wave Wait Time DTalkative DAilowed for Silence DSilent [JCoping Skill Activity (Dascribe) ?ontinued to Monitor - DAccepting Support DAssisted Student with Work Completion ElTIred QWalked Student to Class Dsleeping Student in Class CiFollowing Directions EEipec?ted Behavior Activity UAssisted Student with Task Completion (cleaning up, etc.) i?iieturned to Class I 19955115?) {g BCommunicated with Caregiver Name; Cl Visited Nurse A El Followed Through on Prior Expectation DApologized for Actions 1 D?Assisted with Processing Activity UCommunicated with Accepted Responsibility for Waintai??d Awareness of Proxernics, Kinesics, Caregiver Name: Actions (cleans up, etc). ara verbal Communication ?eecing DAssisted with Coping Skill Activity BWorked Independently . DSwitched Staff Roles DRestroomI Bodily Needs DOther (Describe) Wanted with Expected Behavior Activity DOther (Describe) UOther Staff Debrie?ng and Future Approaches to Decrease or Eliminate Behavior from Reoccurring: ElTeam Meeting Learning Supports, UParent Meeting Date: UCoilect ABC Data etc.) Date: . . - Cl Review URevise Social Skill Instruction BComplete Competing Pat iways Chart El Conduct Functional Behavioral Assessment DRE-view Replacement Behavior DReview Positive Behavior Supports DConsider Student DReview IEP Goals 8.: Data UAccess Community Supports URevise Academic Support wContact-AEA Supports i UOther: Describe any injuries to student, employees, others, or property damage: l? the, Communication Documentation Parentfguardian mu be forth-?r {if} (i -. Nam ".33 Relationship: I Date "limb: Method: I By: Describe attempts to notify the parentIguardian if contact cannot be made on day of incident: Written documentation mimi? hp mat to parent/guardian within 3 sch: Date set ?EMail ?w mu?iin 3 days of the occurrence) Sent bu" Emmi upuu men quuest or parentng ardian El Fax upon written request of parent/guardian Name of parent] guardian the documentation was sent El Hand Delivered in Person site i Piestreint end Seciu ion ocumenteue? . UOth?er (Please Describe): Individual who Is beginning to regain control Time Started: {1 I Time Ended: Duration: Studer. ate of Incident: Schooi: I i _r Seclusinn Location: Time In: Time Gut: Duration: Con?nement of a student in a room from I which the student's egress is restricted /Ir L5 I, [l?k Student Entered Seclusion by: EIWalked on their own Transport UCPI interim Physical Transport 2 Safely moving an Physics-i Restraint Used to manage individuals who have become dangerous to themselves or others; used as a last resort Staff Members inunlued: MW Team Control DCPI Children?s Control Other (Please Describe): Before SeclusieniRe?reintfi?rensport (Check Implemented Items) Time Started: to? Time Ended: migration: - "Ix Hearth-Preferred Ac?vitvn ask - an. AI Lei ?nite. Setting Events Antecedents Student Behavior Stet? ReSponse (Events Lndirecdv impacting the (Immediate triggers or predictors of immediate? after (Calm aniudgmentalilc?ons taken to behavioral outcome) the problem behavior.) antecedent bahiiwor and Location: I $va verbal Direction ?Anxious (Describe): Wave Redirection's DSubject: FL A I DGiven Work/Activity i) I ?W?ered Coping Skill! break, etc. Manny: ClUnexpected Change in Routine 4 UPlannedlgnore UCon?ict Prior to School CIPresented w/Social interaction 17 DGave Time to Dre-escalate DCon?ict at School Wold by: DGave Encou ragement/Pra?ise CIChange in Routine UDenied Access to ItemlActivitv DDefensive (Describe): UPositive Reminders (Whenfll?len) Dif?culty in Previous Class El Preferred Activity Removed I DGave Support Cl Homework Not Done CITeacher Attending to Others UAssignment Mod ?ed El Missed Medication I Elven Canadian/Redirection UChanged Instruction USubstitute Teacher "El People too Close- Wsed Proxemicsnginesics DAcademic Failure DLoud Noises/Room Behavior Leading to Warn Verbal Communication UHunger' [Bright Lights - Seclusion] Restraint CPI Supportive Stance CIFatigue DWith a Speci?c Peeris) UVerbai Aggression EIVisual Cues Usedi UWork too Hard/Easy DVerbaI Threats/intimidation UModeled Expected Behavior DLarge Group Instruction DWork Repetitive/too Long ?ph??l?al Threats! Intimidation ClErnpathic Listeniilg - [Small Group Instruction Ulndependent Work El?hysical Aggression/Self ?KG-ave Choices Instruction Din Pain - hysical Aggression/Others Out (Whitre l3 EJUnstrurctured Time DSitting For Extended Time Aggressi on/ Property Eltoss of Privilege/:Reward DApproached By Adult UWea pon Possession DSet limits [Th an, When/T hen) UScheduIed Non Preferred Activity ?Elopement for Team Support UWaiting ElOther (Please Describe): El Remove Other Students 'DTransition to: from: Gather: \i ,e .m BotherNews! (hematite Mid new: Olaf I) r- We - ?Erwin?Is ran .n-f'tc" ouch . ?Dimim- +0 to Imp Quad woS' akkt +0 cc?ch c,er up to gm hatigwgr Possible FunctionIPurpose of Behavior &3 I L) as) PM), Student have been trying to gain: Student may have been trying to M: as? DSocial interaction DPeer or [1 Adult mode? Interaction ClPeer or .Mdult .l?rg?f'teaglv Eng, ?5 - ElSensory Stimuiation _[35ensory Stimulation b? Est P?heetee? Eteettetet and Seemeth Eoeemeotettoe I gtuden? Bate of-E?c??ent: a . I mating -- Re rd ectiorteof the student and staff during physical restraint, transport, and/or sectusio n. Students must be monitored co 'antly and documentation Completed at a minimum of every two minutes; Fotrestrofnts and s'edusions to ed beyond each Clogs period or every 60 minutes, obtain Signature of administration in . .- oathoozotioo. Time wee of the Student mattingSecl'usionZRestraint Staff Responee to absentee? ?ctions [3:235 I Signature [to go beyond ever?; '63 minutes or ee?h' 2 . 6 I a. - revgehooi Demise tiny-small Restraint and S-eciusron DocumentetEW?t @1 I Date eiincident: I i Student Actions ann Dehrie?ng After incident Ste-ii; Actions After incident I Student Actions Student Debrie?ng - ?Suppor?ve/ Undivided Attention DCWing I DProcessing Activities (Describe) Listening I DCalrn DUsed Restatements for Understandingfdari?cation . Cl Rational . QlGave Wait Time DTallcative Wllowed for Silence DSilent Utoping Skill Activity {Describe} ??ootinued to Monitor - ?Accepting Support DAssisted Student with Work Completion ?'?red allied Student to Class ?leeplng USupported Student in Class 1 UFollowing Directions DEipected Behavior Activity . CIAssisted Student with Task Completion (cleanin I up, etc.) ?aeturned to Class {Desi-libel mCommunicated with Caregiver Name; Cl Visited Nurse - - UFollowed Through on Prior Expectation UApologized for Actions DAssisted with Processing Activity I DCommunicated with Cl Accepted Responsibility for Maintained Awareness of Proxernics, Kinesics, Caregiver Name: Actions (cleans up, etc.) Para verbal Communication UPaci'ng I DAssisted with Coping Skill Activity ElWorked independently - . DSwitched Staff Roles DRestroom/ Bodily Needs amber {Describe} UAssisted with Expected Behavior Activity DOther (Describe) owed ?iD Elbther Staff Debrie?nfg and Future Approaches to Decrease orlEliminate Behavior from Reoccurring: ElTeam Meeting Learning Supports, UParent Meeting Date: UCollect ABC Data etc.) Date: . . Cliieview - DRevise Social Skill Instruction DComplete Competing Pat iways Chart DConduct Functional Behavioral Assessment DReview Replacement Behavior DReview Positive Behavior Supports UConsider Student UReview Goals Data [JAccess Community Supports DReviseAwdemic quporg; Supports DDther: WWD-iedi ?rt; 32% . is? Descritre any iniuries to student, employees, others, or property damage: ii I Claim a Size ginger . Communication Documentation 's Same) View; Parent! guardian must be contacted on day n? ?i'lent. A . )1 Name ht new?: ?Ht-?Ed; Relationship: I WV Date: 1 Time:{ Method: a By: Describe attempt - - rotify the parent/guardian if contact cannot be made on day of incident: I Written doc: gbe sent to parent} guardian within 3 school - . Date sent: Sent by: - I 3' Mail (postmarkeo Witnlila days of the occurre nce) Cl Email upon written icqucst u. pdlellugum?dian Fax Upon written request of parent/guardian Cl Hand Delivered in Person 'l Name nf narentieuardian the documentation was sent to: I a. Wat Physical Restraint and: Seeiusien Documentation Con?nement of a student in a room from which the student? 5 egress is restricted Stude ate of Incident: ?chool . Grade: i Seclusion Location: Time in: Time Dot: Duration: ?175 Student Entered Seciusion by: HG Physical Transport Safely moving an individual who is beginning to regain control ?-Walked on their own UOther (Please Describe): DCPI Transport DCPI Interim Cibntrol Time Started: Tlrne Ended: Ddration: NCI Physical Restraint DCPI Team Control Time Started: Time Ended: Digiration: Used to manage individuals who have Children?s Contwi become dangerous to themselves or others; . Lused as a iastresmt Cl Other (Please Describe): I Sin?! Before Seclusion/Restmint/Transport (Check implemented Items) Setting; Events Antecedents Student Behavior Staff Response behavioral outcome) (Evants i_n_directly impacting the (immediate triggers or predictors of the problem behavior.) Immediately after (Calm 8: Nonjudgmentai factions taken to de?escalate student behavior and avoid Antecedent 5991mm hm?) I Location; aiven Verbal Direction UAnxious (Describe): ?Gave Redirection; n: L?leiven Work/Activity CIO?ered Coping Sicill/ break, etc. ctivity: DUnexpected Change in Routine DPIanned Ignore UCon?ict Piibrr to Sch?hl DPrese-nted vii/Social Interaction UGave Time to De?escalate DCon?ict at School R?fold ?No? by: I DGave Encou ragement/Praise DChange in Routine E?enied Access to Item/Activity ?Defensive (Describe):_ E?Positive Reminders {Whenrrhem 'DDif?cultv in Previous Class El Preferred Activity Removed Man-i; m? g?ave Support El Homework Not Done DTeacher Attending to Others DMissed Medication Xaiven Correction/Redirection 1mm, UAssignment Mod ?ed [hi/WW? Additional Comments: DChanged Instruct on USubstitute Teacher DPeople too Close 0 Used ProxemicsAKinesics DAcademic Failure ULoud Noises/Room Behavior Leading to Ufara Verbal Communicatioh UHunger CIBright Lights SecMsion/Restraint Epsed CPI Supportive Stance- DFatigue DWith a Speci?c Peer(s) Merbal Aggression EjVisual Cues Used! Dillness DWork too Hard/Easy Emerbal Threats/ intimidation UModeied Expectdd Behavior ElLarge Group Instruction EIWork Repetitive/too Long Cl?mpathic Listenidg - DSmail Group Instruction Dlndependent Work Aggression/Self BGave Choices Ellndividual Instruction Din Pain Aggression/Others . Cl??me Out (Where): Cl Unstructured Time EISitting For Extended Time Aggression/Property Cl'Loss of Privilege] Reward DApproached By Adult UWeapon Possession ESet Limits (Then, When/Then) UScheduled Non Preferred Activity UElopement ?Called for Team Support DWaiting DOther (Please Describe): Remove Other Students ?DTransition to: from: UOther: mm, l? i i Possible Function] Purpose of Behavior Student may have been trying to gain: Student may have been trying to Md: ?l DSociai Interaction UPeer or Cl Adult ElSocial Interaction ElPeer or DAduit - D?ensory Stimulation .DSensorv Stimulation i . I Preferred AcLivity/item Acthrity??ask . . he?tm?tm Phaeteet Reetrernt end} Seetaeran Beeamentetson .. i Student: I I Bate af?ne-Ede" Daring Rec rd actions m, ancient and staff during physicai restraint, transport, and/or seeiusion. Students must be monitored co stantly and documentation compieted at a minimum of every Mo minutes. teath For_restraints and sfeclasions to tread beyond each class period or every 60 minutes, obtain signature of admfnistratfon indicating authorization. Staff Time nee Aettone of the Student Daring Seclueiani?estreint Staff Reeaonee to ?bsemea Actiane i . .H . s' 1?5! 3 - rtitnirsi'?isitrza?ter Signature (to ga beyond every 69 minutes?ar'ea?izh claes period} ??me Date to E: ii idS ,ph-t; iiyrsieai Restraint and Seciusion Documentation Student: Bate oi incident: Student Actions and Debrieiing After incident - Stat? Actions After incident Student Actions Student Debrie?ng EZSupportive/ Undivided Attention 4 Baking DProcessing Activities (Describe) Eli-Impetigo listening Cairn DUsed Restatements for Understanding/Clarification Cl Rational ?lGave Wait Time DTalkative milovved for Siience ?Silent Cite-ping Skill Activity (Describe) QContinue-d to Monitor ,QAccepting Support DAssisted Student with Work Completion mi?ired xi?vv'alked Student to Class ?sleeping lElSupported Student in Class RFollovving Directions DEkpected Behavior Activity Ci Assistedj?l?ent with Task Completion (cleanin up, etc.) @Returned to Class (DP-5mm DCommunicated with Caregiver Name; C) Visited Nurse ElFoiiowed Through on Prior Expectation DApologized for Actions DAssisted with Processing Activity DCommunicated with Accepted Responsibility for iniaintained AwarenESs of Proxemics, Kinesics, Caregiver Name: Actions (cieans up, etc.) Para verbal Communication Cl Pacing DAssisted with Coping Skill Activity DWorke?d Independently - A I Dvaitched Staff Roies DRestroomIBodily Needs ?other (Describe) 30M) DAssisted with EXpected Behavior Activity Bother (Describe) Other Staff Debrie?ng and Future Approaches to Decrease tar-Eliminate Behavior from Reoccurring: etc.) Date: DTearn Meeting Learning Supports, DParent Meeting Date: DCollect ABC Data 1 DReview DRevise Sociai Skill instruction CiComplete Competing Pat ?Mays Chart A DConduct Functional Behavioral Assessment DReview Replacement Behavior DRevievv Positive Behavior Supports DConsider Student El Revievv Goals Data UAcness Community SUpports DRevise Academic Support DContact-AEA Supports UOther: A )Describenapy injuries to student, emplogees, others, or property damage?) I Sin 55w b/aod 1 (1. L. Communication Documentation Parent/guardian must 9 rnnI-ar-o?J p- - A Name r?F A Relationship:,, 0% ctec Date: I Timid; Method: Describe attempts to notify the parentfguardian if contact cannot be made on day of incident: Hm Bv=_ Date sent: Mail (postrriarkecl within 3.days of the occurrence) Written mist be sent to parent] guardian within 3 school Sent by; lj Fax upon written request of parentlguardian i?Namn nr {guardian the documentation was sent to: Hand Delivered in Person - El Email upon written request of parentfgubrdian _l I I xii?s, - . I Gem-?manic? ?ne-Sal D?E?i?i thsicai Restraint and seclusion Documentation individual who is beginning to regain control DOther (Please Describe): . Student:' Date of Incident: School: :7 1_ Grade: .- . I - . Seclusion Location: Time in: Time Out: Diliration: Con?nement of a student in a room from which the student?s egress is restricted 8 - (3 Student Entered Seclusion by: E?valked on their own DCPI Transport NCI Physical Transport Safely moving an DCPI Interim ?1 NCI Physical Restraint Used to manage individuals who have become dangerous to themselves or others; used as a last resort Staff Members involved- Control DCPI Child ren?s Control i"I nrher [Please Describe): Time Started: Before Seclusion/Restraint/Transport (Check Implemented Items) r. Tame [mm Time Ended: Setting Events Antecedents Student Behavior Staff Response - (Events indirectly impacting the (Immediate triggers or predictors of mmediately after (Calm 3: Noniudgmental actions taken to behavioral outcome) the problem behavior.) Antecedent de?mlm Smile? ?ham? and ?Old seclysionlratraint) (?xation: Verbal Direction DAnxious (Describe): Gave Redirectionls DSubject: EIGiven Work/Activity I Eloffered Coping Skill! break, etc. CIActivity: DUnexpected Change in Routine DPlanned Ignore EICon?ict Prior to School ElP'resented w?c-ria' CIGave Time to De?lescalate DCon?ict at School Wold "No" by; ElGave Encouragement/Praise IZIChange in Routine menial Access to Item/Activity Mefensive (Describe): EIPositive Reminders (When?hen) EIDif?culty in Previous Class El Preferred Activity Removed l:l Gave Support ElHornework Not Done ClTeacher Attending to Others IMM- DAssignment Mod fied DMissed Medication ElGiven Correction/Redirection UChanged instruct on I DSubst?it-ute Teacher DPeople too Close Cl Used Proxemics/ Kinesics A DAcademic Failure CILoud NoisesIRoom Behavior Leading to DPara Verbal Communication. Ell-lunger UBright Lights Seclusionl Restraint @??sed CPI Supportive Stance UFa-tigue a Speci?c Peer(_s) EIVerbal Aggression leisual Cues Used) l] illness DWork too Hard/Easy __,EVerbal Threats/Intimidation UModeIed Behavior DLarge Group Instruction Repetitive/too Long El Empathic Listeniillag . ElSmall Group Instruction El Independent Werk [3 Physical Aggression/Self Gave Choices Dindividual Instruction Din Pain Aggression/Others ElTirne Out (Wherel?): DUnstructuredj'ime ElSi'tting'For Extended Time Uthsical Aggressian Property Loss of Privilegef Reward CIApproached By Adult I .UWeapon Possession Else-t Limits (1st an, Whenri?hen) 4.3% ?6 USchedUled N011 Preferred Activity DEIopement gg?alled for Tearn Support I w. ElWaiting UOther (Please Describe): El Remove Other students . ?CITransition to: from: ClOther-E? mound ears vim cLoAMoem Um Additional CommentsPossible FunctionIPurpose of Behavior Student mavhave been trying to ga' in: Student?may have been trying to avoid: El?ociai Interaction [ZIPeer or Cl Adult ElSocial lntemdion El Peer or D-Aduli. ljSensory Stimulation _DSensory. Stimulation referred Activity/Item El Non?Preferred Activityfj?ask . 7- mg; . 1355; i?'f?ibifi?? itoesc'nbe) I (sat DPresented w/Snrie' 'nterection EICon?ict at School liTold ?No? by: h; I - . @3355Met Wee-mite mam Regtrramt and Seciusron Dow mentatron I Student of Incident: School: Grade- I Seclusion Location: Time In: Time Out: Duration: Con?nement of a student in a room from a I i ,3 I WhiCh the student?s egress is restricted 9\ (91? Student Entered Seclusion by: ?Walked on their own DCPI Transport DCPI Interim Control Physical Transport Safety moving an [Mather (please Describe): I Individual who is beginning to regain control Tlme Started: Time Ended: detion: NCI Physicai Restraint - EICPI Team Control Time Started: Time Ended: Duration: Used to manage individuals who have Children's Control bacome dangerous to themselves or others; . I used a? lastresm Other (Please Describe). Staff Members Involved: Before Seclusion/Restraint/Transport (Check Implemented Items) Setting Events Antecedents Student Behavior Staff Response - (Events indirectly impacting the (Immediate triggers or predictors of Immediately after sakeniso - stu i behaworal outcome) the problem behavior.) Antecedent smwf?m?) 2 an ave ?otation: Firemen Verbal Direction DAnxious (Describe): Gave Redirections DSubject: Given Work/Activity Coping Skill/ break: Etc- DActivity: DUnexpe-cted Change in Routine Uplanne?i lgnore DCoanict Prior to School EIGave Time to De?escalate UChange in Routine UDenied Access to Item/Activity ??efensive (Describe): Elgave Encouragement/Praise EJGiven Correction/Redirection KPositive Reminders (When/Then) [Difficulty in Previous Class Preferred Activity Removed f? DGave Support DHomework Not Done ClTeacher Attending to Others ?lh?r?lrx I DAssignrnent Mod ?ed DMissed Medication Vagina, ,S?th? EIChanged Instructan DSubstitute Teacher DPeopie too Close fl?h A J00 El Used Proxemics?iKinesics DAcademic Failure DLoud Noises/Room Behavitnjleading to CI Para Verbal Communication UHunger DBright Lights Segusion/Restraint Wsed CPI Supportive Stance UFatigue DWith a Speci?c Peer(s) merbal Aggression UVisual Cues Usedl Dillness DWork too Hard/Easy lj?iferbal Threats] Intimidation UModeIed EXpecteld Behavior DLarge Group instruction? DWork RepetitiVe/too Long UPhYSicalThreats/In?Mida?D? UEgppathic Listenirlag . USmall Group Instruction Ellndependent Work thysical Aggression/Self - gave Choices Individual Instruction Din Pain mysical Aggression/Others ElTirne Out (Where): El Unstructured Time EISitting For Extended Time Physical Aggression/Property CI Loss of Privilege] Reward v" a 0 CIApproached By Adult I DWeapon Possession USet Limits (1"[111 an, When/T hen) Q?gw 'UScheduled Non Preferr?d Activity CiElopernent ?lled for Team Support 5 CIWaiting DOther (Please Describe): CIRemove Other students 'DTransition to: from: UOther: Additional Comments: Tm rm i - Isle-?r him? i U30. i, ?le I (1955M M2239 MM . on/Purpose of Behavior Student may have been trying to gain: Student may have been trying to M: ?i DSocial Interaction DPeer or Cl Adult DSodal Interaction UPeer or DAdult i - Cl?ensorv Stimulation _E}Sensory Stimulation :l Preferred Activity] Item I Union?Preferred Adh?rurraqt . Physieai Eteatreint and Documentation Stuaent: - I Date aiinc?iaent: . Dating Rec rd actions of'the student and staff during physicai restraint, transport, and/or sociusion. Students must be monitored to nth; and documentation compieted at a minimum of every two minutes; tog-TE: For. restraints and seclusion; to eea? beyond each class period or every 60 minutes, obtain signature of administration indicating authorization. me 055 woo Actions of the Student Staring Seciosionl?estraint tat? Reaponae to absorved Actions :2le Admi Signature (to go beyond every 69 minutes or oath Class pe?od) - - a! Rapi?e - "s ?remen-at emesretot and Seciusion Decomeme?im? Student: 1 Date otincident: Student Actions and Deoriei?ing After incident Staff Actions After incident student Actions Student Debrie?ng DSupportive/ Undivided Attention ?ailing ElProcessing Activities (Describe) DEmpathic Listening ECalm DUsed Restatements for URational . . move Wait Time ClTalkative' CIAllowed for Silence ?Siient DCoping Skili Activity {Describe} l?fti?gntinued to Monitor - QAccepting Support I IDAssisted Student with Work Completion ??red UWalked Student to Class HSIeeping DSupported Student in Class ElFollowing Directions DEspected Behavior Activity . DAssisted Student with Task Completion (cleaning up, etc.) DReturned to Class (Describe) . - UCommunicated with Caregiver 'Name; Visited Nurse Foilowed Through on Prior Expectation CIApologized for Actions DAssisted with Processing Activity DCommunicated with Accepted Responsibility for Diviaintained Awareness of Proxemics, Kinesics, 8 Caregiver Name: Actions (cleans up, etc.) Para verbal Communication DPaci?ng DAssisted with Coping Skill Activity DWorked independently 3 I USwitched Staff Roles, DRestroom/ Bodily Needs Elgther {Describe) DAssisted with Expected Behavior Activity DOth'er (Desm?be) . . - ClOther i . Staff Debrie?ng and Future Approaches to Decrease orIEiiminate Behavior from Reoccurring: DTeam Meeting Learning Supports, DParent Meeting Date: DCollect ABC Data etc.) Date: . - - Review FBNBIP Revise Social Skill Instruction Cltomplete Competing Pat 1ways Chart DConduct Functional Behavioral Assessment DReview Replacement Behavior UReview Positive Behavior Supports DConsider Student Review Goals 8: Data DAccess Community Supports URevise Academic Support UContact'AEA Supports DOther: Describe any injuries to student,_employees, others, or property damage: hem Communication Documentation Parent/guardian must be r? r' Name of nercrm I 1 Relationship; Date: lime: Method: ([011, 6, By: Describe dttemlpt? to notify the paiunuguai'man IT contact cannot be made on day of incident: Written docum?hhtinn must be sent to parent] guardian within 3 school Da sent: ?l Sent by: a Mail (prulldI nuu wluml a uays of the occurrence) El Email upon written request of parent/gu ardian \Fax upon written request of parentfguardian El Hand Delivered In Person lei" I CPD 295?s? Name of parentfguardian the documentation was sent ti I i new 35*" :u Cumtm?zg Sofa Ete?ric?e thsieel testreint and Seciosion Documentation e: .j . Student' I ofincident: Schooi: I . .- 1 Seclusion Location: Time In: Time Out: Deretion: Con3S7 Student Entered Seclusion by: alked on their own DCPI Transport DCPI Interim iilCi Physical Trensport Safeiy moving an miner (please Describe): i. who [5 beginning to regain control 6 Time Started: ?me Ended: Dilation: NCI Physicai Restraint - - Team Control Time Started: Time Ended: Dtiiration: Used to manage individuals who have DCPI Child renrs Comm) 1:1 0mm.pr named. Staff Members Involved: I Befbre (Check Implemented Items) Setting Events Antecedents Student Behavior Staff Response - (Events i?direcdv'impacting the (Immediate triggers or predictors of Immediately after (Calm Noniudgmental 19550115 taken?? behavroral outcome) the problem behavior.) Antecedent ?Mimi? and ELocation: CIleen Verbal Direction DAnxious (Describe): Miami Redirection? DSubject: DGiven Work/Activity UOffered Coping Skiil/ break. eta. Efktivity: DUnexpected Change in Routine DPlanned ignore UCon?ict Prior to School UPresented w/Snrial Interaction 353% Time to DEE-Scalate DCon?ict at School mid ?No? by: I, DGave Ehcouragement/Pr?ise Uchange in Routine menial Access to Item/Activity E?efensive (Describe): mositive Reminders (WhEnfThen) UDifficulty in Previous Class Preferred Activity?emoved I EGave Support UHomework Not Done DTeacher Attending to Others CIAssignn-ient Modi?ed UMissed Medication UGiven Correction] Redirection DChanged Instruct on bstitute Teacher UPeop?le 100 Close 1' 0 Used 'Prbxemicsmines-ics DAcademic Failure IDLoud Noises] Room Behavior Leading to I Para Verbal Communication DHunger UBright lights SeclusionIRestraint CPI Supportive Stance i DFatigue a_ Speci?c Peer(s) DVerbal Aggression ?Visual Cues Used! EIWork too HardlEasy I WerbalThreats/lntimidation gModeled Expect?d Behavior (:lLarge Group Instruction DWork Repetitive/too Long UEmpathlc Listeni?g . DSmalI Group Instruction Ulndependent Work EIPhysical Aggression/Self DGave-Choices El Individual instruction Din Pain Wysical Aggression/Others Out (Where): DUnstructured Time USitting For Extended Time Uthsical Aggression! Property El Loss. of Privilege! Reward DAporoached By Adult ElWeapon Possess-ion ClSet limits: (1?t [Th an, When/Then) EISched'uled Non Preferred Activity UEiopement I UCaIled for Team tiupport DWaiting' DOther (Please Describe): D-Remove Other students 'ElTransition to: from: DOther: . Wm?: (D - . i r?dtflitionaLEnmr-oents: - I r; (s (5 acts? Moe. Mot? Possible FunctionI?Purpose oi Behavior FATE Lib?c to [Murat CL out" Soil; Student may have been trying tag: in: ElNon-Preferred ask . Student may have been trying/co avoid: 4 D?ociallnteraction or UAdult DSocia'llnteraction [ZIPeer or UAduh. . . ensorvStimulation fl- l- ?e?arred Activity/item Tibriea. . . "vs-{Eeft"? Restraint and Seclusien Documentation Studen? Date ofIncident: School: Grade: I Seclusion - Location: Time In: Time Out: Duration: Con?nement of a student in a room from which the student?s egress is restricted 01: (ml/h I Student Entered Seclusion by: EIWaIked on their own Transport DCPI Interim Physical Transport Safer moving an Other (piease Describe): individual who is beginning to regain control I Time Started: "1 Time Ended:(i(7l Duration:2m? NCI Physical Restraint EICPI Team Control Time Started: "lime Ended: Used to manage individuals who have [3031 Children's Contra Eggleadgrsigeggst to themselves or others; Other (Please- Df?ii?be): I Staff Member: lnunlund: Before Seclusion/ Restraint! Transport (Check Implemented Items) Setting Events Antecedents Student Behavior Staff Response - (Events i_ndirect y impacting the (Immediate triggers or predictors of Immediately after (Calm 5'1 Noniudgmental factions taken to behaworal outcome) the problem behavror.) Antecedent S?gl?fe?g?; bah?iwmr and gLocation: E?iven Verbal Direction UAnxious (Describe): Gave Redirection; USubject: UGiven Work/Activity UOffered Coping Slcill/ break, etc. mctivity: \m 0 EIUnexpected Change in Routine EIPlanned Ignore DCoanict Prior to School Presented var/Social interaction . Gave Time to De-,escalate DCon?ict at School Wold ?No? by: I DGave Encouragement/Praise nge in Routine El?enied Access to Item/Activity E?efensive (Describe): Positive Reminders (When/Then) DDifficulty in Previous Class El Preferred Activity Removed I DGave Support [:lHomework Not Done ClTeacher Attending to Others IL IDLLJ DAssignment Mod ?ed DMissed Medication ElGiven Correction/Redirection 2r CIChanged Instruction DSubstitute Teacher El People too Close Cl Used Proxemics?Kinesics DAcademic Failure El Loud Noises/ Room Behavior Leading to U?ara Verbal Communication UHunger DBright Lights Seclusion/ Restraint msed CPI Supportive Stance DFatigue DWith a Speci?c Peer(s) EVerbal Aggression l??Visual Cues Used too Hard/Easy ElVerbaI Threats/Intimidation 'EIModeIed Etcpected Behavior DLarge Group Instruction DWork Repetitive/too Long Threats! Intimidation Empathic Listeniriag . USmaIl Group Instruction Dlndependent Work UPhysicaI Aggression/Self [:IGave Choices Ellndividual Instruction El In Pain Whysical Aggression/Others El'?me Out (Where DUnstructured Time DSitting For Extended Time ?hysical Aggression! Property L955 of Privilege/Reward EIApproached By Adult - EIWeapon Possession 'get Limits (1?It [Th an, When/Then) EIScheduled Non Preferred Activity El Elopement ECalled for Team Support UWaiting - DOther (Please Describe): Remove Other St?gudents 'UTransition to: from: DOther: DDther: El Additional Comments: . i Possible Function] Purpose of Behavior Student may have been trying to M: DSocial Interaction UPeer or Cl Adult DSociaI Interaction DPeer or DAduIt 5 - DSensory Stimulation I I .DSensory Stimulation ?ierred Activity] Item If? {h I LDNomPrefe-n?ed Acthiity? ask - Student may have been trying to gain: P?Wstea? Resttatnt and Eee?ue?an Eaeumeatattan Date a? Incident: During rd actions of the student and staff during physical testraint, transport, and/or seclusion. Students must be monitored co stantly and documentation completed at a minimum of every two minutes. NOTE: Forvrestraints and seclusions to ceed beyond each class period or every 60 minutes, obtain signature of administration in dicotan authoi?ization. wed ?ctions of the Student During Seciusion/Restraint ff ResponSe to Gbsew Actidns ?air ?Im' . 1 4% dz Signature (to go beyond every 60 minutes or each class period) 3f 2 fl Student: B?hysica I Date of incident: i Restraint and Seciusien Documentation Student Actions and Dehrie?l?ing After incident Stati Actions After incident Student Actions Student Debrie?ng Undivided Attention Editing Processing Activities (Describe)_ ElEmpathic Listening y?ZQCalm "EUsed Restatements for Understanding/Clarificatipn \QRational CIGave Wait Tlme "D'Tailgative y?Aiiowed for Silenca ElgSilent ElCoping Skill Activity (Describe) ?Continued to Monitor @ccepting Support UAssisted Student with Work Completion Eli?lred Walked Student to Class Ulsleeping QSupported Student in Class Wollowing Directions EEkpec?ted Behavior Activity DAssisted Student with Task Completion (cieanine uo. etc.) meturned to Class {11.41} 7L (Desaibe) I mommunicated with Caregiver Name; Cl Visited Nurse a ?ollowed Through on Prior Expectation DApologized for Actions Fen/hm), I'lc {Eb DAssisted with Processing Activity ClCommunicated with Caregiver Name: Accepted Responsibility for Actions (cleans up, etc.). Para verbal Communication Diviaintained Awareness of Proxemics, Kinesics, DPaci'ng ElAssisted with Coping Skill Activity DWorked independently - ESwitched Staff_Roles DRestroom/Bodily Needs EJOther (Describe) EASSisted with Expected Behavior Activity DOth'er (Describe) UOther Staff Debrie?ng and Future Approaches to Decrease orEliminate Behavior from Reoccurring: etc.) Date: ElTeam Meeting Learning Supports, EParent Meeting Date; ElCollect ABC Data DReview FBNBIP EiRevise Social Skill instruction Clcomplete Competing Pat 1ways Chart El Conduct Functional Behavioral Assessment ?Review Replacement Behavior UReview Positive Behavior Supports ElConsid er Student ElReview Go ais Data CIAccess Community Supports ClRevise Academic Support DContact'AEA Supports DOther: Describe ,apy injuries to student, employees, others, or roperty damage: I 5min Mac /n WWM me, ?l??fk Communication Documentation Parent/guardian must be "t incident Date: Name of pe-fmn contacted: Mugging; a not Far} Tide 1 ielationsh's?xl [/113ch let Describe attempts to notify the parent/guardianur contact cannot be made on day of incident: 1 Method: Written do?E "13rd: be sent to parent] guardian within 3 school davs- Date sent: Mail (postm?arked {within 3 days of the occurrence) Sent by: Email upon written reqUesL u; parenuguaroian D\Fax Upon written request of parent/guardian Hand Delivered in Person LName of pa rent/guardian the documentation was sent ti 3 Ceer Rapids ?r r?mmui?YS-d?wm?ig?? Physical Restraint__and Seclusion Documentation I "5 Student: I Date oflncident: School: Grade: I Seclusion a Location: Time In: Time Out: Duration: Confinement of a student in a room from which the studenfs egress is restricted Cl"; 32 in? Student Entered Seclusion by: Physiial Transport Safely moving an individual who is beginhing to regain control DWalked on their own DOther (Please Describe): \ECPITransport Time Sta rted2850 Time Ended?g?QDuration: ali?? DCPI Interim Control NCI Physical Restraint? DCPI Team Control Time Started: Time Ended: Duration: Used to manage individuals who have DCPI Children?s Control themsewes Dr Others: Cl Other (Please Describe): Staff Members involved: (Check Implemented Items) Setting Evants Antecedents Student Behavior Staff Response (EvenB indirectly impacting the (immediate triggers or predictors of 1m med iately after {Calm affliDnS Elia) to behavroral outcome) the problem behavror.) Antecedent behawor and award ELocation: when Verbal Direction DAnxious (Describe): @Gave Redirections I DSubject: UGiven Work/Activity mattered Coping Skill] break, etc. DActivity: UUnexpected Change in Routine ?lPIanned Ignore Con?ict Prior to School DPresented w/Social Interaction leave Time to De~esca ate DCon'?ict at School EITold o? by: DGave Encouragem ent/ Praise DCha nge in Routine ClDenied Access to Item/Activity Wefensive (D95cn'be): (?Positive Reminders (When/Then) DDif?colty in Previous Class Preferred Activity Removed DGave So pport El Homewmk Not Done EITeacher Attending to Others DAssignment Modi?ed DMissed Medication ELGiven Correction/Redirection 1 j} 2,470 mhanged Instruction Used Proxemics/Kinisics DSubstitote Tea cher [:lPeople too Close DAcademic Failure DLoud Noises/ Room Behavior Leading to ?Para Verbal Communication Dillinger UBright Lights Seclusion/ Restraint Used CPI Supportive Stance EIFatigue I]th a Speci?c Peer(s) EIVerbal Aggression - ElVisuaI Cues Used DWork too Hard/Easy UVerbal Threats/Intimidation EIModeled Expected Behavior IZILarge Group Instruction DWork Repetitiveftoo Long CIPhysiml Threats/Intimidation Empathic Listening DSmalI Group Instruction, Ellndependent Work Aggression/Self DGave Choices El Individual Instruction 'Clln Pain Physical Aggression 0th ers ClTime Out (Where): DUnstructured Time . DSitting For ExtendedTm-ie Aggression/ Property 1;]Loss of Privilege/Reward DApproached By Adult D?Weapon Possession e53: Limits fThen, no on I Non Preferred Activity DEIopement Elialled for Team Support ?bi 343-), - DWaiting Ether (Please Describe): DRemove Other Students 0 VM 0% ~DTransition to: from: (him I {cg/?U UOther: U) DDther: I Hr Cl A, ?r Additional tornments: ?ij JH ii 4M7!sz _i ~?0f WW (SW . Possible Eu?nction/Purpose of Behavior Student may have been trying to gain: Student may have been trying to avoid: SociaLlrJIBfaCtlDEL ?Peer or Adult __DSocial Interaction El Peer or DAdult lE-Sensory Stimulation DSensory Stimulation El Preferred Activity/ Item DNon?Preferred Activity/T ask . . if: I, a a stzh?db?m and Seclusmn Documentatton Student: 1 Date of Incident. -- I . During Record actions of the student and staff during physical restraint, transport, and/orseclusion. Students must be monitored conStantly and documentation completed at a minimum of every Mo minutes. NOTE: For restroan and seclusions to exceed beyond eoch Class period or every 60 min ufe5, obtain Sign more of indicating authorizationTime Observed Actions of the Student During Secluslonl?'estrelnt Staff Response to Observed Actions - habit I - I Administrator Signature (to go beyond- every 50 minutes or each class period] Time Date Physica? Restraint and Seclusion Documentation av f? 3? LStud ent: Date of Incident: 1 During Record actions of the student and staff during physical restraint, transport, and/or seclusion. Students must be monitored constantly and documentation completed at a minimum of every two minutes. NOTE: For restraints and seclusions to exceed beyond each ciass period or every 50 minutes, obtain signature of administration indicating a ath orization. taff Response to Observed Actions mills bserved Actions of the Student During SeCIUSion/Restraint Time administrator Signature (to go beyond every 50 minutes or each class period) Time Date a Restraint and Seclusmn Documentation StUdent: I Date oflncident: Student Actions and Debrie?ng After incident Staff Actions; After Incident Student Actions Student Debrie?ng ?oppor?vej Undivided Attention DCrying Processing Activities {oar-jibe) Empathic Listening EJle 44%; r? (1 2M EIUsed Restatements for Understanding/Clari?cation Wa?onal II ,Emrga? ii I lEGave Wait Time IlIIjTalk'ative II DAllowed for Silence USilenItI' DCopingISltiIIl Activity {peso-Ilsa) ElContinued toIMoInitor @Accepting Support I I I muster} Student" with Work Completion IUTrred 'Ewmked Studentto Class USleepingI ?Supported Student in Class . . Following Directions Expected Behavior Activity UAssis'tedI Student with Task Completion [cleaning up, etc.) ?lReturhe?d to Class (95mm) I DCommunicated with Caregiver Name: El Visited Nurse DFollowedThrough on Prior ExpectatiOn UApoiogiZed forIActions UAssisted with Processing Activity DComrnunicated with Caregiver Name: Accepted Responsibility for Actions (cleans up, etc.) - I UMaintaineId Awa'rEness of Proxemics, Kinesics, Para verbal Communication I BPacing - UAssisted with Coping Skill Activity UWorked independently DSwitched Staff Roles DRestroom/ Bodily Needs Bother {Describe} UAssiste-d with Expected BehaviorActivity I DOther (Describe) El Other Staff Debrie?ng and Future Approaches to Decrease or Eliminate Behavior fl?om Reoccurring: DTeam meeting (IEP, Learning Supports, etc.) Date: - i rent eeting Date: UColiect ABC Data El Review Wevise Social Skill Instruction UCorn plete Competing Pathways Chart I . EIConduct Functional Behavioral Assessment DReview Replacement Behavior El Review Positive Behavior Supports DConsider Student El Review Goals Data D'Access Community Supports I El Revise Academic Support Supports DOtheri Describe any injuries to student, employees, others, or property damage: Communication Documentation Parent/guardian must be contacted on dav of incident. Name of mar-mu Relationship; Mm I Date: lime: . Method: 0 By: Describe atkeiwsu to notify the parent/guardian ifcontact cannot be made on day ofincident: . . - written docomehtatiqn must be sent to parent/guardian within 3 school davs. Date Sent: Sent by: I Mail (postmaiikedIIwIthm iafysi?fiiga??n'? El Fax upon written request of parent/guardian El Hand Delivered in Person A. . Name of parent/guardian the documentation Was sent to: .IL . "kl- Sd?DPi-Di??ci Physical Restraintand Seclusion Documentation a tudentT - Date oflncident: School: i l?Seclusion Locati n: Time In: Time Out: Duration: Con?nement ofa student in a room from 0 1 ?iiZ. SK 1'5? ?1130 ISTOrwrimh which the student?s egress is restricted Student Entered Seclusion by: NCI Physical Transport: Safely moving an gift/awed on their own CIOther (Please Describe): UCPITransport DCPI Interim Control Individual who is regain control Time Started: Tlme Ended: Duration: NCI Physical Restraint? l: CPl Team Control Time Started: Time Ended: Duration: use?, to manage IndeualS Who have DCPI Child ren?s Control become dangerous to themselves or others; . . used as a iasnesort El Other (Please Describe:? S'lraff Members involved: (Check Implemented Items) Antecedents - Student Behavior Staff Response Setting Events (Events i_ndirectfy irn pacting the (Immediate triggers or predictors of Immediately after- (Calm &tlonjudgrnen12]a ctions taken to de?mlate student behavior and avoid behavroral outcome) the problem behavror.) Antecedent seduan/rmint) Location; ??iven Verbal Direction Noxious (Describe): UGave Redirections ElSubject: EIGiven Work/Activity EM Offered Coping Skill/ break, etc- 'DActivity: DUnexpected Changein Routine in Elanned Ignore El Con?ict Prior to School UPraented w/SociaI Interaction El Gave Time to Dre?escalate Conflict at School [:ITold o? by: El Gave Encouragern ent/ Praise El Change in Routine CIDenied Access to Item/Activity Defensive (Describe): El Positive Reminders (When/Then) Dif?culty in Previous Class Preferred Activity Removed QXQ (Mm El Gave Support DHornEWork Not Done DTeacher Attending to Others 0 I UAssignment Modified Missed Medication EIGiven Correction/Redirection DChanged Instruction DSubstitute Teacher UPeople too Close El Used Proxemics/Kinesics DAcademic Failure EILoud Noises] Room Behavior Leading to DPara Verbal Communication El Hunger UBright Lights Seclusionf Restraint El Used CPI Supportive Stance UFatigue I]th a Speci?c Pearls) DVerbal Aggression NWsual Cues Used DIlIness [:IWorIc too Hard/Easy Wanna! Threats/Intimidation DModeled Expected Behavior [:ltarge Group Instruction DWork Repetitive/too Long Cl Physical Threat?nt?rmidation El Empathic Listening [:lSmall Group Instruction, Ulndependent-Work UPhysical Aggression/Self UGave Choices El Individual ction ?Clln Pain Whysical Aggression/Others Chime Out (Where): El Unstrudured Time . USitb'ng For Extended Time Aggression/Property EILoss of Privilege] Reward DApproad-ied By Adult D_Weapon Possession DSet Limits (ft fThen, W?henfl?hen) DScheduled Non Preferred Activity El Elopement El Called for Team Support DWaiting UOther (Please Describe): El Remove Other Students - DTiansition to: from: El Other: DDther: Additional Comments: . Possible Function/Purpose of Behavior Student may have been trying to gain: Student may hava been trying to avoid: DSocial interaction DPeer or Cl Adult .mSocial Interaction Peer or CIAdult USensory Stimulation DSensory Stimulation Preferred Activity/ Item min?Preferred Activity/Task Jitter . 1??th 55??le Restralnt and Seclusmn Documentation I Date of IncidentI?x; I I Student: During Record actions ot the student and staff during physical restmint, transport, and/or seclusion. Students must be every two minutes. NOTE: For restraints and monitored co nstantiy and documentation completed at a minimum 0 seclusions to exceed beyond each cfass period or ever 60 minutes, obtain signature of administration indicating 1733 oath oriZotion. Staff Response to Observed Ac?o ns Time Observed ?ctions of the Student During Seclusion/Restraint Initials notes or each ciass period} Time Administrator Signature [to go beyond euezy an un Date . so? - . .. . . Physical Restraint and Seclusron Documentah?n I Student: iDate of Incident: During? Record actions of the student monitored constantly and documentatio seclusions to exceed beyond each closs period or every 50 minutes, 0 . authorization. and staff dun'ng physical restraint, transport, and/or seclusion. Students must be completed at a minimum of every two minutes. NOTE: ond btofn sign oture of administration in dlcotfn taff Response to Observed Actions Tlrne Observed Actions of the Student During Seclusion/Restraint fl 0 Hme Date Admintsuatur Signature (to?go beyond every 60 minutes or each class period) 57 Cede? Physical Restraint and Seclusi?on Documentation Tel Student: Date of Incident: Student Actions and Debrie?ng After incident Staff Actions After incident Student Actions Student Debrie?ng )i?iDSuppottivef Undivided Attention DCrying ?i?mcessing Activities (Desotibej Empathic Listening GE Calm Used RestatemenE for Und ersta nd ingf Clari?cation DRa?onal EGave Wait Time DTaikative . EIAilowed for Silence Eisno?nt Scoping Skiil Activity (Desm?be) ?tontinoed to Monitor . chep?ting Support CIAssisted Student with Work Completion ti?iired alked Student to Class [Bleeping USupported Student in Class Following Directions DEXpected Behavior Activity DAssisted Student with Task Completion (cieaning up, etc-) EReturnet-i to Class CICornmunicated with Caregiver Name: I ll Visited Nurse DFoIlowed Through on Prior Expectation BApoiogized for Actions ElAssisted with Processing Activity DComrnunicated with El Accepted Responsibility for EIMaintained Awareness'of Proxemics, Kinesics, Caregiver Name: Actions (cleans up, etc.) Para verbai Communication Dilatith ElAssisted with Coping 5km Activity independently EISwitched StaffRoies DRestmom/Bodiiy Needs er (Desa'ibe) ElAssisted with Expected Behavior Activity DOther_(oescribe} El Other Staff Deb rie?ng and Future Approaches to Decrease or Eliminate Behavior fi?orn Reoccurring: etc.) Date: 1 DTearn Meeting Learning Supports, DParent Meeting Date: El Coilect ABC Data . DReview d?ovtsosooai Skill Instruction DCompiete Competing Pathways Chart EICond'uct Functional Behavioral Assessment UReview Replacement Behavior El Review Positive Behavior Supports UConsid er Student DReview IEP Goals Data DAccess Community Supports i3 Revise Academic Support DContact AEA Supper?13 BOther: Describe any injuries to student, empioyees, othersr or property damage: may - Communication-Documentation Parent/guardian must be cont n" 4w n-f incident. Name of person co ,actedz' Date: - Time: Relationship: My Method; I Describe attempts to notify the parent/guardian if contact cannot be made tin day of incident: I By: Mail (postmat tteu .5 days ofthe occurrence) Written documanh?nn must be sent to parent/guardian within 3 school days. El Email upon uestmofmpa cfg?or'd El Fax upon written request of parent/guardian El Hand Delivered In Person I Name of pa rentfgua rdian the documentation was sent to: x? {CedangpI-ds . f? Communwmi?z??m Phasiea? Restraint and Sealasian ?oaarnentatson IStudent: - litigateg?osieE?th Sur?ng Record actions of the student and staff during physical restraint, transport, and/or seclusion. Students'must be monitored constantly and documentation completed at aminimum of every two minutes. NGTE: For restraints and seam-WM i=0 ewe-Ed beyond each Class permd 0" 59 mi? Utes; Obtain signature of administration indicating authOrizotionli- .- r. . Staff initials taff Response to absolved Actions . a ti em a (Iv . lsserved Actions of the Stu?ent Sur?ng Seciusia nIRestraint a, . Administrator Signature (to go beyond every 58 minutes or each class period) Time I Date J?c. (CedarRQPids I f? Physical Restraint and Seeciusion Docnrnentation I Student: .. I Date of incident: Student Actions and De briefing After incident Staff Actions After incident Student Actions Student Debrie?ng DSupportive/ Undivided Attention DCrying DProcessing Activities (Describe) Ci Em pathic Listening CI Calm El Used Restatements for Understanding/Clari?cati on [:lRational Cleave Wait Time UTalkative :lA Iowed for Silence (ESiient i3 Coping Skill Activity (Describe) [:lContinued to Monitor [:IAccepti ng Support DAssisted Student with Work Completion Eli??ed UWalked Student to Class DSleeping [:lSupported Student in Class DFollowing Directions ElExpected Behavior Activity DAssisted Student with Task Completion (cleaning up, etc.) [:IReturned to Class (??crlbel ECommunicated with Caregiver Name: vaoim e? 3% Cl Visited Nurse CIFoliowed ThroiJgh on Prior Expectation CIApologized for Actions CIAssisted with Processing Activity" ECommunicated with Cl Accepted for EIMaintained AWareness of Proxemics, Kinesics, CaregiVer Name: grudge, Actions (cleans up, etc.) Para verbal Communication Cl Pacing UAssisted with Coping Skill Activity DWorked lndependentiy USwitched Staff Roles El Restroom/Bodily Needs EOther (Describe) w] DAssisted with Expected Behavior Activity CIOther (Describe) I I: Other Staff Debriefing and Future Approaches to Decrease or Eliminate Behavior from Reoccurring: UTeam Meeting Learning Supports, I : Parent Meeting Date: DCoilect ABC Data etc.) Date: Review [3 Revise Social Skill on C3 Complete Competing Pathways Chart DConduct Functional Behavioral Assessment El Review Replacement Behavior Review Positive Behavior Supports Cl Consider Student El Review Goais Data ?Access Community Supports Cl Revise Academic Support Cl Contact AEA Supports El Other: Describe any injuries to student, employees, others, or property damage: Communication Documentation Parent/guardian must be contacted on dav of incident. Name ofperson contacted: RelationshipDate: I nme: Method: Dianna (By: DescribTe?attlempts to notify the parent/guardian if contact cannot be nlade on day of incident: Written documentation must be sent to parent/guardian within 3 school days. I Date sent: Sent by; Mail (postmarked within 3 days of the occurrence) El Email upon written request of parent/guardian Fax upon written request of parent/guardian El Hand Delivered in Person Wang of parent/guardian the documentation was sent to: AL \7 Cedaerpids- Physics; Restraint and Seclusion Documentation Student Date of Incident: Schoolzr Seclusion Location: Time In: Time Out: Duration: Confinement of a student in a room from r3 0 i . which the student's egress is restricted Student Entered Seclusion by: DWaIked on their own Transport EICPI interim Control NCI PhysicaiTransport Safely moving an gather (please Describe): individualwho is beginningtoregain control Time Started?nb .nme Duration: 1 Physical Restraint - Team Control Time Started: Time Ended: Duration: Used to manage individuals who haire DCPI ch?drenrs Control - become dangerous to the mselva or others; . used as a last resort El Other (Please Describe). Staff Members Involved: Before SeclusionIRestraint/Transport (Check implemented items) Setting Events Antecedents Student Behavior Staff Response (Events indirectly impacting the behavioral outcome) (immediate triggers or predictors of the problem behavior.) Immediately after Antecedent (Calm Er Nonjudgmental actions taken to tie?escalate student behavior and avoid seclusionf restraint) XI Locati or UGiVen Verbal Direction DAnxious (Describe): WGave Redirections bject: EIGiven Work/Activity WOffered Coping Skill/ break, etc. ?Activity: braw?gi- DUnexpected Change in Routine CIPlanned ignore CICon?ict Prior to School El Presented vii/Social interaction Time to De?escalate DConflict at School UTold o? by: Encouragement/ Praise DChange in Routine El Denied Access to Item/Activity DefensiVe (Describe): Positive Reminders (When/T hen) ElDifficuity in Previous Class Ci Preferred Activity Removed 5w gap 3 n4 I whim) UGave Support CIHomeiivork Not Done CITeacher Attending to Others ~sz peml DAssignment Modi?ed _l:lMissed Medication Given Correction/Redirection u;ka par 0 [JChanged instruction [Substitute Teacher DPeople too Close km do; amp r's Cl Used Proxemics/Kinesics DAcademic Failure El Loud Noises/Room Behavior Lebding to El Para Verbal Communication DHunger El Bright Lights Seclusio nl Restraint EUsed CPI Supportive Stance DFatigue DWith a Speci?c Feeds) BLVerbal Aggression DVisual Cues Used Dillness DWork too Hard/Easy ?-Verbai Threats/Intimidation Modeled Expected Behavior ELarge Group InstrUCtion DWork Repetitive/too Long ?Physical Threats] intimidation Em pathic Listening all Group Instruction independent Work El Physical Aggression/Self Gave Choices individual Instruction CI in Pain Physical Aggression/Others Out (Where): Unstructured Time EISitting For Extended Time Physical Aggression] Property Loss of Privilege] Reward DApproached By Adult ClWeapon Possession DSet Limits lThen, WhenfT hen) Cisizheduled Non Preferred Activity El Elopement Emailed for Team Support ZiWaiting [:IOther (Please Describe): El Remove Other Students EIT'ransition to: from: DOther: EIOther: - - El Additional Comments: was. 4., Jul-aw '1 A at?: Hui?e shat-F. awn? Hit malady/ad hired id Possible Function/Purpose of Behavior Student may have been trying to gain: Student may have been trying to avoid: DSociai lnteracti on [:iPeer or Cl Adult .E'Sociai interaction MPeer or EIAduit USensory Stimulation DSensory Stimulation ,9 . l?lPreferred Activity/item Syn?Preferred Activity/T ask Cedar Rapids; r? meunit?is??im? tinttsicei Restraint end Seciesien Decementetien 1 Student: I -- -- Demueitncidm?. Easting Record actions of the student and staff during physical restraint, transport, and/or seclusion. Students must be monitored constantly and documentation completed at aminimum of every two minutes. NGTE: For restraints and seciusions to exceed beyond each ciess period or every 60 minutes, obtain signature of administration indicating authorization. - Staff Time Qbserued Actiens et the Student During Seciusieni?estreint Staff Response te Ghserved Actiens - initials 6.: ?Iz?m ti t: i in Ad ministrater Signature (te ge beyend every es minutes or each ciess period) Time Date HAL Cedar Rapids Eat Community School District; i Restraint and Seciesion Documentation I Student: I Date of incident: i i L. Student Actions and Dehriefing After incident Staff Actions After incident Student Actions Student Debrie?ng DSupportive/ undivided Attention EICrying El Processing Activities (Describe) El Em pathic Listening 1?Caim Used Restatements for Understanding/Clari?cati on EIRational DGave Wait Time BTaIkative ElAiiowed for Siience DSilent Coping Skill Activity (Describe) El Continued to Monitor DAccepti ng Support ego ie {d epiaeemiet? ?Assisted Student with Work Com pietion CITired Retest; Laps a pimps; DWalked Student to Class DSleeping ?Supported Student in Class DFollowing Directions @Expected Behavior Activity El Assisted Student with Task Completion (cleaning up, etc.) MReturned to Ci ass El Visited Nurse (Describe) BCommunicated with Caregiver Name: El Foliowed Through on Prior EXpectation DApologized for Actions EIAssisted with Processing Activity Communicated with CaregiVer Name: w] Accepted Responsibility for Actions (cleans Up, etc.) Maintained Awareness of Proxemics, Kinesics, 81 Para verbal Communication DPacing up RAssisted with Coping Skill Activity nl+at= pa??e aches-it DWorked independently 1 Reg r: ClSwitched Staff Roles El Restroom/Bodily Needs UOther (Describe) EIAssisted with Expected Behavior Activity ?0ther (Describe) EIOtherW Staff Debriefing and Future Approaches to Decrease or Eliminate Behavior from Reoccurring: BTeam Meeting (IEP, Learning Supports,_ etc.) Date: DParent Meeting Date: El Collect ABC Data 7 CI Review [:iRevise Social Skill Instruction DConduct Functional Behavioral Assessment [Review Replacement Behavior Consider Stud ent DReview Goals Data EAccess Community Supports DComplete Competing Pathways Chart Weview Positive Behavior Supports l_l:lRevise Academic Support El Contact AEA Supports DOther: Describe any injuries to student, employees, others, or property damage: Communication Documentation Pa re ntlgua rdian mustEco ntacted on day of incident. Name of person contacted: - Relationship: Date: Time.- Method: ,0 [AL-mg I By: 4' Describa to notify the parent! guardian if con tact cannot be rriade on day of incident: Date sent: Written documentation must be sent to pa rent/guardian within 3 5c Sent by: Mali (postmarked vv?ithina?days of the occurrence) hool days. El Email upon written reques-Eaf parent/guardian Fax upon written request of parent/guardian El Hand Delivered in Person [Name of parent/guardian the documentation was sent ti JR. Edi Physical Restraint__and Seclusion Documentation School: Date of Incident: lEl. Seciusion "ime ln: Con?nement of a student in a room from which the student?s egress is restricted Time Out: 3% Duration: ?mfg: Student Entered Seclusion by: Physical Tran5port :2 Safely moving an individual who is beginning to regain control DWalked on their own ?CPITransport DOther [PleaSe Describe): Sta :33. Tim .53: I. DCPI Interim Co ntrol Durationzagm Physical Restraint?'7 DCPiTeam Control Used to manage individualsw'ho have children?s Control blacome dangerous to themselves or others; - . . used as a last-ragga - Dther(Please Describe). Staff Members Involved: I . 4 Items) ?a Time Started; zeal?[roe Endeigfwumtion:qmm Befo re?Seclusion/Restraint/Tra nsport' (Check lmplemente Setting Eve nts' A'nte'CE dents. - {Stu dent Behavior; (Events impacting the {immediate triggers or predictors of I 1mm edfately_aft9r behavioral outcome) the problembehavior.) mtet?dent I Staff Response. I . {Calm Stldonjudgmental?ac?ons takedto tie-escalatestudent be'havior and avoid ?swsion/ratiaint) -. KGiven Verbal Direction CIArn-zious (Describe): H?ave Redirections Location: A ?gu?jee; DGiven WorkIActivity etc. DActivib); UUnexoect'ed Changein Routine UPl'anned Ignore I t] Con?ictiPrior to School Prise" n-ted Via/Si)le! Interaction KGave ?meto De?escalate - Conflict at School DTold by: ?gave Encouragem ent/Piaise CIDenied Access to item/Activity nge in Routine ElDefensive (Describe): DDif?culty in Previous Class Preferred Activity'Removed goositive Reminders (whenfThen) UG'aveSuoport'V El HOmework ot Done DTeacher Attending to Others UAssignmentModi?ed-: I . DMissed Medication Correction/Redirection . DSubstitute Teach er DPeople too Close Usecl .Proxernis'??inejics ClAcademic Failure Eltoud Eloisa/Room Behavior Leading to UParal-Verbai Communi?ition DHuriger I DBright Lights SegflUSionfRes??aint El Used CPI?S?hpbo?rtiVe Stance UFatigue ElWith a Speci?c Peerls) EVerbal Aggression Cues Used Dillness DWork too Hard/Easy DVerbai Threats/Intimidation DModeled Expected Behavior DLarge Group Instruction DWork Repetitive/too Long DEmpathic Listening DSmall Group instruction UlndependentWork Aggression/Self EIGave Choices El Ind ividuai ction ?Dln Pain ?fhysical Aggression/Others U'?me Out (Where): El Unstructured Tim . ElSitting For Extended Time Aggression/Property El Loss of Privilege/Revvard DApproached By Adult QWeapon Possession Use: limits rrhen, When/Then) 5?7) DScheduIed Non Prefe?ed Activity DElopement Walled for Team Sapport I UWaiting DOther (Please Describe): El Remove Other Students -[3Transition to: from: DOther: g_ . Mothers Madgd MM . . Do. i . Additionalcommener/?i?i?z?a .1 .. 1-3me 72) 1 .53.. .. 1' maria: - 7 Possible FunctionIPurpose of Behavior Student may have been trying to gain: Stu dent may have been trying to avoid: _l:iSocial interaction El Peer or DPeer or gAduit flj'Sensory Stimulation USensory Stimulation El referred Activity/Item UNoanrefe rred Activity/T ask I, 35 Seam? .E I .I physic? Restraint and i . - l? "tilil??te -- I d. - 3-3? I - ,f faint, transpoft, andfor seciusion. Stud?f?i? must be urin' phy'sitai rest NOTE: For restrainE and Quring R??prd actions of the student athtaff monito Hedi-5c?) QI-isi?antiy a nd ducumenta'?fonpleted at a gjfieyegry 1:31.10 minutes. Sg?lu?ions ek?qed be 31pr aqu ciuss period or may 60 ature of administration indicatingohggme?d taffResgPo?s??a 919.; Rd? 'i'fimc? .5 n_ I'Adrninistr-atur Signature (to go begin-rid ?V?r?r 50 rhih?t??s 6i" each class period) Date g] ?15: 6.11;: 1' - Gimmiwgch??.m?m Physicai Restraint and Seciusion Documentation .. El Student: I Date of Incident: 4] During - Record actions of the student and staff dun'ng physical restraint, transport, and/or seclusion. Students must be monitored constantly and documentation completed at a minimum of every two minutes. NOTE: For restraints and seciasions to exceed beyond each class period or every 60 min ates, obtain signature of administration indicating authorization. taff Initials Time Observed Actions of the Student During Seciusion/Restraint Staff Response to Observed Actions Administrator Signature (to go beyond every 50 minutes or each class period) Time Date ??Si Wm?wgd?qdnt?fp? Physical Restraint and Seclusmn Documentation . . . Etudent: Date oflncident: Student Actions and Debrie?ng After. incident Staff Actions After Incident Student Actions . I sStt'y?e'n't Debrie?ng Undivided Attention I DCrying - . Wrotessing Activitiegmesoibe) DEmpathic Listening .l E?Calm - Weed Restatements for Understanding/Clarification ?naeonal if "cleave Wait Time UTall-iative I - DAgowed for Silence Usilent - Dching' Skill Activity tombs) Manama to Monitor wAccepting Support ?UAssisted Student with Work Completion Diired . .. - [Walked Student to Class DSIeeping A DSuPported Student in Class ?Following Directions UExpected Behavior Activity DAssisted Student with Task Completion {cleaning op, etc.) ?Retur?ned to Class DCommunicated with Caregiver Name: Visited Nurse momma Through on Prior-Expectation UApologized for Actions Unssisted with PtoceSsirig Activity DCornmunicated with El Accepted Responsibility for DMaintain ed Awareness of Proxemics, Kiriesics, 8: Caregiver Name: Actions (clea ns up, etc.) Para verbal Communication DPacing UAssisted with Coping Skill Activity I UWorked independently I I DSWitch ed Staff Roles DRestroom/Bodiiy Needs UDther {Desa?ibel- UAssisted with Expected Behavior Activity DOther {Describe} - . El Other Staff Debrie?ng and Future Approaches to Decrease or Eliminate Behavior from Reoccurring: CITeam Meeting (IEP, Learning Support, UParent Meeting Date: DCoIlect ABC Data etc.) Date: 3 l- DReview FBAIBIP - ?Ki-levee Social Skill Instruction UComplete Competing Pathways Chart I DConduct Functional Behavioral Assasment [HReview Replacement Behavior UReview Positive Behavior Supports DConsider Student DReview Goals 8; Data DAccess Community Supports DRevise Academic Support EIContactAEASupporB DOther: Describe any injuries to student, employees, others, or property damage: COmmunication Documentation Parent] guardian must be contacfpri nn Hen: n4: Name of person contacted: I Relationship: 0m Date; Method: aphng lBy: Describe attempts to notify the parent/guardian if contact cannot be made on day of incident: Written documentation must be sent to parent/gua rdian within 3 school days. .DateseIJt; .. . . S?nt by: Mail (postman-Ken Within 3 days ofthe occurrence) Email iidiaT'i El Fax Upon written request ofparent/guardian Hand Delivered In PerSon I Name of pa'Irent/gua rd ian the decumentation Was Sent to: .. . if?? Physical Restraintend Seclusion Documenta) Student: I Date oflncident: School: I Grade: a Seciusion Locationzwlan Time im/Zj?rget Time Duty/r35 Duration; - fig-h, Con?nement ofa student in a room from which the student?s egress is restricted Student Entered Seclusion by: Physical Tran5port Safely moving an individual who is beginhing to regain control DWalked on their own l: CPl interim Control DOther (Please Describe): nSport Time Sta rtedf?r'gg lime Ended oration: Physical Restraint Team Control Time Started: Time Ended: Duration: Used to manage individuals who have Childrenls Control become dangerous to themselves or others; . I used an last r30?: El Other (PleaSe Descnbe). StaffMembers involved - -- - (Check implemented items) Setting Events Antecedents Student Behavior Staff Response (Calm 81 Nonjudgmen?tal actions taken to de?escalate student behavior and avoid immediately after Antecedent (Events i_ndirecdy impacting the behavioral outcome) (immediate triggers or predictors of the problem behavior.) [3 Location: DGiven Verbal Direction DAnxious (Describe): Gave Redirections DSubject: Maven Work/Activity Hottered Coping Skill/ break, etc. DActivity: Unexpected Change in Routine DPlanned ignore El Conflict Prior to School ElPresented w/Sociai Interaction UGave Time to De-escalate . UCon?ict at School UToid o? by: Elgave Encouragem ent/ Praise Cl Change in Routine El Denied Access to Item/Activity Defensive (Dacribe): KPosltive Reminders (whenfihen) Cl Dif?culty in Previous Class El Preferred Activity Removed den/2m DGave Support Homework Not Done - DTeach er Attending to Others . ad UAssignment Modi?ed DChanged instruction Wiven Cc?ggtigpj?edirection DMissed Medication DSubstitute Teacher DPeopl too Close Used Proxemics/Kinesics DAca demic Failure ULoud Noises] Room Behavior Leading to Ufara Verbal Communication l:l_Hunger DBright Lights Seclusion;r Restraint MUsed CPI Supportive Stance Fatigue DWith a Speci?c Peer(s) MVerbal Aggression [:lVisual Cues Used Diliness UWork too Hard/Eastl 'DVerbal Threats/intimidation DModeled Expected Behavior El Physical Threats} intimidation Cl Physical Aggression/Self El Physical Aggression/Others R'Physical Aggression/Property El Empathic Listening MSave Choices D'?me Out (Where): DLoss of Privilege/ Reward DWork Repetitive/too Long Uindependent Work 'Elln Pain DSittin For Extended Time DLarge Group instruction EISmall Group instruction, Instruction DUnstructured Time DApproached By Adult D?Weapon Possession E?Set UmiE (1st fThen, When/Then) [Scheduled Non Preferred Activity El Eiopem ent El Called for Team Support DWaiting DDther (Please Describe): URemove Other Students - EITransition to: from: DOther: A I . El I vile-it4.4/1 J. -?cI-Lzz/ 1; i "r Pssible Function/Purposfa I Student may have been trying to gain: Student may have been trying to Mg: I. DAdult UPeer or DAduit br Interaction DSensorv Stimulation DSensory Stimulation MPreferred Activity/ item MN on?Preferred ActivityfT ask 7 I - ?eeti- Restraint and Seclusmn Documentation or Be ord actions of the student and staff during physical restraint, tra nspoit, andfor seclusion. Students must be 0 so nstan?dy and documentation Compieted at a minimum, of every two minutes. NOTE: For restraints and exceed beyond each class period or event Ed minutes, obfom Signature ofodmmistrotlon Indicating i ?Dete oflnci'dent' authorization. Staff Initials taff Response to Observed Actions Win)? Ma ?i bseru?dAetions of the Student During Sedusio Restraint vi '1 II 001'?. Wowout Eons Time ud LE Administtator Signature [to go beyond every bu minutes or'each class period] or '37 . . Physicai Restraint and Seciuston Documentation - It -. ltm?.? a' [Still?CE: 1Date oflncident: I I :l monitored constantly and documentation completed at a minimum of every two minutes. NOTE: Forrest seclusions to exceed beyond each class period or every 60 minutes, obtain signature of administration indicating authorization. Staff Staff Response to Observed Ac?ons Initials Time Observed Actions of the Student During Seclusion/Restraint I "f . ML a ww?i - (.1, (we Vex dc- ul? Moan! I (.474 bold or ?Ki 0 if Administrator Signature (to go beyond every 5U minutes or each class period) Time i Physiciai Restraint and Stacius-ion Documentation Date oflncident: __.__StaffActions After Incident - -. Student-Actions andI-Debrie?ng After incident Student Actions Stpdent Debrie?ng DSupportive/ Undivided Attention DCn/ing EProcessh?ig Activities (Describe) Empathic Listening I ?Caim (9M5 Msed Restatement: for Understanding/tieri?cation? (El-Rational El GaveWait Time UTaIkatiue . DAiiowed for Silence USiient Damping 5km Activity {Descnbej Momma; tQtE/Lonjgogg ?amepting Support Completion {D?red UWaiked Student to Class I DSIeeping DSU pported Student in Ciass Egoiiowing Directions IgExpected Beh a'vior Activity UAssisted Student with Task Compietion_(cleaning up, etc.) with Caregiver Name: Returned to Class {wee/dear {DFellewedThretigh on Prior-Emes-?tatim. .- [tji?inaipgized forActians - "M'de (i ., . maintain- preteen-3mm, with for: .. @a-?jnggiver Name: ?ctions?ici?eaps up, etc{Elmaintazn'ed Awareness of Pr?o?xe?mtcs,? Kineslcs, 85 - Pat?'verhai communicator. I Bit-adios] 'xs -. massage With coping Skili Activity Riv-?tted independently 7,1: 9 idlssit?hedstlaff Rees. i Restijoom/Bodiiy Needs - on spaced 'd?h'??i?o'metintyi- . I a .y I (PEER-heir Staff es'togpecrease or Memes. I pth?f Eliminate Behavior from Reoccorrin'g; - l. etcgh Date: 1. Iii. . c" UTE?nMee?cing'UEP, LearningSr'uppgt?EJHK "'u?arent 'Dateii?lim a Cleaner: ABC Data DRevilgw A, famijfitevise social-Skill Instruction DCompIete Competing Pathways Chart Waview Re-piac'ement Behavior Review_E?ositive Behavior Supports UConduct Functional Behavioral Assessment- DConsider Student ?eview Goals 8: Data. EI-Access Community Supports DReviseAcademicSupport hDContact AEA Support-s Other: De'scribe any injuries to'student, employee; others, or property damage: MW Communication Documentation Parent/guardian must be contacted on dav of incident. Name of person contacted- Mathad 3. .. Date; Describe attempts to notify the.? pa rentf?tia'rdian if contact Cannot By* adeon day ofjncident: Mai! (postmarked Within 3 days ofthe occurrence] Written documentation must be-sent to parent/guardian within 3 schoolgiavc Email upt . um.? acqucot u: nment/guardian Hand Delivered in Person Fax upon written request of parEnt/guardian Name of parent/guardian the doCUmentatiOn Was to: Physical Restrainta nd Seclusron Documentatrogm Student: i i_Date oflncident School: Grade: I IEP: Seclusion- Location: by - Timeln: Trme Out: Duration: Con?nement ofa student in a room from ?4 can)? I i which the student?s egrEss is restricted i if i 2 l? 0 Sim liq/Qt. Student Entered Seciusion by: DCPiTransport Physical Transport 2 Safely moving an @Nalked on their own Other (Please Describe): CPI interim Co ntrol individualwho is beginning to regain chiJ'Dl Time Started: Time Ended: Duration: r?l?wiCl Physical Restraint? DCPI Team Control Time Started: Time Ended: Duration: Used to manage individuals who have C) children?s Control Drawers} El Other (Please Describe): Staff Men-abers inVoIved: (Check Implemented Items) Setting Events Antecedents . Student Behavior Staff Response (Events mdimwy irn pacting the (immediate triggers or predictors of Immediately after (Cairn Er Nonjudgmentai actions taken?to behavroral outcome) the problem behavror.) Antecedent Smite?igb?hawor End ?Did Location (Mn Verbal Direction EIAnxious (Describe): H??ave Redirectio ns [:ISubject: DEiven Work/Activity W?ered Coping SkiIIX/feakigtc. Electivity: DUnexpected Change in Routine /Cl Planned Ignore Con?ict Prior to School Presented w/Social interaction El Gave Trme to De?escalate El Con?ict at School EITold ?No? by: El Gave Encouragern ent/ Praise DChangein Routine DDenied Access to ltemfActivity El DefEnsive (Describe): El Positive Reminders (When/Then) DDif?culty in Previous Class Preferred Activity Removed liq/Km QM {Worm UGave Support EIHorneworl-c Not Done DTegcher Attending to Others a} DAssignment Modified Ci Missed Medication cmwen Correction/Redirection L. Changed instruction DSubstitute Teacher DPeople too Close El Used Proxemicstinesics CIAcademic Failure Eltoud Noises/ Room Behavior Leading to DPaia Verbal Communication El Hunger DBright Lights Seclusion/ Restraint El Used CPI Supportive Stance . El Fatigue DWith a Speci?c Peerls) CIVerbaI Aggression ElVisual Cues Used DWorl-c too Hard/Easy CIVerbal Threats/Intimidation DModeled Expected Behavior El Large Group Instruction DWork RepetitiveItoo tong minim! Intimidation El Empathic Listening EISmall Group I nstruction, Elindependent Work - Uthsical AggressionfSelf [:IGave Choices El individual ction 'EIln Pain I UPhysicaI AggressionfOthers ElTirne Out El Unstructured Time . DSitting For Extended Time Physical Aggression/Property El Loss of Privilege/R evvard UApproached By Adult [:IWeapon Possession DSet Limits (ft/Then, When/Then) DScheduIed Non Preferred Activity ClElopement Called for team Support DWaiting DOther (Please Describe): El Remove Other Students - EITransition to: from: 5M DOther: Dome? lile [3 Additional Comments: . Possible FunctionIPurpose of Behavior Student may have been trying to ggin: Student max)r have been trying to avoid: ocial Interaction or Cl Adult L?JSocial Interaction El Peer or UAduit CISensorvStimulation DSensory Stimulation El Preferred Activity/?ltem El Non?Preferred Activity/T ask abysmal Restraint and Seclasron Documentation I Student. I Date of lnciderl' During acaons or me sLuoent and staff during physical restraint, transport, andfor seclusion- Students must be monitored constantly and documentation completed at a minimum of every two min LEE. NOTE: For restraints and seclusions to exceed beyond each class period or every 60 min ates, obtain signature of administration indicating authorization. ta?" Initials Sta?'Response to Observed Actions Time Observed ?ctions of the Student During SeclusionfRestraint .1: Time Date I Administrator Signature go peyond eVery DU minutes or each class period} . 12.. u' A I - ti?: Ed?G??iDm Physicai Restraint and SeciLISIon Documentation "it" I Date Elf [HCident: During?- Record actions ofthe student and staff during physical restraint, transport, and/or seclusion. StudenE must be mon'rtored consta ntiy and documentation completed at a minimum ofeVery two minutes. NOTE: For restraints and seciasions to exceed beyond each class period or every 50 min ates, obtain signature of administration indicating . authorization. 1: Staff TIrne Observed Actions of the Stu dent Du ring Se clusioanestl-aint Staff Response to Observed Actions Initials .. ream/a Administrator Signature (to go beyond every 60 minutes or each class period} Time Date as; cs. Igg- I i I, chi cf" PhySIcal Restraint and Seclusion Documentation I Date of Incident: Student Actions and Deb riefing After incident Staff Actions After incident Student Actions Student Deb rie?ng [Rammed Un divided Attention [JCrying DProcessing Activities (Describe) El Empathic Listening Wain: El Used RestatemenE for Understanding] Clari?cation CIRational EIGave Wait Time DTalkative mllowed for Silence ESiIe?nt DCoping Skill Activity (Describe) montinUed to Monitor UAccepting Support - UAssisted Student with Work Completion DWaiked Student to Class 2 'l DSleeping USupported Student in Class Following Directions ?xpected Behavior Activity CIAssisted Stud lent with Task Completion (cleaning up, etc-) DRetu [tied to Class (Wine) QC 3 MS.ng with Caregiver Name: in Visited Nurse tam DQ 15ml [mi/18K UFoilowed Through on Prior Expectation UApologized fo Actions 5 gavj?a EIAssisted with Brocessirig Activity Commu nicated with Caregiver Name: Actions (cleans up, etc) Accepted Responsibilityefor Para verbal Communication El Maintained AWareness of ProXemics, Kine-sics, 3; UPacing I DAssisted with Coping Skill Activity DWorked Independently DSwitche?d Statf- Rae's DRestroom/ Bodily Needs EIOther (peso-the) DAssisted with Expected Behavior Activity Other {Describe) I Other Staff Dehcie?ng and Future Approaches to Decrease or Eliminate Behavior from Reoccurring: Meeting LearningSupports, etc.) Date: i DParent Meeting Date: El Collect ABC Data Review - Sd?al Skill Instruction DComplete Competing Pathways Chart ElConduct Functional DRevievv Replacement Behavior' EI Review Positive Behavior SupporB Consider Stu dent EIReview Goals 3L Data DAccess Community SopporE- IZI'Contact AEA Supports- . Other: Revise Academic Support Describe any injuries to student, employees, others, or property damage: till?; 5931} Fla/(Inky 4,355? - Communication Documentation Patent] guardian must be contacted on day of incident. Na met-of pe contacted: Relationship; More, 1 Date: 7 Methodi Til?By: Describe attempi?slto notify the-parentfguardiah iticotitact can not be made on day of incident: Mail (postmarked within 3 days ofthe occurrente) ll Writtengdo'cum entatio'n must he sent to pare nt/ guardian wit him 3 school dais. I . .. Emailupon Written request pair uardian CI Fax upon written request of parentfgua rdian El Hand Delivered in Person 1 Name of parent/guardian the documentation was sent to: M1. g4"ICedCich:picie .g 1' Community School District physicai Restraint and Seciusion Documentation "Marin Confinement of a student in a room from which the student?s egress is restricted $3:th gowns 2533(2) Student. Date of Incident: School. Grade: IEP: Seclusion - Location: Time In: Time Out: Duration: fij. i? if Student Entered Seclusion bv: Physical Transport Safer moving an individual who is beginning to regain control ClWaiked on their own CIOther (Please Describe): Ecru Transport Interim Control . Time Started: Time Ended: Duration: NCI Physical Restraint CICPI Team Control Time Started: Time Ended: Duration: Used to manage individuals who have (:(Cpl Children?s Comm; become dangerous to themselves or others; . used a? lastresort Other (Please Describe). Staff Members Involved: Before Seclusion/Restraint/TranSport (Check Implemented Items) Setting Events Antecedents Student Behavior Staff Response (Events i_nd irectlv im pa cting the behavioral outcome) (Immediate triggers or predictors of the problem behavior.) immediateiy after Antecedent (Cairn Nonjudgmental actions taken to de-escaiate student behavior and avoid seclusion/restraint) mwiven Verbal Direction DCoanict Prior to School EIPresented w/Social Interaction _l:l Location: IE'Anxious (Describe): E?Gave Redirections DSubject: '?siven Work/Activity cf?; bagging aha?f? Efoered Coping Skill)l break, etc. DActivity: Unexpected Change in Routine Cleg?w QPianned Ignore L.) QGave Time to De?escaiate ClCoanict at School EIToid ?No? by: Encouragement/Praise DChange in Routine Denied Access to Item/Activity Cl Defensive (Describe): El Positive Reminders (When/Then) ClDifficuity in Previous Class Preferred Activity Removed DGave Support DHomework Not Done EITeacher Attending to Others DAssignment Modi?ed DMissed Medication EIGiven Correction/Redirection DChanged Instruction DSubstitute Teacher ElPeopIe too Close I: Used Proxemics/Kinesics DAcademic Failure El Loud Noises/Room Behavior Leading to ClPara Verbal Communication El Hunger Bright Lights Seclusion/ Restraint gamed CPI Supportive Stance DFatigue EIWith a Specific Peer(s) CIVerbal Aggression Enlisual Cues Used Dillness aWork too Hard/Easy DVerbai Threats/intimidation EIModeled Expected Behavior ?ange Group Instruction Work Repetitive/too Long EJthsicaI Threats/Intimidation CIEmpathic Listening DSmaii Group Instruction Elindependent Work [ZIPhysicaI Aggression/Self Reeve Choices Dlndividual instruction Pain Whvsical Aggression/Others EITime Out (Where): EIUnstructured Time ElSitting For Extended Time Dthsical Aggression/Property EILoss of Privilege/Reward EIApproached By Aduit UWeapon Possession Limits (1st ?he'n, When/Then) EIScheduled Non Preferred Activity EElopement Mailed for Team Support I: Waiting El Other (Please Describe): Remove Other Students DTransition to: from: DOther: El Additional Comments: Possible Function/Purpose of Behavior Student may have been trying to gain: Student may have been trying to a void: USocial Interaction EIPeer or Adult DSocial Interaction ElPeer or DAduIt DSensory Stimulation IZISensorv Stimulation DPreferred Activity! Item Won-Preferred Activity/Task car Wattage I a I . Seciasten Documentation - Student: I Bate 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 at a minimum of every two minutes. NGTE: For restraints and seclusions to exceed beyond each class period or every 60 minutes, obtain signature of administration indicating authorization. Time Observed Actions of the Student gating SecloSIon/Restramt Stat-i Response to Goseroed Actions EELS - ?2 r? Administrator Signature (to go beyond every 60 minutes or each class period) Time i ?edcar?capicie Student: 'Cgmmu?iiwsrcimo?bmm thsicai Restraint: arid Seciusion Documentation Date of incident: Student Actions and Debrieiing Atter incident Staff Actions After incident Student Actions Student Debriefing EISupportive/ Undivided Attention DCrying E?Processing Activities (Describe) El Empathic Listening [:lCalm AVE: (3 (0.15.1?3?38' @Used Restatements for Understanding/Ciarification CIRationai ?Al re?: @Gave Wait Time CITaikative I (fifrsl?fiielw [ET?Allowed for Siience Went Efoping Skill Activity (Describe) montinued to Monitor [:lAccepting Support 39%- ks-t/ DAssisted Student with Work Completion DTired i CIWalked Student to Class [:lSieeping EiSupported Student in Class [:lFoliowing Directions Expected Behavior Activity EIAssisted Student with Task Completion (cleaning up, etc.) CIReturned to Class (Describe) ElCommunicated with Caregiver Name: Cl Visited Nurse [:IFoliowed Through on Prior Expectation DApoiogized for Actions E?ssisted with Processing Activity CICommunicated with Caregiver Name: Cl Accepted Responsibility for Actions (cleans up, etc.) DMaintained Awareness ofProxemiCS, Kinesics, 8i. Para verbal Communication DPacing EAssisted with Coping Skill Activity [:lWorked independently EISwitched Staff Roles DRestroom/Bodily Needs Cl Other (Describe) ClAssisted with Expected Behavior Activity C) Other (Describe) [:IOther Staff Debriefing and Future Approaches to Decrease or Eliminate Behavior from Reoccurring: etc.) Date: CITeam Meeting (IEP, Learning Supports, ElParent Meeting Date: ABC Data Cl Review ElRevise Social Skill instruction DComplete Competing Pathways Chart CIConduct Functional Behavioral Assessment EIReview Replacement Behavior EIReview Positive Behavior Supports CIConsider Student Review IEP Goals Data EIAccess Community Supports emevise Academic Support CI Contact AEA Supports [:lOther: Describe any injuries to student, employees, others, or property damage: Communication Documentation Parent/guardian must be contacted on day of incident. Name of person co ntactei. Date: Time: Relationship; Method: Describe attempts to notify the parent/guardian if contact cannot be made on day of incident: I By: Date sent' Written documentation must be sent to parent/guardian within 3 schooLdays. Sent by: Eric/la? (postmarked within 3 days of the occurrence) El Email upon Written requesc u: parent/guardian El Hand Delivered In Person El Fax upon'written request of parent/guardian rName of parent/guardian the documentation was sent to; . more? i a Peder Rapids . 3 Community School District Physical Restraint and Seeiusion Documentationo Student: Date of incident: School: i Seciusion Location: Time in: Tim_e_0ut: Duration: Confinement ofa student in a room from fog-Evy 5 3 '53 which the student?s egress is restricted Student Entered Seciusion by: DWalked on their own Interim Control Physical Transport Safely moving an individual who is beginning to regain control DOther (Please Describe): Transport Time Started: Time Ended: Duration: Physical Restraint Team Control Time Started: Time Ended: Duration: Used to manage individuals who have children's Contra; become dangerous to themselves or others; . used as a last resort (Please Descnbe)? Staff Members involved: Before Seclusion/Restraint/Transport (Check implemented items) Setting Events Antecedents Student Behavior Staff Response (Events i_ndirectlv impacting the (immediate triggers'or predictors of (Cairn 8t Nonjudgmentai actions taken to immediately after de-escaiate student behavior and avoid behavioral outcome) the problem behavior.) Antecedent seclusion?estraint) El Location: EGiven Verbal Direction DAnxious (Describe): Gave Redirections QSubject: (time)ij Given Workactivity IZIOffered Coping Skill/ break, etc. DActivity: ?EUnexpected Change in Routine Wlanned ignore EiConfiict Prior to School El Presented w/Sociai interaction EGave Time to De-escalate ?Conflict at School ?No? by: Encouragement/Praise EChange in Routine El Denied Access to item/Activity ??befensive (Describe): IZIPositive Reminders (When/T hen) CIDifficulty in Previous Class Preferred Activity Removed ElGave Support Hid/i no bide, CiHomework Not D'one DTeacher Attending to Others ClAssignment Modified Hit/Ni? (WALL CI Missed Medication Given Correction/Redirection DChanged instruction CISubstitute Teacher DPeopie too Close Used Proxemics/Kinesics ElAcademic Failure Loud Noises/Room Behavior Leading to Verbal Communication ClHunger ClBright Lights Seclusion/ Restraint [QUsed Supportive Stance ElFatigue EIWith a Specific Peer(s) Verbal Aggression EVisual Cues Used Elliiness DWork too Hard/Easy IZIVerbal Threats/intimidation leodeled Expected Behavior EiLarge Group instruction Elerk Repetitive/too Long Physical Threats/i ntimidation El Empathic Listen inn EiSmali Group Instruction Elindependent Work Aggression/Self E?ave Choices - ?ndividuai instruction Elin Pain Why/sisal Aggression/Others EITlme Out (Where)?? EiUnstructured Time DSitting For Extended Time ?EPhysical Aggression/ Property ElLoss of Privilege/Rewa rd EJApproached By Aduit DWeapon Possession Limits (151 fThen, When/Then) E?Scheduied Non Preferred Activity ClElopement Btalled for Team Support [ZiWaiting Homer (Please Describe): Remove Other Students DTransition to: from: (a Bother: EJOther: El Additional Comments: Possible Function/Purpose of Behavior Student may have been trying to gain: Student may have been trying to avoid: CISocial Interaction Cl Peer or Cl Adult ElSociai Interaction ElPeer or ElAduit EISensory Stimulation EiSensory Stimulation CIPreferred Activity/ item Won?Preferred Activity/Task . Qederideed?. ., . i A as Communrtri?bheem?m?t ttestresnt end Seeiassan I Student: 1 Date attneident: During Record actions of the student and staff during physical restraint, transport, and/or seclusion. Students must be monitored constantly and documentation completed at a minimum of every two minutes. NOTE: For restraints and seclusions to exceed beyond each class period or every 60 minutes, obtain signature of administration indicating authorizationTime Ghserued Actions of the Student During Seclusion/Restraint Staff Response ta Ola-served dctlens Ingiags i . Administrator Signature (to go beyond every 60 minutes or each class period) Time Date . . - 1 (3?6er Rapids up. C6m131uhiWScl1OQlDist?Ct I Student: tysical Resttaint and Seclusion Documentation Date of Incident: Student Actions and Dehriefing After incident Staff Actions After incident Student Actions Student Debriefing @Supportive/ Undivided Attention ?ltering Processing Activities mammal QEmpathic Listening DCalm : Used Restatements for Understanding/Clarification CIRationai ElGave Wait Time Walkative mllowed for Silence IIJSilent DCoping Skill Activity (Describe) Montinued to Monitor chepting Support EIAssisted Student with Work Completion DTired DWalked Student to Class DSleeping DSupported Student in Class ?tollowing Directions El Expected Behavior Activity @Assisted Student with Task Completion (cleaning up, etc.) DReturned to Class (Describe) DCommunicated with Caregiver Name: Visited Nurse Mollowed Through on Prior Expectation DApologized for Actions UAssisted with Processing Activity DCommunicated with Caregiver Name: mccepted Responsibility for Actions (cleans up, etc.) DMaintained Awareness of Proxemics, Kinesics, 8: Para verbal Communication ClPacing DAssisted with Coping Skill Activity ClWorked Independently {Dblc?f??iji?ixi ElSwitched Staff Roles DRestroom/Bodiiy Needs DOther (Describe) with Expected Behavior Activity ClOther (Describe) [:lOther Staff Debriefing and Future Approaches to Decrease or Eliminate Behavior from Reoccurring: etc.) Date: DTeam Meeting (IEP, Learning Supports, DParent Meeting Date: EICollect ABC Data [:lReview FBAIBIP wavise Social Skill instruction ElCompiete Competing Pathways Chart [:lConduct Functional Behavioral Assessment El Review Replacement Behavior DReview Positive Behavior Supports DConsider Student IIJReview Goals 8; Data DAccess Community Supports Revise Academic Support DContact AEA Supports DOther: Describe any injuries to student, employees, others, or property damage: Communication Documentation N'a me of person contacted:_ Date: Parent/guardian must be contacted on dam of. incident. Time: Describe attempts to notify the parent/guardian if contact cannot be inade on day of incident: Relationship: Method: Him/(g, 'By: Written documentation must be sent to parent/guardian within 3 school days. Date sent: Sent by: E?Mail (postmarked within 3 days of the occurrence) El Email Upon written request of parent/guardian Hand Delivered In Person El Fax upon'written request of parent/guardian Name of parent/guardian the documentation was sent to: - "o 44? Qedor?rapids Restraint and Seciusion Documentation Confinement of a student in a room from which the student?s egress is restricted QC) Ci. i Student; Date oflncident: School: Grade: 1- IEP, Seciusion - Location: Time In: Time Out: Duration: 8 in?: i n. Student Entered Seclusion by: DWalked on their own ELCPI Transport DCPI interim Control Physical Transport Safely moving an Bether (please Describe): of?! L.) Cr. 5 2 Win.) individual who is beginning to regain control . . I . Time Started: Time Ended: Duration: MCI Physical Restraint - CICPI Team Control Time Started: Time Ended: Duration: Used to manage individuals who have Dcp; Chudrenrs Control become dangerous to themselves or others; . . used asa lastresm El Other (Please Describe). Staff Members Invoived: Before Seclusioo/Restraint/Transport (Check Implemented Items) Setting Events Antecedents Student Behavior Staff Response (Events l_ndirectly impacting the (Immediate triggers or predictors of Immediately after {Calm Er Nonjudgmentai actions taken to de-escaiate student behavior and avoid be havloral outcome) the problem behavior.) Antecedent SECIUSion/restraint) Eliocation: "(?16in Verbal Direction ClAnxious (Describe): ??ave Red irections object: ?given Work/Activity lamb?, i?aaql IZIOffered Coping Skili/ break, etc. DActivity: DUnexpected Change in Routine Wlanned Ignore ClConflict Prior to School CIPresented w/Social Interaction CIGave Time to De-escalate ElConfiict at School ?No? by: EIGave Encouragement/Praise in Routine DDenied Access to Item/Activity ClDefensive (Describe): Epositive Reminders (When/Then) ElDifficulty in Previous Class CI Preferred Activity Removed E?ave Support CIHomework Not Done ClTeacher Attending to Others DAssignment Modi?ed ElMissed Medication ElGiven Correction/Redirection DChanged Instruction ElSubstitute Teacher El Peepie too Ciose Mysed Proxemics/Kinesics Failure DLoud Noises/Room Behavior Leading to Verbal Communication Hunger Bright Lights Seclusion/Restraint 'SJJsed CPI Supportive Stance Fatigue DWith a Specific Peer(s) Werbal Aggression Cues Used CIWork too HardXEasy ?yerbal Threats/intimidation IZIModeIed Expected Behavior Large Group Instruction DWork Repetitive/too Long Threats/Intimidation Empathic Listening Group Instruction Clindependent Work Physical Aggression/Self CI Gave Choices Elindividual instruction Din Pain Eighysical Aggression/Others EJJime Out (Where): CIUnstructured Time DSitting For Extended Time Whysical Aggression/PrOperty Loss of Privilege/Reward UApproached By Adult DWeapon Possession DSet Limits [1st fThen, When/T hen) DScheduIed Non Preferred Activity for Team Support EIWaiting f. .IZIOther (Please Describe): IZIRemove Other Students ETransition to:% from: 9A 463 gig, DOther: ClOther: El Additional Comments: Possible Function/ Purpose of Behavior Student may have been trying to gain: Student may have been trying to avoid: DSocial Interaction DPeer or Cl Adult DSociaI Interaction or UAduIt DSensory Stimulation IZISensory Stimuiation Cl Preferred Activity/ Item Egon-Preferred Activity/Task - . ?t Wer?eeids . . . . a a a a thsseai Restraint and Seeiesmn ELI-acumentatren Student: I Bate at incident: I During Record actions of the student and staff during physicai restraint, transport, and/or seclusion. Students must be monitored constantiy and documentation completed at a minimum of every two minutes. NOTE: For restraints and seclusians to exceed beyond each class period or every 60 minutes, obtain signature of administration indicating authorizationObserve-d Actions of the Student unng Seclasmn/Restraint Staff Response to Observed Acttens {$2315 ?43 bk 0:0 Comma. a: Vet Administrator Signature (tn ga nevend every 60 minutes or each ciass period) Time ?ate i Cedar Rapids Physical Restraint and Seciusion Documentation I Student: I Date of Incident: Student Actions and Debriefing After Incident Staff Actions After incident Student Actions Student Debriefing DSupportive/ Undivided Attention Waring Efrocessing Activities (Describe) EIEmpathic Listening I Ft EUsed Restatements for Understanding/Clarification Wational ELGave Wait Time Blkative ??gllowed for Silence DSilent DCoping Skill Activity (Describe) DContinued to Monitor DAccepting Support EIAssisted Student with Work Completion CITired KWalked Student to Class DSleeping ?supported Student in Class CIFoiiowing Directions EiExpected Behavior Activity DAssisted Student with Task Completion (cleaning up, etc.) DReturned to Class (Describe) Lg w; moi (room DCommunicated with Caregiver Name: Cl Visited Nurse DFollowed Through on Prior Expectation ClApologized for Actions Seesaw twist/c Fmr?WE??w DAssisted with Processing Activity DCommunicated with Caregiver Name: Actions (cleans up, etc.) El Accepted Responsibility for ?Maintained Awareness of Proxemics, Kinesics, 84 Para verbal Communication DPacing DAssisted with Coping Skill Activity DWorked independently EIvaitched Staff Roles Cl Restroom/Bodily Needs El Other (Describe) ?Assisted with Expected Behavior Activity DOther (Describe) DOther Staff Debriefing and Future Approaches to Decrease or Eliminate Behavior from Reoccurring: EITeam Meeting Learning Supports, etc.) Date: IZIParent Meeting Date: : Collect ABC Data CIReview CIRevise Social Skill Instruction [JComplete Competing Pathways Chart DConduct Functional Behavioral Assessment CIReview Replacement Behavior DReview Positive Behavior Supports ~E?onsider Student El Review Goals Data IZIAccess Community Supports Cl Revise Academic Support EIContact AEA Supports Describe any injuries to student, employees, others, or property damage: Communication Documentation Parent/guardian must be contacted on day of incident. Name of person contacted Date: I lime: Relationship: Marker Method: Pkg-mg I 'By: Describe attempts to notify the parent/guardian if contact (3 annot be made on day of incident: +Yieci no angular who deicemwt) get Written documentation must be sent to parent/guardian within 3 school days. Date sent: Sent by: ?Mail (postmarked within 3 days of the occurrence) El Email upon written request of pa rent/guardian El Hand Delivered In Person El Fax upon'written request of pa rent/gua rdian I Name of pare nt/guardian the documentation was sent to: . ?42343.3! El?n?. - ?i Restraint and Beclusion Documentation (. Student: Date of incident: School: Grade: Seclusion - Location: Time in: Time Out: Duration: Confinement of a student in a room from ?3 lg i i? 23 5 her} which the student?s egress is restricted i2; 03 12-: ?65) it?) he} in Student Entered Seciusion by: thsical Transport Safely moving an individual who is beginning to regain control Walked on their own interim Control ClOther (Please Describe): TranspOrt Time Ended: Time Ended: Duration: Duration: Time Started: Time Started: Physical Restraint Used to manage individuals who have become dangerous to themseives or others; used as a last resort Staff Members Involved: DCPI Team Control Chiidren?s Control Cl Other (Please Describe): Before Seclusion/Bestrairut/Transport (Check impiemented items) Setting Events Antecedents Student Behavior (Events indirectiv impacting the (immediate triggers or predictors of immediatew after behavioral outcome) the problem behavior.) Antecedent Staff Response (Calm 81 Nonjudgmental actions taken to de~escalate student behavior and avoid seclusionfrestraint) ?Gave Redirections Eloffered Coping Skiil/ break, etc. ?Planned ignore Wave Time to De?escalate ?Gave Encouragement/Praise ?positive Reminders (When/Then) KGave Support Wssignment Modified EIChanged instruction u- ?given Verbal Direction Cl Given Work/Activity UUnexpected Change in Routine DPresented w/Social Interaction CITold ?No? by: CiDenied Access to Item/Activity Cl Preferred Activity Removed EJeacher Attending to Others EiGiven Correction/Redirection ELocation: ?Subject: (?rain DActivity: [JConflict Prior to School EJConflict at School EJChange in Routine Cl Difficulty in Previous Class EJHomework Not Done DMissed Medication DAnxious (Describe): at .J El Defensive (Describe): DSubstitute Teacher Pepple too Close Hysed Proxemics/Kinesics [:lAcademic Failure ElLoud Noiseszoom Behavior Leading to DPara Verbal Communication DHunger [Bright Lights Seclusion/Restraint Hysed Supportive Stance Fatigue ?With a Specific Peer(s) Am, DVerbai Aggression EIVisual Cues Used [Silliness DWork too Hard/Easy Threats/intimidation DModeled Expected Behavior EJLarge Group ction DWork Repetitiveftoo Long Uthsicai Threats/intimidation UEmpathic Listening EJSmali Group Instruction Ellndependent Work Aggression/Self ElGave Choices IIJIndividual instruction Elln Pain Whysicai Aggression/Others Emma Out El Unstructured Time DSitting For Extended Time Aggression/Property EILoss of Privilege/Reward DApproached By Adult DWeapon Possession DSet Limits fThen, When/Then) UScheduied Non Preferred Activity DEiopement DCalled for Team Support DWaiting mower (Please Describe): Remove Other Students EITransition to: from: MA Loiimg?m? EEOther: DOther: Jam El Additional CommentsVila" dear Graven. burl girl:- Lege?er?. Ti?? ed up orkinm in! one" ?he 0Lth dyer 'i?lm. School lav?iv was? treating) Wis like a 3m. Possible Function/Purpose of Behavior Student may have been trying to gai_n: Student may have been trying to avoid: ?ocial interaction Wear or KAduit ElSocial Interaction DPeer or EIAdult DSensory Stimulation DSensory Stimulation El Preferred Activity! item DNon-Preferred Activity/Task I ?edor?otoids ?C?mwr'itv?dm'm?mt Reettaiot and Seotueion Doeumeotetton gimme; Qate oftncident: During Record actions of the student and staff during physieai restraint, transport, and/or seclusion. Students must be monitored constantly and documentation completed at a minimum of every two minutes. MQTE: For restraints and seclusions to exceed beyond each class period or every 60 minutes, obtain signature of administration indicating authorization. St Observed Actions of the Student ring Seciusion/Restraint Staff Response to Doseryed Actio Administrator Signature (to go beyond every 60 minutes or each ciass period) Time Date ?Comh?uhtty SchooiDiscriet Pity?cei Bestreiet arid Se-ciusieri Decunserttetio-n I Student: I Date of incident: Student Actions and Debriefing After Incident Staff Actions After incident Student Actions Student Debrie?ng ESupportive/ Undivided Attention DCrying El Processing Activities (Describe) ?impathic Listening DCaim ?Used Restatements for Understandirig/Clarification ERationai ?Gave Wait Time ETaikative QAllowed for Siience DSilent UCoping Skili Activity (Describe) ?Continued to Monitor Ep?iccepting Support EAssisted Student with Work Completion DTired DWalked Student to Class [:lSleeping mupported Student in Class EFollowing Directions DExpected Behavior Activity mssisted Student with Task Completion (cleaning up, etc.) Weturned to Class (Describe) UCommunicated with Caregiver Name: Cl Visited Nurse ??oilowed Through on Prior Expectation {:JApologized for Actions DAssisted with Processing Activity DCommunicated with Caregiver Name: Actions (cleans up, etc.) El Accepted Responsibility for Maintained Awareness of Proxemics, Kinesics, Para verbal Communication UPacing DAssisted with Coping Skill Activity 'EWorked Independentiyw Que?. own we. USwitched Staff Roles DRestroom/Bodiiy Needs DOther (Describe) UAssisted with Expected Behavior Activity EIOther (Describe) DOther Staff Debriefing and Future Approaches to Decrease or Eliminate Behavior from Reoccurring: DTeam Meeting Learning Supports, etc.) Date: UParent Meeting Date: UColiect ABC Data Cl Review URevise Social Skill Instruction DComplete Competing Pathways Chart DConduct Functional Behaviorai Assessment DReview Repiacement Behavior Review Positive Behavior Supports Consider Student UReview Goals Data UAccess Community Supports El Revise Academic Support Contact AEA Supports Other: Describe any injuries to student, employees, others, or property damage: Communication Documentation Parent/guardian must be contacted on day of incident. Name of person contacted: Reiationship: Moi-E,? Date: I Time: Method: Phem I 'By: Describe'a-tte'mpts to notify the parent/guardian if contact cannot be made on day of incident: Written documentation must be sent to parent/guardian within 3 school days. Date sent: Sent by: Mail (postmarked within 3 days of the occurrence) Cl Email upon written request of parent/guardian CI Hand Delivered in Person 'l:l Fax upon'written request of parent/guardian :3 I Name of pa rent/guardian the documentation was sent to: ?363er Rapids 'Cnmmur?rityS?ohool[District I Studen'. Grade: Physieai Restraint and Seciusion Documentation i Date of Incident: ?m FSeciusion Confinement of a student in a room from - which the stude nt?s egress is restricted Location: Time In: 2 Evil- Time Out: 30/ Duration: Ti Student Entered Seciusion by: NCI Physical Transport Safely moving an individual who is beginning to regain controI DWatike'd on their own DOther (Please Describe): CPI Transport 2:671) ,2,qu DCPI Interim Control Time Started: Time Ended: Duration: NCE Physical Restraint - EICPI Team Control Time Started: Time Ended: Duration: Used to manage individuals who have children?s Centre) become dangerous to themselves or others; . . used as a last resort El Other (Please Describe). Staff Members Involved: Before Seclusion/Bestraint/Transport (Check Implemented Items) Setting Events Antecedents Student Behavior Staff Response (Events i_ndirectly impacting the behavioral outcome) (immediate triggers or predictors of the probiem behavior.) immediately after Antecedent (Calm El Nonjudgmental actions taken to de?escalate student behavior and avoid seclusion/restraint) ?EILocationy: A DGiven Verbal Direction (Describe): Gave Redirections ?Subject: Wye)"; wGiven Work/Activity DOffered C0ping break, etc. IZIActivity: UUnexpected Change in Rautine Ignore DCoanict Prior to Schooi EiPresented w/Social Interaction EiGave Time to De?escalate DConfiict at School ?No? by: lide EiGave Encouragement/Praise DChange in Routine CIDenied Access to Item/Activity El Defensive (Describe): DPositive Reminders (When/Then) CIDifficulty in Previous Class Preferred Activity Removed EiGave Support EIHomework Not Done UTeacher Attending to Others DAssignment Modi?ed DMissed Medication )3 Given Correction/Redirection EiChanged instruction DSubstitute Teacher DPeople too Close Ci Used Proxemics/Kinesics CIAcadernic Failure EiLoud Noises/Room Behavior Leading to EiPara Verbal Communication DHunger CIBright Lights Seciusion/ Restraint EiUsed CPI Supportive Stance CiFatigue DWith a Speci?c Peer(s) EiVerbai Aggression EiVisuai Cues Used Cililness too Hard/Easy Threats/Intimidation DModeled Expected Behavior CiLarge Group Instruction Repetitive/too Long Threats/Intimidation EiEmpathic Listening CiSmaIi Group Instruction Ellndependent Work Physicai Aggression/Self EiGave Choices Eilndi-vidual Instruction Ciln Pain Whysicai Aggression/Others EiTime Out (Where): DUnstructured Time DSitting For Extended Time Whysical Aggression/ Property EiLoss of Privilege/Reward DAppro ached By Aduit DWeapon Possession ?Set Limits (1=l fThen, When/Then) DSchedUIed Non Preferred Activity EiCalled for Team Support CiWaiting EiOther (Please Describe): DRemove Other Students IZITransition to: I from: Opp/1H9) (VA i IZIOther: DOther: Additional Comments: Possible Function/Purpose of Behavior Student may have been trying to gain: Student may have been trying to avoid: DSocial Interaction DPeer or Adult EISociaI interaction Peer or DAduit CISensory Stimtiiation DSensory Stimuiation Cl Preferred Activity/Item ?Non-Preferred Activity/Task . . ,c Restraint and Seeiasion 'ocamentatioe I I I Bate ofincident: . I ?aring Record actions of the student and staff during physical restraint transport, and/or seclusion. Students must be monitored constantly and documentation completed at a minimum of every two minutes. NGTE: For restraints and seclusions to exceed beyond each class period or every 60 minutes, obtain signature of administration indicating authorization. I Staff initials Time Observed Actions of the Student Daring Seclusion/Restraint Staff Response to Observed Actions 1 ?5 Administrator Signature (to go beyond every 60 minutes or each class period) Time Date I mgr-feeder Rapids COm?ta'iLih'rtv grime; District: 1 Student: Restraint and Seciusion Documentation I Date of incident: Student Actions and Deprieting After incident Staff Actions After incident Student Actions Student Debriefing DSupportive/ Undivided Attention DCrying L- Processing Activit esgoescribe) Listening DCalm 5365,; i I l'n?gm: @Wegtatements for Understanding/Clarification masons: I i attempting.? Time ?aikative IZIAllowed for Silence ClSilent CICoping Skill Activity (Describe) DContinued to Monitor DAccepting Support Mssisted Student with Work Completion CITired pWalked Student to Class DSleeping ESupported Student in Class ?D?ollowing Directions DExpected Behavior Activity Student with Task Completion (cleaning up, etc.) M?eturned to Class (Describe) with Caregiver Name: El visited Nurse QFollowed Through on Prior Expectation DApologized for Actions Mssisted with Processing Activity CICommunicated with Caregiver Name: Accepted Responsibility for Actions (cleans up, etc.) i I I I DMamtamed Awareness of Proxemlcs, KlneSIcs, Para verbal Communication CIPacing DAssisted with Coping Skill Activity DWorked independently Staff Roles DRestroom/Bodiiy Needs CIOther (Describe) ClAssisted with Expected Behavior Activity (Describe) DOther Staff Debriefing and Future Approaches to Decrease or Eliminate Behavior from Reoccurring: - CITeam Meeting Learning Supports, etc.) Date: DParent Meeting Date: DCollect ABC Data Review CIRevise Social Skill Instruction DComplete Competing Pathways Chart Conduct Functional Behavioral Assessment CIReview Replacement Behavior CIReview Positive Behavior Supports ,E?Consider Student CIReview Goals 8: Data CIAccess Community Supports MRevise Academic Support AEA Supports Other: Describe any injuries to student, employees, others, or property damage: Communication Documentation Parent/guardian must be contacted on clan of incident. . Relationshipmw.f j. Methodfm them annot be made on day of incident: Name of person contacted: Date: 5 Describe attempts to notify the parent/guardian ir contact IBF: Written documentation must be sent to parentlguardian within 3 school dang. Date sent: Sent by: ail (postmarked within 3 days of the occurrence) Email upon Written request or parenugoamuu . )0 Hand Delivered In Person if. Fax upon-written request of parent/guardian Name of parent/guardian the documentation was sent to. - Mall/x ??gkt? Cedar Rapids Restraint and Seciuston Documentation Date oflncident: School: Grad; I i Seclusion Location: Time In: Time Out: Duration: Confinement ofastudentinaroom from a" - .. i which the student?s egress is restricted 8/ DWalked on their own CICPI interim Control ElOther (Please Describe): Student Entered Seclusion by: HG Physical Transport Safely moving an individual who is beginning to regain control 'glg?Pl Transport Time Started: Time Ended: Duration: Physical Restraint Time Started: Time Ended: Duration: Used to manage individuals who have become dangerous to themselves or others; Team Control DCPI Children?s Control El Other (Please Describe): used as a last resort Staff Members involver Before Seclusion/Bestrairat/Transport (Check Implemented Items) Setting Events (Events indirectly impacting the behavioral outcome) Antecedents (immediate triggers or predictors of the problem behavior.) Student Behavior Immediately after Antecedent Staff Response (Cairn 8t Nonjudgmental actions taken to de-escalate student behavior and avoid seclusion/restraint) Location: DGiven Verbai Direction CIAnxious (Describe): QGave Redirections ESubject: El Given Work/Activity tRottered Coping Skill/ break, etc. CIActivity: EIUnexpectecl Change in Routine Planned ignore DConfiict Prior to School ClPresented Interaction EIGave Time to De-escalate El Conflict at School ?No? by: @Gave Encouragement/Praise EIChange in Routine Cl Denied Access to item/Activity EIDefensive (Describe): \EPositive Reminders (When/Then) El Difficulty in Previous Class Preferred Activity Removed EIGave Support EIHomework Not D'one El Teacher Attending to Others [:lAssignment Modified EIMissed Medication EIGiven Correction/Redirection EIChanged Instruction EISubstitute Teacher El People too Close El Used Proxemics/Kinesics ElAcademic Failure El Loud Noises/Room Behavior Leading to El Para Verbal Communication Hunger Bright Lights Seclusion/ Restraint Used CPI Supportive Stance Fatigue EIWith a Specific Peer(s) EIVerbal Aggression ?EIVisual Cues Used El illness EIWork too Hard/Easy DVerbai Threats/intimidation DModeled Expected Behavior [IILarge Group instruction EIWork Repetitive/too Long Threats/intimidation ?Empathic Listening DSmall Group Instruction Independent Work Aggression/Self Gave Choices Clindividual Instruction Elln Pain CI'Iime Out (Where): Cl Unstructured Time CISitting For Extended Time Physical Aggression/Property El Loss of Privilege/ Reward DApproached By Adult DWeapon Possession Limits (1St IThen, When/T hen) UScheduled Non Preferred Activity EIElopement ?ECalled for Team Support DWaiting (Please Describe): 'IZIRemove Other Students ClTransition to: from: EIOther: EIOther: El Additional Comments: Possible Function/ Purpose of Behavior Student may have been trying to gain: Student may have been trying to M: CISocial Interaction EIPeer or Adult EISociai interaction DPeer or EIAdult DSensory Stimulation nCISensory Stimulation El Preferred Activity/ Item Activity/Task EEK- ?tae?i?dd?t??i?idg . .. - . - -- Communitygoheolmxemot otwetmt Eegtt?amt and decimated?esameetetroo Studeh? Sate oftecldent: {luring Record actions of the student and staff during physical restraint, transport, and/or seclusion. Students must be monitored constantly and documentation completed at a minimum of every two minutes. MGTE: For restraints and seclusions to exceed beyond each class period or every 60 minutes, obtain signature of administration indicating authorizationTime Qbserved Actions of the Student During Secluded/Restraint Staff Response to Ghseryed Actions mam? 1 Q6 Administrator digneture (to go beyond every 60 minutes or each class period) Time Date (Seer Reaping fan.- .: rriw?n lulu-0&1; :x Studr int and Seciusion Documentation :l Date of incident? I. Student Actions and Elie-briefing After Incident Staff Actions After incident Student Actions Student Debriefing DSupportiveI Undivided Attention DCrying DProcessing Activities (Describe) Empathic Listening EICalm EIUsed Restatements for Understanding/Garificatlon ?DRationai DGave Wait Time ETaikative ClAIlowed for Silence I DSilent ClCoping Skili Activity (Describe) CIContinued to Monitor DAccepting Support DAssisted Student with Work Completion EITired EIWaiked Student to Ciass Elsieeping Student in Class DFoliowing Directions EIExpected Behavior Activity ElAssisted Student with Task Completion (cleaning up, etc.) CIReturned to Class (Describe) DCommunicated with Caregiver Name: CI Visited Nurse DFollowed Through on Prior Expectation DApologized for Actions ElAssisted with Processing ACtivity DCommunicated with Caregiver Name: CI Accepted Responsibility for Actions (cleans up, etc.) El Maintained Awareness of Proxemics, Kinesics, 8; Para verbal Communication DPacing ClAssisted with Coping Skill Activity EIWorked Independently DSwitched Staff Roles DRestroom/Bodily Needs El Other (Describe) DAssisted with Expected Behavior Activity CI Other (Describe) DOther Staff Debriefing and Future Approaches to Decrease or Eliminate Behavior from Reoccurring: etc.) Date: EITeam Meeting (IEP, Learning Supports, El Parent Meeting Date: CICoilect ABC Data Cl Review DRevise Social Skill Instruction ElCompiete Competing Pathways Chart CIConduct Functional Behavioral Assessment DReview Replacement Behavior DReview Positive Behavior Supports CIConsid er Student EIReview Goals Data CIAccess Community Supports El Revise Academic Support CIContact AEA Supports CIOther: - Describe any injuries to student, employees, others, or property damage: 1+ 2x 3471 N05) r5?) vv {Sle?t' 7D 2+2 mm (Li- Sitar?? Communication Documentation Parent/guardian must becontacmd nn day of incident. Name of person contacted: Date: I Time: Relationship: (fl/1 Mamet-.19.? +0 Descrii..- ?News to notify the parent/guardian if contact cannot be made on day of incident: Date sent: Written mag be sent to parent/guardian within 3 school Sent by? El Mail (postmarked within 3 days of the occurrence) El Email upon written request of parent/guardian El Fax upon'written request of parent/guardian ?Hand Delivered in Person I Name of parent/guardian the documentation was sent to: . . Mart-us - .gedertteegtg i . . . 3? gom?m?m" Restraintand Secluston Documentation Waf?e C(usr?qn mag? Student' I Date ofincident: School: Seciusion Location: Time In: Time Out: Duration: Confinement of a student in a room from which the student?s egress is restricted Student Entered Seciusion by: NCI Physical Transport Safely moving an individual who is beginning to regain control DWalked on their own EIOther (Please Describe): DCPI Transport DCPI Interim Control used as a last resort Staff Members involved: become dangerous to themselves or others; I3 Other (Please Describe): Time Started: Time Ended: Duration: MCI Physical Restraint - EICPI Team Control Time Started: Time Ended: Duration: Used to manage individuals who have CPI Chudrenrs Control ;qu HG rt? Before Seclusion/Restraint/Transport (Check Implemented Items) Setting Events (Events indirectly impacting the Antecedents (Immediate triggers or predictors of Student Behavior immediately after Staff Response (Cairn 8t Nonjudgmental actions taken to tie-escalate student behavior and avoid behavrorai outcome) the problem behavror.) Antecedent seclusion/restraint) @Locatior UGiVen Verbal Direction DAnxious (Describe): E??ave Redirections CISubject: CIGiven Work/Activity DOffered Coping Skill/ break, etc. metivityr?i?ay? [gmgg DUnexpected Change in Routine t@ianned Ignore EIConfiict Prior to School Mresented w/Social Interaction [EGave Time to De-escaiate DConflict at School EIToid ?No? by: ElGave Encouragement/Praise DChange in Routine DDenied Access to item/Activity I?EDefensive (Describe): Mositive Reminders (When/Then) EIDifficuity in Previous Class El Preferred Activity Removed ClHomework Not Done EITeacher Attending to Others st: (list?i? cme about EIGave Support DAssignment Modi?ed DMissed Medication DGiven Correction/Redirection home, .ZC?it {on are .2 EIChanged Instruction ClSubstitute Teacher CI People too Close El Used Proxemics/Kinesics CIAcademic Failure ElLoud Noises/Room 7 Behavior Leading to DPara Verbal Communication EIHunger DBright Lights Seclusion/ Restraint Cl Used CPI Supportive Stance EJFatigue DWith a Specific Peer(s) Werbai Aggression [:iVisuaI Cues Used DWork too Hard/Easy ClVerbaI Threats/Intimidation DModeled Expected Behavior Ci Large Group instruction DWork Repetitive/too Long Threats/Intimidation Empathic Listening ClSmall Group instruction EIIndependent Work Aggression/Self DGave Choices Dindividuai instruction Eiin Pain mhysicai Aggression/Others DTime Out (Where): ElUnstructured Time DSitting For Extended Time EPhysical Aggression/Property ElLoss of Privilege/ Reward ElApproached By Adult [:IWeapon Possession mt Limits (15? /Then, When/Then) EIScheduied Non Preferred Activity CIElopement DCalled for Team Support DWaiting EIOther (Please Describe): Ci Remove Other Students ETransition to rom: IZIOther: EIOther: El Additional Comments: Possible Function/Purpose of Behavior Student may have been trying to gain: Student may have been trying to avoid: DSocial Interaction EiPeer or Cl Adult Interaction CI Peer or CIAdult EISensory Stimulation ElSensory Stimulation ElPreferred Activity/Item MowPreferred Activity/Task c?mmuit?3t$3hmi?tm?i Physicai Restraint and Seciasion ?Biocamentation i Student: Date oiineident: i Sur?ng Record actions of the student and staff during physical restraint, transport, and/or seciusion. Students must be monitored constantly and documentation completed at a minimum of every two minutes. more: For restraints and seclusions to exceed beyond each class period or every 60 minutes, obtain signature of administration indicating authorization. Stati initials i Staff Response to Observed Actions 'i?ime Giaserved Actions oi the Student During Seciosion/Restraint a Administrator Signature (to go beyond every 50 minutes or each class period) Time Date I Cedar Rapids C?lt?t?ur?ih! ate?lanai Niki-rips- HL - . Restraint and Seclusion Date of Incident: Student Actions and Debriefing After incident Staff Actions After incident Student Actions Student Debriefing Undivided Attention @?Crying eEj?rocessing Activities (Describe) r:?i?mpathic Listening : Caim f) [(93 SQnged Restatements for Understanding/Ciarification EIRationai @ave Wait Time ElTaIkative I @?lowed for Silence : Si ent DCoping Skill Activity (Describe) Wontinued to Monitor ?chepting Support DAssisted Student with Work Completion DTired EIWaiked Student to Class ClSleeping DSupported Student in Class DFoiiowing Directions @Expected Behavior-Activity L?JAssisted Student with Task Completion (cleaning up, etc.) : Returned to Class lDesmbel'ToOE; (1,469 Air.? EICommunicated with Caregiver Name: e'l??iilisited Nurse iEe?ollowed Through on Prior Expectation EiApoiogized for Actions DAssisted with Processing Activity : Communicated with El Accepted for DMaintained Awareness of Proxemics, Kinesics, 81 Caregiver Name: Actions (cleans up, etc.) Para verbal Communication cing DAssisted with Coping Skill Activity ClWorked Independently EISwitched Staff Roies DRestroom/Bodiiy Needs mther (Describe) {Ga gm); SWessisted with Expected Behavior Activity DOther (Describe) are, (iffy/v I EIOther Staff Debriefing and Future Approaches to Decrease or Eliminate Behavior from Reoccurring: : Team Meeting Learning Supports, L?JParent Meeting Date: IZICollect ABC Data etc.) Date: Cl Review : Revise Social Skill Instruction DCompIete Competing Pathways Chart : Conduct Functional Behavioral Assessment El Review Replacement Behavior Cl Review Positive Behavior Supports ?onsider Student EIReview IEP Goals 8; Data DAccess Community Supports Cl Revise Academic Support : Contact AEA Supports : Other: Describe any injuries to student, employees, others, or property damage: Communication Documentation Parent/guardian be contacted on dnulfkmident. Name of person contacted Relationship: Date: lime: Method: Bh?e Describe attempts to notify the parent/guardian if contact cannot be madewon day of incident: Written be sent to parent/guardian within 3 school days. Date sent: Sent by: ?Q?Mail (postmarked within 3 days of the occurrence) El Email upon written request of parent/guardian El Fax upon'written request of parent/guardian Hand Delivered In Person Name of pa rent/guardian the documentation was sent to: R, . ,Cecicar Rapids (?n?thijr?litv Restraint end Seciusion Doeumeetetion Date of Incident I I i Seclusion? Location: I . Time In: Time?Out: Duration: ?is \i?ii?im, r29 *0 0? We DWalked on their own DCPI Interim Control Homer (Please Describe): QKCJEQZ .3 vet? Student Entered Seciusion by: Physical Transport Safeiv moving an individual who is beginning to regain controi DCPI Transport Time Started:0lj ii?) Time Ended?) Duration: (11,134 NCI Physicei Restraint - DCPI Team Coritrol Time Started: Time Ended: Duration: Used to manage individuals who have (:(Cpl chirdrenrs Control become dangerous to themselves or others; . . used as a last resort Other (Please Describe). Staff Members Involved Before Seclusion/Restreint/Trensport (Check Implemented Items) Setting Events Antecedents Student Behavior Staff Response (Eve i_ndirectlv im pacting the behavioral outcome) (Immediate triggers or predictors of the probiem behavior.) Immediateiv after Antecedent (Caim Si Nonjudgmental actions taken to de-escalate student behavior and avoid ElLocation: EJGiven Verbal Direction EIAnxious (Describe): secjusion/restraint) Egave Redirections DSubject: Given Work/Activity EOffered Coping Skili/ break, etc. EActivity: Mk Ver DUnexpected Change in Routine Wpianned Ignore DConflict Prior to S?rjhoolt IZIPresented w/Social Interaction Ef?ave Time to De-escalate CIConflict at School ?No? by: Gave Encouragement/ Praise DChange in Routine enied Access to Item/Activity 1 El Defensive (Describe): CIPositive Reminders (When/Then) CIDifficuIty in Previous Class Preferred Activity Removed ??gp'm vi (MAC 3 i CIGave Support CIHomework Not Done IZITeacher Attending to Others Qubz I DAssignment Modified CI Missed Medication IZIGiven Correction/Redirection ?m In Dchanged Instruction CISubstitute Teacher IZIPeopie too Close QM Used Proxemics/Kinesics CIAcademic Failure ElLoud NoisesXRoom Behavior Leading to EPara Verbal Communication ClHunger Lights Seclusion/ Restraint Used CPI Supportive Stance ElFatigue DWith a Specific Peeris) Aggression CIVisuai Cues Used CI Illness EJWork too HardZEasy Threats/Intimidation Modeied Expected Behavior CI Large Group Instruction Work Repetitive/too Long Uthsical Threats/intimidation D?Empathic Listening Small Group Instruction Bindependent Work Aggression/Self ElGave Choices Clindividual Instruction Elln Pain CIPhysical Aggression/Others EITime Out (Where): CI Unstructured Time EISitting For Extended Time Whysical Aggression/ Property Loss of Privilege/ Reward DApproached By Aduit Weapon Possession CI Set Limits (151 fThen, When/T hen) EIScheduIed Non Preferred Activity CI Eiopement _C ?Cailied for Team Support DWaiting (Please Describe): MRemove Other Students mTransition to: (?jf??fromz?jmm EIOther: : Other: I CI Gm: Additional Comments: Possible Function/ Purpose of Behavior Student may have been trying to gain: Student may have been trying to avoid: EISociaI interaction CI Peer or Cl Adult EISociaI Interaction CIPeer or DAduIt EISensory Stimulation DSensory Stimulation CINon-Preferred Activity/Task EPreferred Activity/Item git-?ke (1A \ij?Q I I: manta-1?? 1. ?269ng WEN . a a a a i mwn'tygd?m?mmt enema-E aestrarnt and Seeiasron Documentation . 1 ENE: I Bate ofineident' A I Staring Record actions of the student and staff during physical restraint, transport, and/or seclusion. Students must be monitored constantly and documentation completed at a minimum of every two minutes. NGTE: For restraints and seclusions to exceed beyond each ciass period or every 60 minutes, obtain signature of administration indicating authorization'i?i Qbserved Actions of the Student During SecluSion/Restraint Staff Response to absentee Actions "1:535 Administrator Signature (to go beyond every 60 minutes or each class period) Time Date . - ?i [Cedar ?opicie Comimhity?chmoi District Mate P?hvsicai Restraint and Seciusioa Document-retiree JE I Date of incident; Student Actions and Debrieiing After incident Staff Actions After incident Student Actions Student Debriefing )?Supportive/ Undivided Attention gCrying Processing Activities {Describe} El Empathic Listening UCaim ?m E) D?Used Restatements for Understariding/Clarification DRational 1 my}? HGave Wait Time ElTalkative (2ng DAllowed for Silence .QSilent Dc?ping Skill Activity (Describe) Montinued to Monitor ?Accepting Support EIAssisted Student with Work Completion ElTired DWalked Student to Class KEJSieeping [?uppor?ted Student in Class ?following Directions ElExpected Behavior Activity ,E?iAssisted Student with Task Completion [cleaning up, etc.) DReturned to Class (Describe) EICommunicated with Caregiver Name: Cl Visited Nurse Elfoliowed Through on Prior Expectation DApoiogized for Actions I NAssisted with Processing Activity DCommunicated with Caregiver Name: Actions (,cleans up, etc.) Accepted Responsibility for DMaintained Awareness of Proxemics, Kinesics, 8.: Para verbal Communication DPacing C\eem?i DAssisted with Coping Skill Activity 'LCIWorked Independently EISwitched Staff Roles ERestroom/Bodily Needs . . DOther {Describe} ElAssisted with Expected Behavior Activity DOther {Describe} DOther Staff Debriefing and Future Approaches to Decrease or Eliminate Behavior from Reoccurring: DTeam Meeting Learning Supports, etc.) Date: ElParent Meeting Date: Collect ABC Data DReview Social Skili instruction DComplete Competing Pathways Chart ClConduct Functional Behavioral Assessment IZIReview Replacement Behavior : Review Positive Behavior Supports Eigensider Student IZIReview IEP Goals 8: Data EiAccess Community Supports mevise Academic Support ElContact AEA Supports DOther: Describe any injuries to student, employees, others, or property damage: Communication Documentation Parent/guardian must be contactedgn dau?incident. Name of "mm" Date: I Time: Describe attempts to notify the parent7guardian if contact cannot be m'ade on day of incident: Relationship: mm Method: )By: 1 Written documentation Inf-"1t be sent to parent/guardian within 3 school dank Date sent: Sent by: E?Mail (postmarked Within 3 days of the occurrence) Email upon written requesr or parent/guardian Hand Delivered In Person Cl Fax upon'written request of parent/guardian Name of pa rent/gua rdian the documentation was sent to: . . .: I I9. ,e?CederRoelds -1 'Com'mun?rty?ehooi Dietrict I Student: Student Actions and Debriefing After Incident P'hvsica? Restraint and Seciusion Documeetetim Staff Actions After incident I Date of incident: Student Actions Student Debrie?ng K35upportive/ Undivided Attention Q?rying WProcessing Activities (Describe) Empathic Listening UCalm by) DtUsed Restatements for UnderstandEng/Clarification ElRational Kipp mix/{m WGave Wait Time DTalkative (1/qu n? Eng, ya; 1 DAllowed for Silence _C]Siient Scoping Skill Activity (Describe) Montinued to Monitor ?Accepting Support CIAssisted Student with Work Completion CITired DWalked Student to Class .CJSleeping Iggupported Student in Class ?foilowing Directions [3 Expected Behavior Activity N?ssisted Student with Task Completion (cleaning up, etc.) DReturned to Class (DescribEl EICommunicated with Caregiver Name: Cl Visited Nurse Elfollowed Through on Prior Expectation DApologized for Actions RAssisted with Processing Activity DCommunicated with Caregiver Name: EB Accepted Responsibility for Actions (pleans up, etc.) El Maintained Awareness of Proxemics, Kinesics, Para verbal Communication DPacing DAssisted with Coping Skill Activity deemed twigs DWorked independently IZISwitched Staff Roles ?Restroom/Bodiiy Needs . . ElOther (Describe) CIAssisted with Expected Behavior Activity Other {Describe} DOther Staff Debriefing and Future Approaches to Decrease or Eliminate Behavior from Reoccurring: DTeam Meeting Learning Supports, etc.) Date: ElParent Meeting Date: ECOilect ABC Data Cl Review Social Skill Instruction EICornpiete Competing Pathways Chart DConduct Functional Behavioral Assessment El Review Replacement Behavior ElReview Positive Behavior Supports Egonsider Student EIReview IEP Goals Data ElAccess Community Supports Wevise Academic Support ElContact AEA Supports CIOther: Describe any injuries to student, employees, others, or property damage: Communication Documentation Parent/guardian must be contacted _on dau B: incident. Name of ?Mt?hd: Date: I Time: Relationship: mam Method: Describe attempts to notify the pa rent/guardian if contact cannot be m'ade on day of incident: I By: 1 Written documentetin" must be sent to parent/guardian within 3 school days. Date sent: . Wail (postmarked watmn 3 days of the occurrence) Sent by: Email upon written request or parent/guardian El Fax upon'written request of parent/guardian Hand Delivered in Person I Name of pa rent/gua rdian the documentation was sent to: ?with I Iii-Iteer Rapids Cup I ?rst; School District Studer Grade: Seclusion Confinement of a student in a room from which the student?s egress is restricted Student Entered Seciusion by: Physical Transport Safely moving an Date of incident: Location: 'i :hool Physicei Restraint and Seciusion Documentation era/arm ClWalked on their own ClOther (Please Describe): Time in: H1 07 ELM Transport tilt; Time Out: Duration: )1 10min interim Control 0'7 Wilt?) who is beginning to regain control Time Started: Time Ended: Duration: NCE Physical Restraint Team Control Time Started: Time Ended: Duration: Used to manage individuals who have children?s Control become dangerous to themselves or others; . . used as a Eastresm Other (Please Describe). HF Staff Members involved WW HM Before SeclusionIRestraint/Transport (Check implemented Items) Setting Events Antecedents Student Behavior Staff Response (Eve i_ndirectiy im pacting the (immediate triggers or predictors of immediately after (Calm El Nonjudgmental actions taken to de-escalate student behavior and avoid behavioral outcome) the problem behavior.) Antecedent .segusion/restram? ClLocation: DGiven Verbal Direction RAnxious (Describe): I Gave Redirections ubject; - maven Work/Activity Gregji'yj "DOffered Coping Skiil/ break, etc. ETActivity: DUnexpected Change in Routine aggreg- (jg ?d DPlanned ignore DCon?ict Prior to Schooi DPresented wr'Sociai Interaction DGave Time to De-escalate [:lConflict at School EITold ?No? by: he: ceme- 0% ?ElGave Encouragement/Praise DChange in Routine DDenied Access to item/Activity Positive Reminders (When/Then) DDifficuity in Previous Class Preferred Activity Removed "Wedge (Wm-pm ?Gave Support Homework Not Done EITeacher Attending to Others DAssignment Modi?ed DMissed Medication UGiven Correction/Redirection DChangeci instruction DSubstitute Teacher DPeople too Ciose Cl Used Proxemics/Kinesics (Academic Failure El Loud Noises/Room I Behavior Leading to ElPara Verbai Communication El Hunger El Bright Lights Seciusion/Restraint MUsed Supportive Stance ClFatigue With a Speci?c Peer(s) DVerbai Aggression DVisual Cues Used Dillness DWork too Hard/Easy DVerbai Threats/intimidation DModeled Expected Behavior ULarge Group instruction DWork Repetitive/too Long Threats/intimidation El Empathic Listening DSmall Group Instruction Mndependent Work El Physical Aggression/Self Gave Choices Dlndividual instruction Din Pain UPhysical Aggression/Others El Time Out (Where): DUnstructured Time DSitting For Extended Time Aggression/Property El Loss of Privilege/Reward DApproached By Adult DWeapon Possession DSet Limits (151 /Then, When/Then) UScheduled Non Preferred Activity ClEIopement I?DCalled for Team Support [ZIWaiting DOther (Please Describe): g?emwe Other Students DTra nsition to: from: f. A EIOther: DOther: 5 Additional Comments: i_i Possible Function/Purpose of Behavior Student may have been trying to gain: Student may have been trying to avoid: DSociai interaction DPeer or Adult DSociai interaction DPeer or ElAdult USensory Stimulation ClPreferred Activity/ Item Sensory Stimulation on-Preferreci Activity/T85k -- ., a a d? P?esteeiitestrernt and SeeiosionBowenentetson I Stud-en I Date otineident: Boring Record actions of the student and staff during physical restraint, transport, and/or seclusion. Students must be monitored constantly and documentation completed at a minimum of every two minutes. NOTE: For restraints and seclusions to exceed beyond each ciass period or every 60 minutes, obtain signature of administration indicating authorization. Staff Time Goserued Actions of the Student During Seclusion/Restraint Staff Response to Observed Actions Administrator Signature (to go beyond every 60 minutes or each class period) Time Date I Me'er Ruplds i . n- . "i Restraint and Seciusiot?t Docm??t*?? Studen 1 Date ofincideni I Student Actions and Debriefing After incident Staff Actions After incident Student Actions LStfudent Debriefing ?Supportive/ Undivided Attention DICrying EProcessing Activities (Describe) ?Empathic Listening fi?Calm DUsed Restatements for Understanding/Garification Bitetionai ?save Wait Time vigiialkative I . ElvAliowed for Silence CISiient DCoping Skili Activity (Describe) ICIIContinued to Monitor MAccepting Support MAssisted Student with Work Completion EITired ix?Waiked Student to Ciass DSieeping %upported Student in Class ?following Directions [3 Expected Behavior Activity EAssisted Student with Task Completion (cieaning up, etc.) y'?Returned to Class (Describe) EICommunicated with Caregiver Name: FUV/isited Nurse ClFollowed Through on Prior Expectation UApologized for Actions ElAssisted with Processing Activity DCommunicated with Accepted Responsibility for DMaintained Awareness of Proxemics, Kinesics, 81 Caregiver Name: 3 Actions (cleans up, etc.)1 A Para verbai Communication [:lPacing ElAssisted with Coping Skill Activity DWorked Independentiy . ElSwitched Staff Roles DRestroom/Bodiiy Needs if] Other {Describe} DAssisted with Expected Behavior Activity DOther (Describe) IZIOther Staff Debriefing and Future Approaches to Decrease or Eliminate Behavior from Reoccurring: ClTeam Meeting Learning Supports, DParent Meeting Date: CICollect ABC Data net?s.) Date: x?Review Revise Social Skiil instruction BComplete Competing Pathways Chart lClConduct Functional Behavioral Assessment CIReview Replacement Behavior El Review Positive Behavior Supports Hponsider Student El Review IEP Goals Data DAccess Community Supports Cl Revise Academic Support EIContact AEA Supports EIOther: Describe any injuries to student, employees, others, or property damage: Communication Documentation Parent/guardian must be cwta?'ed rm day of incident. A Nam I 1 Relationship: mm l/l I Date Time: Methodwm DESCFIDE attempts to notify the parent/guardian if Contact cannot be made on day of incident: Written documentation must be sent to parent/guardian within 3 schr-' f'm-c Date sent: Sent by. K?B?Mail (postmarked within 3 days of the occurrence) El Email upon written [Equubl u. paicutfaual mun El Fax upon'written request of parent/guardian El Hand Delivered In Person Name of parent/guardian the documentation was sent to: I x" .1 . iCecilia" Rapid-5 f. Czommun ity School District Physical Restraint and! Seciusion Documents.-- I I Student I Date of Incident: School Grad?" FSe-clusion Location: Time In: 3 Time Out: Duration: Confinement of a student in a room from [a 21067 .1 which the student?s egress is restricted (I) Student Entered Seclusion by: Physical Transport Safely moving an individual who is beginning to regain control DWalked on their own EIOther (Please Describe): f. Transport DCPI interim Control Time Started: Time Ended: Duration: Physical Restraint DCPI Team Control Time Started: Time Ended: Duration: Used to manage individuals who have Dcp} Chiidrenrs Control become dangerous to themselves or others; . . used as a last resort El Other (Please Describe). Staff Inunluarll Before Seclusion/Restraint/Transport (Check Implemented Items) Setting Events Antecedents Student Behavior Staff ReSponse (Eve indirectly im pacting the (Immediate triggers or predictors of immediately after (Calm El Nonjudgmental actions taken to de-escalate student behavior and avoid EIConflict Prior to School El Presented vv/Sociai interaction behavroral outcome) the problem behavior.) Antecedent sedusion/restraint) DLocation: DGiven Verbal Direction HAnxious (Describe): NGave Redirections DSubject: Q?iven Work/Activity pm?g gong-q DOffered Coping Skill/ break, etc. _El Activity: EJUnexpected Change in Routine Hg?wqh ?qufh g? EPlanned ignore . . 'EGave Time to De?escalate DConflict at School ?No? by: Encouragement/Praise DChange in Routine Spanied Access to Item/Activity El Defensive (Describe): Mositive Reminders (When/T hen) mif?culty in Previous Class Preferred Activity Removed EGave Support DHomework Not Done EITeacher Attending to Others DAssignment Modi?ed DMissed Medication DGiven Correction/Redirection Echanged Instruction DSubstitute Teacher El People too Close El Used Proxemics/Kinesics DAcademic Failure DLoud Noises/Room I Behavior Leading to ElPara Verbal Communication DHunger Bright Lights Seclusion/ Restraint Used Supportive Stance DFatigue CiWith a Specific Peer(s) ClVerbal Aggression EIVisual Cues Used EWork too Hard/Easy DVerbal Threats/Intimidation Modeled Expected Behavior DLarge Group instruction EIWork Repetitive/too Long Uthsical Threats/ Intimidation DEmpathic Listening MSmall Group instruction El independent Work E?Physical Aggression/Self - EGave Choices Dlndividual Instruction Din Pain 'EE'Physicai Aggression/Others ElTime Out (Where): El Unstructured Time DSitting For Extended Time Cl Physical Aggression/ Property Loss of Privilege/ Reward DApproached By Adult Possession Limits (151 IThen, When/T hen) DScheduled Non Preferred Activity ?Elopement EICalied for Team Support DOther (Please Describe): DRemove Other Students iIlTransition to: from: ~e?Other: DOther: El Additional Comments: Possible Function/Purpose of Behavior Student may have been trying to gain: Student may have been trying to avoid: DSociai interaction EIPeer or Cl Adult ElSocial Interaction EIPeer I or UAdult DSensory Stimulation DSensory Stimulation Wreferred Activity/Item Mon-Preferred Activity/Task Cedar Restores. a P'laesicai Restraint andseclusion'D?oeonaentatron - I Student I Date of incident: I Eiurin-g Record actions of the student and staff during physical restraint, transport, and/or seclusion. Students must be monitored constantly and documentation completed at a minimum of every two minutes. For restraints and seclusions to exceed beyond each class period or every 60 minutes, obtain signature of administration indicating authorization. . . . . ?r Tim Observed Actions of the Student During Seclusron/Restramt Star? Response to Observed notions ?lms a Administrator Signature (to go beyond every 60 minutes or each class period) Time Date . . . . . . . . . . Cedar Rapids Ptaysicai Restraint and Seciusion Documentation Student: Date of incident: Student Actions and Debriefing After incident Staff Actions Aiter incident Student Actions Student Debriefing ElSupportive/ Undivided Attention DCrying El Processing Activities (Describe) DEmpathic Listening EICaim DUsed Restatements for Understanding/Ciarification DRationai Ugave Wait Time CITaikative iwartime: for Silence CISiient DCoping Activity (Describe) ?ontinued to Monitor DAccepting Support CIAssisted Student with Work Compietion CiTjred EIWalked Student to Class ?leeping EISupported Student in Class El Foiiowing Directions EIExpected Behavior Activity ElAssisted Student with Task Completion (cleaning up, etc.) DReturned to Ciass (DescribEl Wommunicated with Caregiver Name' Visited Nurse EIFoilowed Through on Prior Expectation DApologized for Actions Assisted with Processing Activity DCommunicated with Caregiver Name: Actions (cleans up, etc.) El Accepted Responsibility for DMaintained Awareness of Proxemics, Kinesics, 81 Para verbai Communication [3Pacing ElAssisted with Coping Skill Activity Worked Independentiy Switched Staff Roles DRestroom/Bodily Needs DOther (Describe) DAssisted with Expected Behavior Activity Other (Describe) DOther Staff Debriefing and Future Approaches to Decrease or Eliminate Behavior from Reoccurring: EITeam Meeting Learning Supports, etc.) Date: CIParent Meeting Date: ElCoilect ABC Data CI Review DRevise Sociai Skili Instruction UComplete Competing Pathways Chart Functional Behavioral Assessment Review Replacement Beh avior CIReview Positive Behavior Supports Consider Student EIReview Goals Data EIAccess Community Supports Revise Academic Support EContact AEA Supports DOther: - Describe any injuries to student, employees, others, or property damage: pg 59, @434: Clea-i" Erica-)tdnrag (are? GUM Communication Documentation Parent/guardian must be contacted on day of incident. .S - i Date. Time: Name of nerson contacted I -- Relationship: Mari/her? .. Method: Descnoe attempts to notify the parent/guardian if contact cannot be made on day of incident: me i 'Bvr Written 1' "Adhere-Ls; be sent to parent/guardian within 3 school days. Date sent: Sent by: Maii wunin 3 days of the occurrence) Email up'on?written request of parent/guardian Rl-Iand Delivered In Person Cl Fax upon'written request of parent/guardian Name of parent/guardian the documentation was sent to: me! . ?3 a" an? #4 Ringside Stimmniit?gmti?mtm? Physioei Restraint end Seeiasten I Student: I Date oitncident: I I 9? Satin-g - Record actions of the student and staff during physical restraint, transport, and/or seclusion. Students must be monitored constantly and documentation completed at a minimum of every two minutes. For restraints and seclusions to exceed beyond each class period or every 60 minutes, obtain signature of administration indicating authorization. Staff initials ?i?irne Gnserued Actions of the Student Eating Seciusion/ Restraint Steti Response to ?bsewed Actions 'Administrator Signetu re (to go beyond every 60 minutes or each class period) Time Date ?eeitai?titeioida Ct"- Physical Restraint and Seeiusion Doemnentetien )Deteofincident: i i Student Actions and De briefing After incident Stat? Actions After tncident Student ACtions Student Debriefing DSupportive/ Undivided Attention Crying El rocessi ng Activities (Describe) Em pathic Listening DCalm DUsed Restatements for Understandirig/Clari?cation Cl Rational DGave Wait Time ??i?alkative (1 Hi) vet), row I. j? ElAllowed for Silence : Si ent. ?Cl Coping Skili Activity (Describe) ,5 Continued to Monitor DAccepting Support .JEI?Assisted Student with Work Com pletion : Tired DWalked Student to Class DSIeeping EISupported Student in Class EIFollowing Directions [E'LExpected Behavior Aqtivity UAssisted Student with Task Completion (cleaning up, etc.) DReturned to Class (Describe) cistern p?teld DCommunicated with Caregiver Name: Visited Nurse ?ollowed Through on Prior Expectation DApologized for Actions DAssisted with Processing Activity : Communicated with El Accepted Responsibility for DMaintained Awareness of Proxemics, Kinesics, 81 Caregiver Name: Actions (cleans up, etc.) Para verbal Communication DPacing DAssisted with Coping Skill Activity DWorked independently USwitched Staff Roles DRestroom/Bodiiy Needs ElOther (Describe) DAssisted with Expected Behavior Activity DOther (Describe) Other Staff Debriefing and Future Approaches to Decrease or Eliminate Behavior from Reoccurring: DTeam Meeting (IEP, Learning Supports, DParent Meeting Date: DCollect ABC Data etc.) Date: . DReview CIRevise Social Skill Instruction ClComplete Competing Pathways Chart DConduct Functional Behavioral Assessment DReview Replacement Behavior Review Positive Behavior Supports El Consider Student El Review IE Goals 81 Data ElAccess Community Supports El Revise Academic Support UContact AEA Supports DOther: Describe any injuries to student, employees, others, or property damage: Communication Documentation Parent/guardian must be contacted on day of incident. Name of person contacted: Relationship: Mom Date: nme: Method: 'Dhme )By: Describe htteinpts to notify the parent/guardian ifco?ntact cannot be m'ade on day of incident: Mesmge Written documentation must he sent to pa rent/guardian within 3 school days. Date sent: Sent by: Mail (post'rnar'laad within 3 days of the occurrence) El Email upon written request of parent/guardian El Fax upon written request of parent/guardian El Hand Delivered in Person [Name of parent/guardian the documentation was sent to: \Eii 1? ?{Cecicu??opids Community 230 Physical Restraint and Seclusion Docurnentauun Confinement of a student in a room from which the student?s egress is restricted Student. Date of incident: School: Grade: IEP: Seclusion - Location: Time In: Time Out: Duration: Ben?orug?oocrx Student Entered Seciusion by: NCI Physical Transport Safely moving an individual who is beginning to regain control ElWalked on their okifvn ClOther (Please Describe): Transport Time Startedi)?03? Time EndediH-(O Duration: min EICPI Interim Control MCI Physical Restraint - used as a last resort Used to manage individuals who have become dangerous to themselves or others; Staff Members Involved: DCPI Team Control (BQPI Children?s Control Cl Other (Please Describe): Time Started: lI?lI Time Ended: Duration: i i '5 339 Sec; Before Seclusion/Restraint/Transport (Check Implemented Items) Setting Events (Events i_ndirectly impacting the behavioral outcome) Antecedents (Immediate triggers or predictors of the problem behavior.) Student Behavior immediately after Antecedent Staff Response (Calm 8t Nonjudgmental actions taken to de-escalate student behavior and avoid seclusion/restraint) IZILocation' E?iven Verbal Direction DAnxious (Describe): ELGave Redirections EIGiven Work/Activity {IlOffered Coping Skill/ break, etc. DActivity: UUnexpected Change in Routine ElPIanned Ignore ElCoanict Prior to School Presented w/Social Interaction CIGave Time to De?escalate ClCoanict at School ClTold ?No? by: Encouragement/Praise DChange in Routine my Denied Access to item/Activity HDefensive (Describe): EPositive Reminders (When/Then) ?Ei-Difficulty in Previous'gids?? [3 Preferred Activity Removed K?ioiihzi IQGave Support L?JHomework Not Done l:lTeacher Attending to Others ?j?im/M ClAssignment Modi?ed DMissed Medication ?Given Correction/Redirection ElChanged Instruction DSubstitute Teacher El People too Close Used Proxemics/Kinesics CIAcademic Failure Loud Noises/Room Behavior Leading to ?Para Verbal Communication Cl Hunger EJBright Lights Seclusion/Restraint tEUsed CPI Supportive Stance ClFatigue DWith a Specific Peer(s) EIVerbai Aggression Q?Visual Cues Used, Eliilness EIWork too Hard/Easy EIVerbal Threats/intimidation leodeled Expected Behavior Large Group Instruction Repetitive/too Long Cl Physical Threats/intimidation [IIEmpathic Listening Group Instruction Dindependent Work Aggression/Self RGave Choices Instruction Clin Pain @{hysical Aggression/Others ClTime Out (Where): Cl Unstructured Time DSitting For Extended Time El Physical Aggression/ Property Eltoss of Privilege/ Rewa rd DApproached By Adult DWeapon Possession DSet Limits (151 frhen, When/Then) ElScheduled Non Preferred Activity ClEIopement ?Called for Team Support [:lWaiting El Other (Please Describe): CIRemove Other Students EITransition to: from: DOther: CIOther: Cl Additional Comments: Possible Function/Purpose of Behavior Student may have been trying to gain: Student may have been trying to avoid: DSocial Interaction ElPeer or Adult EJSocial Interaction or ElSensory Stimulation CISensory Stimulation DPreferred Activity/ Item Mon-Preferred Activity/Task we?re. .. . a .. Seth-thrgehe'el 315*?5?3 Pines-reel Restraint end Sec?nsren ?Dseenmentetien l5tucfent: I I lDe-te ofincident: I During Record actions of the student and staff during physical restraint, transport, and/or seclusion. Students must be monitored constantly and documentation completed at a minimum of every two minutes. NGTE: For restraints and seclusions to exceed beyond each class period or every 60 minutes, obtain signature of administration indicating authorization. we? Time Qbserved Actions of the Student During Seclusion/Restreint Etet?t Response to Observed Actions Initials Lick-cl? LA (EA Administreter Signature (to go bevend every 53 minutes or each class period) Time Date we? Statements - . . . . . . "i Phitearei Restraint and Seciusron Documentation I Student: a I Date of incident: Student Actions and Debriefing After incident Staff Actions After incident Student Actions Student Debriefing DSupportiveI Undivided Attention DCrying El Processing Activities {Describe} Empathic Listening DCaim ?rmed Restatements for Understanding/Ciarification CIRational @gave Wait Time (@Jalkative [:l'Ailowed for Silence EISiient EiCoping Skill Activity (De5cribe) ElContinued to Monitor DAccepting Support Wit/1 CIAssisted Student with Work Completion EITired @Walked Student to Class CISieeping ?supported Student in Class DFoilowing Directions ?Expected Behavior Activity DAssisted Student with Task Completion (cieaning up, etc.) ElReturned to Class (Describe) EICommunicated with Caregiver Name: El Visited Nurse Mag/\mfggad EIFoilowed Through on Prior Expectation DApologized for Actions ElAssisted with Processing Activity EICommunicated with EAccepted Responsibility for ElMaintained Awareness of Proxemics, Kinesics, Caregiver Name: Actions (cleans up, etc.) Para verbal Communication DPacing Lop new ElAssisted with Coping Skill Activity UWorked Independently ?943,515,, - My?? DSwitched Staff Roles DRestroom/ Bodily Needs Clother (Describe) Wssisted with Expected Behavior Activity DOther (Describe) : 0ther Staff Debriefing and Future Approaches to Decrease or Eliminate Behavior from Reoccurring: EITeam Meeting (IEP, Learning Supports, ElParent Meeting Date: EICoiiect ABC Data etc.) Date: El Review DRevise Social Skill instruction DCompiete Competing Pathways Chart DConduct Functional Behavioral Assessment El Review Replacement Behavior EIRevievv Positive Behavior Supports EIConsider Student EIReview IEP Goals 8; Data ElAccess Community Supports El Revise Academic Support ElContact AEA Supports EIOther: - Describe any injuries to student, employees, others, or property damage: Communication Documentation Parent/guardian must be contacted on day of incident. Name of person contacted: I Relationship: Date: (lime: I Method: Dng/ . (By: I Describe attempts to notify the parent/guardian if contact cannot be made on day of incident: Written documentation must be sent to parent/guardian within 3 school days. Date sent: Sent by: El Mail (postmarked within 3 days of the occurrence) El Email upon written request u. Cl Fax upon'written request of parent/guardian .Ehand Delivered In Person I Name of parent/guardian the documentation was sent to: - -- -- - - Marta Iguaer Rapid? L?ommunity School Disl?ld PETVSECEE Restraint and Seciosion Documentation Student: Date of incident: School: Grade: Seclusion Location: Time in: Time Out: Duration: Confinement of a student in a room from . .c . .. . - which the student?s egress is restricted )chacssm I r?i Student Entered Seclusion by: NCI Physical Transport Safely moving an individual who is beginning to regain control DWalked on their own DOther (Please Describe): Transport Time Sta rtedJQ g?iime Hem DCPI Interim Control Physical Restraint - used as a last resort Used to manage individuals who have become dangerous to themselves or others; DCPI Team Control Time Started: Children?s Control Other (Please Describe): Time Ended: Duration: bvif?ln ?Hiram Cam-iral nice-rate Staff Members involved: Before Seclusion/RestraiInt/Transport (Check Implemented Items) Setting Events (Events indirectly impacting the Antecedents (immediate triggers or predictors of Student Behavior immediately after Staff Response (Calm 8r Nonjudgmental actions taken to de-escalate student behavior and avoid behavioral outcome) the problem behawor.) Antecedent sedusion/restraint} L?iocation: Verbal Direction IZIAnxious (Describe): R?ave Red irections ?ubject: ElGiven Workactivity DOffered Coping Skiil/ break, etc. Wctivity: El Unexpected Change in Routine Planned ignore L?JCoanict Prior to School DPresented w/Social Interaction RGave Time to De?escalate L?JConflict at School CITold ?No? by: ?Gave Encouragement/Praise DChange in Routine El Denied Access to Item/Activity .QDefensive (Describe): Wositive Reminders (When/Then) DDifficulty in Previous Class ereferred Activity Removed Vet/i Ideal. Um? l?r-chvi RGave Support L?JHomework Not Done )3 Teacher Attending to Others . rm mgaxa EAssignment Modi?ed DMissed Medication EIGiven Correction/Redirection 50-? ?1.13, Changed Instruction DSubstitute Teacher El Peeple too Close Used Proxemics/Kinesics DAcademic Failure ElLoud Noises/Room Behavior Leading to Verbal Communication Hunger Bright Lights Seclusion/ Restraint Used CPI Supportive Stance EIFatigue EIWith a Specific Peer(s) Aggression Mime! Cues Used Dillness too Hard/Easy EIVerbaI Threats/Intimidation Modeled Expected Behavior EILarge Group Instruction EIWork Repetitive/too Long Uthsical Threats/ intimidation lIIEmpathic Listening EISmall Group instruction Ci Independent Work Physical Aggression/Self Gave Choices Elindividual instruction Elin Pain ?i?hysical Aggression/Others DTime Out (Where): DUnstructured Time For Extended Time Aggression/ Property DLoss of Privilege/ Reward EIApproached By Adult iZIWeapon Possession RSet Limits (151 fThen, When/Then) IZIScheduIed Non Preferred Activity DEiopement ?Calied for Team Support EIWaiting IZIOther (Please Describe): ElRemove Other Students EITransition to: from: 0th er: Other: Additional Comments: Possible Function/Purpose of Behavior Student may have been trying to gain: Student may have been trying to avoid: [Social Interaction L?JPeer or Cl Adult interaction EIPeer or ElAdult DSensory Stimulation EiSensory Stimulation Non?Preferred Activity/Task Preferred Activity! Item we? or Rapist-e: ornmuntty Scherzo! District ?fit-e?. . Physioei testreinteno?i Seoiosion?Doeomentetion I Student: . I Date otinoia?ent: . Eating Record actions of the student and staff during physical restraint, transport, and/or seclusion. Students must be monitored constantly and documentation completed at a minimum of every two minutes. MQTE: For restraints and sec/usions to exceed beyond each class period or every 60 minutes, obtain signature of administration indicating authorization. Staff initiate ?Finn Qbserved Actions of the Student During Seciusion/Restreint Stet-t Response to Observed Actions cran?axwm~ ":13 30a man/t rt" ?it: "t Administrator Signature (to go beyond every 60 minutes or each class period) Time Date ??f?fCedE??R?l?ldS as: .Come-tunitySoimolDietrict J, I Student: Physicai Restraint and Seclusion Documentation I Date of incident: Student Actions and Deb-rioting After Incident Staff Actions After incident Student Actions Student Debriefing DSupportive/ Undivided Attention @Crying QProcessing Activities (Describe) Cl Empathic Listening DCalm "hm Vt ii.? DUsed Restatements for Understanding/Garification L?JRational DGave Wait Time IZITaikative [:JAllowed for Silence L?JSilent DCoping Skill Activity (Describe) DContinued to Monitor DAccepting Support ElAssisted Student with Work Completion : Tired DWalked Student to Ciass Elsleeping DSupported Student in Ciass EIFollowing Directions El Expected Behavior Activity ElAssisted Student with Task Completion (cleaning up, etc.) L?JReturned to Class (Describe) DCommunicated with Caregiver Name: Visited Nurse EJFollowed Through on Prior Expectation DApoiogized for Actions DAssisted with Processing Activity Commu nicated with Caregiver Name: Actions (cieans up, etc.) ?3 Accepted Responsibility for DMaintained Awareness ofProxemics, Kinesics, 8i. Para verbai Communication EiPacing glam/i (mg? with Coping Skill Activity IZIWorked Independently DSwitched Staff Roles CI Restroom/Bodiiy Needs '3 Other (Describe) DAssisted with Expected Behavior Activity Other (Describe) [:lOther Staff Debriefing and Future Approaches to Decrease or Eliminate Behavior from Reoccurring: : Team Meeting Learning Supports, etc.) Date: ElParent Meeting Date: ElColiect ABC Data Review El Revise Social Skill instruction ClCompiete Competing Pathways Chart L?JConduct Functional Behavioral Assessment ElReview Replacement Behavior El Review Positive Behavior Supports Consider Stu dent EIReview Goals 8t Data ElAccess Community Supports Revise Academic Support DContact AEA Supports ElOther: Describe any injuries to student, employees, others, or property damage: Communication Documentation Parent/guardian must be contacted on day of incident. Name of person contacted: Date: I Time: Describe attempts to notify the parent/guardian if contact cannot be made on day of incident: Relationship: Method?wwj le=. Written documeptatipn must be sent to parent/guardian within 3 school davs. Date sent: . (gm-Mail (postmarked within 3 days of the occurrence) Sent by: Email upon written request of pacdnt/guardian El Hand Delivered in Person Fax upon'written request of parent/guardian I Name of parent/guardian the documentation was sent to: ?it! he! Cedar Rapids I II. ?tri?tommWiVSd?PP?D?ei-?Rt Physical Restraint end Seciusion Documentation Student: 1 Date of Incident: School: IEP: Seciusion Location: Time in: if?! Time qut: Duir tion:.I in? Cf Confinement of a student in a room from -M ?1 lg' if wi which the student?s egress is restricted fr? Student Entered Seclusion by: DWaiked on their own Transport EICPI Interim Control I Physical Transport Safely moving an Dower (please Describe): indmdualwho is beginning to regain control Time Started: Time Ended: Duration: NCI PhVSical Restraint - Team Control Time Started: (Qig?ime Duration: Used to manage individuals who have Children?s Control Ll'inrm? themselves or others; other (Please Describe): Staff Members involved: A IW A I Before Seciusion/Bestreint/Transport (Check implemented items) Setting Events Antecedents Student Behavior Staff Response (Events indirectly impacting the (immediate triggers or predictors of immediately after (Calm 3: Nonludgmental actions iaan to behavioral outcome) the problem behavior.) Antecedent bahaVi?r and a?m'd . Location: DGiven Verbal Direction ElAnxious (Describe): @Gave Redirections CISubject: {Mu/kg. ClGiven Work/Activity Epffered Coping Skill/ break, etc. DActivity: DUnexpected Change in Routine [?Pianned ignore ClConflict Prior to School ClPresented w/Social Interaction gj ave Time to De-escalate DConflict at School ElTold ?No? by: Wave Encouragement/Praise Whenge in Routine DDenied Access to item/Activity ClDefensive (Describe): mPositive Reminders (When/Then) Cl Difficulty in Previous Class Cl Preferred Activity Removed Support Cl Homework Not Done [:lTeacher Attending to Others ?Assignment Modified DMissed Medication DGiven Correction/Redirection [Richanged instruction CJSubstitute Teacher ClPeople too Close Used Proxemics/Kinesics EJAcademic Failure ClLoud Noises/Room Behavior Leading to were Verbal Communication DHunger Bright Lights Seclusion/Restraint ?lmed CPI Supportive Stance Cl Fatigue ClWith a Specific Peer(s) ClVerbai Aggression Misual Cues Used Dillness DwOrk too Hard/Easy ClVerbal Threats/Intimidation MModeled Expected BehaviOr El Large Group instruction DWork Repetitive/too Long Threats/intimidation meathic Listening DSmall Group Instruction Ellndependent Work EiPhysical Aggression/Self EGave Choices ?ndividual Instruction Elln Pain Whysical Aggression/Others @?me Out (Where): Cl Unstructured Time ClSitting For Extended Time Mhysicai Aggression/Property ULoss of Privilege/Reward DApproached By Adult DWeapon Possession USet Limits (1*1 /Then, When/Then) UScheduled Non Preferred Activity DEiopement EICalled for Team Support DWaiting DOther (Please Describe): CIRemove Other Students ClTransition to: from: DOther: another: Pele/til info/Mi *2 1:1 Additional Comments: all Clement-S Possible Function/Purpose of Behavior Student may have been trying to gain: Student may have been trying to m: ClSociai interaction DPeer or m?Aduit ElSociai interaction DPeer or CIAdult DSensory Stimulation EISensorv Stimulation - -- . um ClPreferred Activity/item Won-Preferred Activity/Task r: mmumyg?hm? Matinee-E Resttatnt and 'Doattn?tentatton - 1 Student: I Bate otineident: I I a 9 Dating Record actions of the student and staff during physical restraint, transport, and/or seclusion. Students must be monitored constantly and documentation completed at a minimum of every two minutes. NGTE: For restraints and seclusions to exceed beyond each class period or every 60 minutes, obtain signature of administration indicating authorization. Time Qbseraed stations at the Student During Seciusion/Restraint Staff Response to absentee Actions fti?ffi . la 5 ?i?l Administrator Signature (to go beyond every 60 minutes or each class period} Time Date i? . .r??CLEei FE geese; ?i Restraint end Seclosion Documentation 1 I Student: I ?ate oftncident: I I getting? Record actions of the student and staff during physical restraint, transport, and/or seclusion. Students must be monitored constantly and documentation completed at a minimum of every two minutes. NQTE: For restraints and seclusions to exceed beyond each ciass period or every 60 minutes, obtain signature of administration indicating authorization. Staff Ti Observed Actions of the Student During Seelusion/Restreint Staff Response to ?bserved Actions mums 30 50v? . .r Salt-z ?1 .l minutes or each ciess period) Time Date Administrs .a . I . 'l .. .. a Communitwciimlmh?mt thsicel Restraint and Seclueton Documentets?li I Student: I Date ofincident: I Student Actions and Debriefing After Incident Staff Actions After incident Student Actions Student Debriefing DSupportive/ Undivided Attention [:lCrying [Egrocessing Activities (Describe) Empathic Listening EICalm Wt}: El Used Restatements for Understanding/Clarification CIRationai @Gave Wait Time [:lTalkative Mllowed for Silence lZlSiient DCoping Skiil Activity {Describe} to Monitor DAccepting Support DAssisted Student with Work Completion mirth} DWalked Student to Ciass DSleeping DSupported Student in Class EIFollovving Directions ElExpected Behavior Activity DAssisted Student with Task Completion (cleaning up, etc.) [:lReturned to Class (Describe) DCommunicated with Caregiver Name: Visited Nurse DFollowed Through on Prior Expectation BApologized for Actions {Kessisted with Processing Activity [:ICommunicated with Accepted Responsibility for RMaintained Awareness ofProxemics, Kinesics, 8: Caregiver Name: Actions (cleans up, etc.) Para verbal Communication [:IPacing ElAssisted with Coping Skili Activity DWorked Independently DSwitched Staff Roles DRestroom/Bodiiy Needs DOther (Describe) DAssisted with Expected Behavior Activity (Describe) DOther Staff Debriefing and Future Approaches to Decrease or Eliminate Behavior from Reoccurring: UTeam Meeting (IEP, Learning Supports, MParent Meeting Date: . A . EJ?Collect ABC Data etc.) Date: Neview El Revise Social Skili instruction DCompIete Competing Pathways Chart DConduct Functional Behavioral Assessment ElReview Replacement Behavior DReview Positive Behavior Supports Student Review Goals 8: Data DAccess Community Supports El Revise Academic Support DContact AEA Supports DOther: - Describe any injuries to student, empIOyees, others, or property damage: bit? Movie Communication Documentation Parent/guardian must be contacted on day of incident: I Name of person contacted: I Relationship: Date: I lime: I Method: By: Describe attempts to notify the parentyguaruian if contact cannot be made oh day of incident: Written documentation must be sent to parent/guardian within 3 school days. Date sent: Sent by: ?Mail (postmarked within 3 days ofthe occurrence) El Email upon written request o?p?arent/guardian Cl Fax upon?written request of parent/guardian Hand Delivered In Person I Name of pa re nt/guardian the documentation was sent to: I I .. I I. waits?! a 4' assessesPhysicai Restraint and Seciusion Documentation. -- Student: Date of Incident: School: Erode: I. IEP: Seclusion - Location: Time In: Time Out: Duration: Confinement of a student in a room from ., 2? {a which the student?s egress is restricted 1% (22/ {Ti} {1 Student Entered Seciusion by: NCI Physical Transport Safely moving an DWalked on their own DOther (Please Describe) ECPI Transport DCPI interim Control individual who is beginning to regain control Time Started Time Ended. Duration. MCI Physical Restraint - DCPI Team Control Time Started: Time Ended: Duration: Used to manage individuals who have DCPI Children?s Control become dangerous to themselves or others; . I used as a last resort El Other (Please Describe). Staff Members Involved: Before Seclusion/Restraint/Transport (Check Implemented Items) Setting Events Antecedents Student Behavior Staff Response (Events Lndirectiy impacting the behavioral outcome) (Immediate triggers or predictors of the problem behavior.) Immediately after Antecedent (Calm Bi Nonjudgmental actions taken to de?escalate student behavior and avoid seclusion/restraint) CiLocation: ?Given Verbal Direction DAnxious (Describe): EGave Redirections ESubject: [Al/if) Given Work/Activity EOffered Coping Skill/ break, etc. Activity: Unexpected Change in Routine \?iPIanned Ignore UConflict Prior to School Presented waociai Interaction UGave Time to De-escalate DConflict at School ?No? by: ElGave Encouragement/Praise DChange in Routine Cl Denied Access to Item/Activity CIDefensive (Describe): DPositive Reminders (When/Then) Cl Difficulty in Previous Class Cl Preferred Activity Removed 3?13 Gave Support ClHomeworI-z Not Done EITeacher Attending to Others DAssignment Modified DMissed Medication CIGiven Correction/Redirection DChanged Instruction DSubstitute Teacher DPeOple too Close El Used Proxemics/Kinesics EJAcademic Failure DLouc?l Noises/Room Behavior Leading to CIPara Verbal Communication Cl Hunger Bright Lights Seclusion/Restraint EUsed CPI Supportive Stance Fatigue EIWith a Specific Peer(s) Werbal Aggression ElVisual Cues Used [Illiiness ElWork too Hard/Easy '?Verbal Threats/Intimidation DModeled Expected Behavior EILarge Group instruction DWork Repetitive/too Long Threats/Intimidation ElEmpathic Listening DSmaIl Group Instruction Dindependent Work I: Physical Aggression/Self ClGave Choices Dlndividual Instruction Elln Pain Aggression/Others EITime Out (Where): ElUnstructured Time EISitting For Extended Time ?EPhysical Aggression/Property Loss of Privil?ege/ Reward DApproached By Adult DWeapon Possession Cl Set Limits (1st lThen, When/Then) Non Preferred Activity DEIopement ECalled for Team Support EIWaiting EIOther (Please Describe): Remove Other Students to: from: EIOther: DOther: Additional Comments: Possible Function/Purpose of Behavior Student may have been trying to gain: Student may have been trying to avoid: EISocial Interaction CIPeer or Cl Adult CISociai Interaction Peer or DAduIt USensory Stimulation DSensory Stimulation El Preferred Activity/ item [Eldon-Preferred Activity/Task lull a?Ivh I .. Tr- Cgmmuhkyg?hm?bmm Pirnrsieai Restraint Seeiusion Booementation Studen? I Bate of incident: During Record actions of the student and staff during physicai restraint, transport, and/or seclusion. Students must be monitored constantiy and documentation compieted at a minimum of every two minutes. NOTE: For restraints and seclusions to exceed beyond each ciass period or every 60 minutes, obtain signature of administration indicating authorization. Staff initiate Ti Qosereed Actions of the Student Eating Seciusion/Restraint Staff Response to Observed Actions Administrator Signature (to go beyond siren;r 60 minutes or each class period) Time Date manrp?i Restraint and Sedation'litoeumentatron - . I Student. Bate oiincident: I ?aring Record actions of the student and staff during physical restraint, transport, and/or seclusion. Students must be monitored constantly and documentation completed at a minimum of every two minutes. NGTE: For restraints and seclusions to exceed beyond each class period or every 60 minutes, obtain signature of administration indicating authorizationTarn Observed Actions of the Student During Seclusron/Restramt Staff Response to Gaserued Actions misals Administrator Signature (to go beyond every 60 minutes or each class period) Time Date Cedar Rapids I Students. Phasicai Restraint and Secinsion Documentation, Date of incident: Student Actions and Debriefing After incident Staff Actions After incident Student Actions Student Debriefing QSupportive/ Undivided Attention DCrying DProcessing Activities (Describe) EEmpathic Listening EICaim \QUsed Restatements for Understandirig/Clarification ElRationai UGave Wait Time ?Allowed for Silence DSilent DCoping Skill Activity (Describe) ?Continued to Monitor [JAccepting Support QAssisted Student with Work Completion [:lTired DWaiked Student to Class DSleeping ESupported Student in Class UFollowing Directions Expected Behavior Activity DAssisted Student with Task Completion (cleaning up, etc.) : Returned to Class (Describe) DCommunicated with Caregiver Name: Visited Nurse ?Foiiowed Through on Prior Expectation DApologized for Actions CIAssisted with Processing Activity DCommunicated with Caregiver Name: El Accepted Responsibility for Actions (cieans up, etc.) DMaintained Awareness of Proxemics, Kinesics, Para verbal Communication : Pacing DAssisted with Coping Skill Activity DWorked independently wwitched Staff Roles DRestroom/Bodiiy Needs Bother (Describe) IDAssisted with Expected Behavior Activity Other (Describe) DOther Staff Debriefing and Future Approaches to Decrease or Eliminate Behavior from Reoccurring: CITeam Meeting Learning Supports, etc.) Date: DParent Meeting Date: DCoilect ABC Data DReview DRevise Social Skiil Instruction DComplete Competing Pathways Chart EIConduct Functional Behavioral Assessment ElReview Replacement Behavior El Review Positive Behavior Supports DConsider Student Review IEP Goais Data ElAccess Community Supports El Revise Academic Support DContact AEA Supports IZIOther: - Describe any injuries to student, employees, others, or property damage: Whit?4H lei-emcee, kin/Kid amid/3W again/knit" Communication Documentation Parent/guardian must be contacted on day of incident. Name of person contacted: Date: Time: Relationship: Method: Phone, Describe attempts to notify the parent/guardian if contact cannot be made on day of incident: I By: Written documentation must be sent to parent/guardian within 3 school days. Date sent: Mail {posrmameu within 3 days of the occurrence) Sent by: El Email upon w: men request of parent/guardian EHand Delivered In Person El Fax upon'written request of parent/guardian I Name of parent/guardian the documentation was sent to: 4.: or -: ??Cedar Rapids- w, TGrommcinity SchooIDistrict Physical Restraint and Seciusion Documentation Date of Incident: Schon Grade - 7 . Seclusion - +tocation: rTime In: Time Out: Duration: Emir I2 1 23; I125) Student Entered Seclusion by: Physical Transport Safely moving an DWalked on their own IZIOther (Please Describe): CICPI Transport DCPI Interim Control individual who is beginning to regain control Time Started Time Ended, Duration. NCI Physical Restraint - ECPI Team Control Time Started: Time Ended: Duration: Used to manage individuals who have Dcp) children's Control become dangerous to themselves or others; . used as a last resort CI OtherlPIea?se Describe). Staff Members Involved Before Seclusion/Restraint/Transport (Check implemented Items) Setting Events Antecedents Student Behavior Staff Response (Immediate triggers or predictors of the problem behavior.) (Events i_ndirectly impacting the behavioral outcome) immediately after Antecedent (Calm 84 Nonjudgmental actions taken to de~escalate student behavior and avoid seclusion/restraint) DLocation: Wiven Verbal Direction CIAnxious (Describe): ,?iZlGave Redirections If] Given Work/Activity EIOffered Ceping Skill/ break, etc. ESubject: Activity: UUnexpected Change in Routine EPlanned Ignore EICoanict Prior to School DPresented w/Social Interaction EGave Time to De?escalate EICoanict at School DChange in Routine "Ei?oid ?No? by: Denied Access to item/Activny [:IGave Encouragement/Praise El Defensive (Describe): ElPositive Reminders (WhenfThen) CIDifficuIty in Previous Class El Preferred Activity Removed CIGave Support EIHomework Not Done DTeacher Attending to Others DAssignment Modified CI Missed Medication Given Correction/Redirection CiChanged Instruction EISubstitute Teacher EIPeopIe too Close [3 Used Proxemics/Kinesics EIAcademic Failure CILoud Noises/Room Behavior Leading to Para Verbal Communication CI Hunger El Bright Lights Seclusion/ Restraint Msed CPI Supportive Stance El Fatigue DWith a Specific Peer(s) EVerbaI Aggression ?UVisual Cues Used EIWork too Hard/Easy ,fElVerbal Threats/Intimidation Expected Behavior Cl Large Group Instruction MWork Repetitive/too Long DEmpathic Listening Group Instruction Elindependent Work TIIPhysical Aggression/Self Gave Choices DIndividual Instruction Din Pain ?Physical Aggression/Others EITime Out (Where):f? EIUnstructured Time DSitting For Extended Time I3Physical Aggression/ Property EILoss of Privilege/ Reward EIApproached By Adult EIWeapon Possession Deer Limits on IThen, When/Then) CIScheduIed Non Preferred Activity Emailed for Team Support DWaiting EIOther (Please Describe): CIRemove Other Students DTransition to: from: DOther: EIOther: El Additional Comments: Possible Function/Purpose of Behavior Student may have been trying to ggi?: Student may have been trying to avoid: ocial Interaction DPeer or WAduIt DSociaI Interaction EIPeer or DSensory Stimulation EISensory Stimulation DPreferred Activity/item EINon~Preferred Activity/Task . .. . is Cemmumtr?ehwibimm Pinesreei Restraint SeeiasionEoeamentation I Student; I Date otineident: During - Record actions of the student and staff during physicai restraint, transport, and/or seciusion. Students must be monitored constantly and documentation compieted at a minimum of every two minutes. NOTE: For restraints and seclusions to exceed beyond each class period or every 60 minutes, obtain signature of administration indicating authorization. Staff initials Tim Observed Actions of the Student Earring Seciasion/Restraint Staff Response to Qbsewed Actions {Mu - Administrator Signature (to go beyond every minutes or each class period} Time Date ef'?CIedceropids 1,3 i; 'ContrnunitchimoiDienict I. 'n I Student; I Date of incident: Restraint and Seciesion De-curnentation Student Actions and Debriefing After incident Staff Actions After incident Student Actions Student Debriefing DSupportive/ Undivided Attention DCrying Processing Activities (Describe) l?Empathic Listening UCaim I {DUsed Restatements for Understariding/Clarification DRationai Wave Wait Time Maikative lilAllowed for Silence DSiient DCoping Skill Activity (Describe) EContinued to Monitor DAccepting Support ?ElAssisted Student with Work Completion EITired EIWaiked Student to Class Elsleeping EiSupported Student in Class EFoilowing Directions DExpected Behavior Activity ElAssisted Student with Task Compietion (cleaning up, etc.) [Returned to Class (Describe) ElCommunicated with Caregiver Name: El Visited Nurse ElFoliowed Through on Prior Expectation UApologized for Actions EiAssisted with Processing Activity Cl Accepted Responsibility for Actions (cleans up, etc.) EICommunicated with Caregiver Name: ElMaintained Awareness ofProxemics, Kinesics, 81 Para verbal Communication [:lPacing EiAssisted with Coping Skili Activity EIWorked Independently \Q??mitched Staff Roles Restroom/Bodiiy Needs El Other (Describe) tlAssisted with Expected Behavior Activity (Describe) UOther Staff Debriefing and Future Approaches to Decrease or Eliminate Behavior from Reoccurring: EJTeam Meeting (IEP, Learning Supports, etc.) Date: DParent Meeting Date: DCollect ABC Data El Review ElRevise Sociai Skill Instruction EIComplete Competing Pathways Chart EIConduct Functional Behavioral Assessment El Review Replacement Behavior CIReview Positive Behavior Supports EIConsider Student El Review Goals Data ElAccess Community Supports El Revise Academic Support EIContact AEA Supports DOther: Describe any injuries to student, employees, others, or property damage: luriin tn Sit/rotten g?lrdk ?i dds?, listed a nail i?P-m ear/tier) mimic, ?l?l?lf0l Communication Documentation Parent/guardian must be contacted on day _of incident. Name of person contacted: Relationship: mai?e?r? . hu? Date: Time: Method: By: Describe attempts to notify the parent/guardian if contact cannot be made on day of incident: Date sent: . mail (postmarked within 3 days ofthe occurrence) Written documentation must be sent to parent/guardian within 3 school days. Sent by: Cl Email upon written request of parent/guardian Hand Delivered In Person Fax upon'written request'of parent/guardian I Name of parent/guardian the documentation was sent to: Morita a ?gr-teem Hermes Community Baht-JG! Diet?ct Physicai Restraint and Seeiusion Documentation which the student?s egress is restricted Student: . Date ofincident: School; Grade: [Em? (Seciusion - TLocation: Time in: Time Out: Duration: Confinement of a student in a room from jig?? f. Student Entered Seclusion individual who is beginning to reg Physical Transport Safely moving an by: ain control EMA/awed on their own ClOther (Please Describe): Time Started: Transport interim Control Time Ended: Duration: Physical Restraint - used as a last resort Staff Members involved: Used to manage individuals who have become dangerous to themselves or others; Team Control . Ir Time Started: CICPI Children?s Control CI Other (Please Describe): Time Ended: Duration: Before Seclusion/Restraint/Transport (Check Implemented Items) Rotting Events (Events indirectly impacting the behavioral outcome) Antecedents (immediate triggers or predictors of the problem behavior.) Student Behavior immediately after Antecedent Staff Response (Calm 8i Nonjudgmental actions taken to de-escalate student behavior and avoid seciusionfrestraint) ClLocation: DGiven Verbal Direction DAnxious (Describe):- E?Gave Redirections CISubject: Maven Work/Activity EActivity: (til: Unexpected Change in Routine Wlanned ignore DConfiict Prior to School w/Sociai interaction Erisave Time to De?escaiate EIConflict at School ETold "No" by: DGave Encouragement/Praise EIChange in Routine WDenied Access to item/Activity ?p?ensive (Describe): DDifficuity in Previous Class Preferred Activity Removed ?ij?o lilii?b WGave Support EIHomework Not Done EITeacher Attending to Others but] ?Q/i xi. . J, DAssignment Modi?ed iZlOffered Coping Skiil/ break, etc. Wositive Reminders (When/Then) Group instruction @Missed Medication ?7 EIGiven Correction/Redirection ?er} DChanged Instruction EISubstitute Teacher DPeople too Close El Used Proxemics/Kinesics EIAcademic Faiiure EILoud Noises/Room I Behavior Leading to Wow Verbal Communication DHunger DBright Lights Seclusion/ Restraint primed CPI Supportive Stance EIFatigue EIWith a Specific Peer(s) I?Verbal Aggression 'ClVisuai Cues Used Diliness ElWork too Hard/Easy Werbal Threats/intimidation EIModeled Expected Behavior El Large Group instruction EIWork Repetitive/too Long ?thsical Threats/ Intimidation @Empathic Listening Elindependent Work Aggression/Self lIIGave Choices instruction Din Pain EPhysical Aggression/Others DTime Out (Where): CI Unstructured Time EISitting For Extended Time ?Physical Aggression! Property DLoss of Priviiege/ Reward DApproached By Aduit ElWeapon Possession DScheduied Non Preferred Activity DElopement Walled for Team Support met Limits (151 {Then, When/T hen) Additional Comments: EWNAPMQ DWaiting (Please Describe): ElRemove Other Students ElTransition to: from: EIOther: CIOth_er: vii} :Lieirm Bird .hiva.? {i 6; El (Dirk-ii if (limit 2?71 Possible Function/Purpose of Behavior Eudent may have been trying to gain: Student may have been trying to avoid: Social interaction EIPeer or WAduit ClSocial interaction EIPeer or ElAduit ElSensory Stimulation DSensory Stimulation A CI Preferred Activity/ item MNowPreferred Activity/Task W0 E. . Ctr/2m: rut}: ..- aria: at Reetretnt and Seciasran Bocamentettm j- . . I irate otiecident: ?aring Record actions of the student and staff during physical restraint, transport, and/or seclusion. Students must be monitored constantly and documentation completed at a minimum of every two minutes. itiQTE: For restraints and seclusions to exceed beyond each class period or every 60 minutes, obtain signature of administration indicating authorizationTim Qbeerued Actions of the Student Quring Seciueran/Restramt Sta-it Resnonse to Gaserved Actions Administrator Signature (to go beyond every 60 minutes or each class period) Tirne Date aid-if? [@Etii'gicai Restraint: and - 1 Student? [late oiincident: Daring - Record actions of the student and staff during physical restraint, transport, and/or seclusion. Students must be monitored constantly and documentation completed at a minimum ofevery two minutes. NOTE: For restraints and seclusions to exceed beyond each class period or every 60 minutes, obtain signature of administration indicating authorization'i?im Goeewed Actions of the Student During SecluSIon/Restraint Staff Response to ()bseraed Actions MEWS 1 ,3 Administrator Signature (to go beyond every 60 minutes or each class period) Time Date m! 9? . - 3E, Cedar Rapids Communitv Sci-too! District I Studentgi Restraint and Seeiusion toeunp?entation I Date of incident: . :l Student Actions and Debrie?ng After incident Sta?i?ic Actions After incident Student Actions Student Debriefing Mpportive/ Undivided Attention Crying 5Q Processing Activ ties (Describe) S?fmpathic Listening ElCaim Jr?j ?ElUsed Restatements for Understanding/Ciarification DRationai (4-)rugvitj . (mave Wait Time mralkative BAilowed for Silence IZISiient DCoping Skill Activity (Describe) llB?ontinued to Monitor EAccepting Support QAssisted Student with Work Completion CITired KANaiked Student to Class USleeping DSupported Student in Class EIFoiiowing Directions DExpected Behavior Activity Student with Task Completion (cleaning up, etc.) IZIReturned to Class (Describe) DCommunicated with Caregiver Name: Cl Visited Nurse EIFoiiowed Through on Prior Expectation CIApoiogized for Actions DAssisted with Processing Activity IZICommunicated with Caregiver Name: El Accepted for Actions (cleans up, etc.) EIMaintained Awareness ofProxemics, Kinesics, Para verbal Communication DPacing ?QAssisted with Coping Skill Activity DWorked independently ESwitched Staff Roles DRestroom/Bodiiy Needs DOther (Describe) CIAssisted with Expected Behavior Activity IZIOther (Describe) IZIOther Staff Debriefing andFuture Approaches to Decrease or Eliminate Behavior from Reoccurring: CITeam Meeting Learning Supports, etc.) Date: IZIParent Meeting Date: EIColiect ABC Data CIReview DRevise Social Skill instruction EICompiete Competing Pathways Chart EIConduct Functional Behavioral Assessment ElReview Replacement Behavior Review Positive Behavior Supports CIConsider Student EIReview IEP Goals 8: Data El Revise Academic Support ElContact AEA Supports Community Supports DOther: - Describe any injuries to student, employees, others, or property damage: Communication Documentation Parent/guardian mugt bp on dam of incident. Name of person contacted Date: I Time:? F, ii 7i Method??i?m 1 Describe attempts tinotify, the parent/guardian it contactfcannotLbehiade on day of ineigent. . Ci?i?b weight) mom I 'By. Written documentation must be sent to parent/guardian within 3 school days. Date sent: @Mail (postmarked within 3 days of the ocwrrence) Sent by: El Email upon written request of parent/guardian El Hand Delivered in Person Cl Fax upen'written request of parent/guardian Name of pa rent/guardian the documentation was sent to . we? ?12; (Jim ""Restraint and Seclusron Doeumerttaltton Student? Date oflncidenti - School: Grade: LEE Seclusion - LocatioF: Time In: Time Out: Duration: Confinement ofa ude ina ?oo ro KW which the studentht is restriztgd ii? Student Entered Seclusion by: DWalked on their own T?CPgransport Interim Control Dower (Please - :9 2 *2 5m i I Time Started: Time Ended: Duration: NCI Physical Restraint - Team Control Time Started: Time Ended: Duration: Used to manage individuals who have Dcp] childrenrs ControI r. I . EESZ?fft?iftziStaff Members Involved: Before Seclusion/Restraint/Transport (Check Implemented Items) Setting Events Antecedents Student Behavior Staff Response (Events i_ndirectly impacting the (Immediate triggers or predictors of mmediately after {Calm 8: Noniudgmental aetions taken to behavioral outcome) the problem behavror.) Antecedent Si?jss'izgfe?gig bahaVl?r and amid ElLocation: Ej?iven Verbal Direction DAnxious (Describe): MGave Redirections EISubject: CIGiven Work/Activity J3?ffered Coping Skill/ break, etc. ElActivity: EIUnexpected Change in Routine CIPIanned Ignore DConflict Prior to School DPresented w/Social Interaction MGave Time to De-escalate DCoanict at School DTold ?No? by: [:lGave Encouragement/Praise CIChange in Routine DDenied Access to Item/Activity Defensive (Desc?be): ElPositive Reminders (When/T hen) ElDifficulty in Previous Class El Preferred Activity Removed Ow Support UHomework Not Done ElTeacher Attending to Others Q?fmp-ig?l??issignment Modified ClMissed Medication ElGiven Correction/Redirection 1(6) (pa I CIChanged Instruction DSubstitute Teacher DPeOple too Close I Used Proxemics/Kinesics DAcademic Failure ClLoud Noises/Room I Behavior Leading to [JPara Verbal Communication ElHunger Bright Lights Seclusion/ Restraint Wsed CPI Supportive Stance ElFatigue DWith a Specific Peer(s) ElVerbaI Aggression ElVisual Cues Used Clillness EIWork too Hard/Easy CIVerbal Threats/Intimidation DModeled Expected Behavior DLarge Group Instruction EIWork Repetitive/too Long Uthsical Threats/Intimidation EEmpathic Listening Small Group Instruction Elindependent Work Aggression/Self @ave Choices [jindividual Instruction Elln Pain Aggression/Others EITime Out (Where): D_Unstruct_ured Time DSitting For Extended Time Physical Aggression/Property El Loss of Privilege/Reward I - I [:lApproached By Adult DWeapon Possession DSet Limits (1tt /Then, When/Then) . I DScheduIed Non Preferred Activity mElopement .E?alled for Team Support EIWaiting Elpther (Please Describe): ClRemove Other Students ETransition tozclONW My!? Diva? DOther: DOther: El AdditionalComments: Possible Function/Purpose of Behavior Student may have been trying to get?n: Student may have been trying to mid: CISocial Interaction ElPeer or Cl Adult EISocial Interaction ElPeer or lIISensory Stimulation IZISensory Stimulation El Preferred Activity/Item EINon?Preferred Activity/Task stsf?g??i?f?fji?ga . . a a ?e Cemmunrty?ctmol?gemot phvg?cgj aged Sgc?ugmn Bate otineident: I I Student: During Record actions of the student and staff during physical restraint, transport, and/or seciusion. Students must be monitored constantly and documentation completed at a minimum of every two minutes. NGTE: For restraints and seclusions to exceed beyond each class period or every 60 minutes, obtain signature of administration indicating authorization. Staff Staff Response to Observed Actions ma?a? Ti 3! Gaserued Actions of the Student Sur?ng Seclusion/Restreint Mitt.- 'r a i r? 2 Administrator Signature (to go beyond every 60 minutes or each class period) Time Date \3 atF-Ceder iterates g?i?mtm?v??Li? ?fwd-*4? Fan- . EMetre-int: and Becamentatiert I Student I Date etlncident: I [gating Record actions of the student and staff during physical restraint, transport, and/or seclusion. Students must be monitored constantly and documentation completed at a minimum of every two minutes. MGTE: For restraints and seclusions to exceed beyond each class period or every 60 minutes, obtain signature of administration indicating authorization. Staff initials Time Gbserved Aetions ef the Student marine ?erhm?ee meter-tint Staff Response te Observed Aetiens Administrater Signature (ta go beyend every 60 minutes or each class period) Time Date {larder Rapids Col?m-juhi-f??rCfr-i-imi I Studentn ?hr?timi and Seciusien Documentation I Date of incident: Student Actions and Debriefing After incident Staff Actions After incident Stude n-t Actio ns Student Debriefing gEElSupportive/ Undivided Attention DCrying EPrpcessing Activities (Describe) Empathic Listening DCalm lid/i l?Y?li? +11? EUsed Restatements for Understanding/Clarification lCl?Rational Egg! I may ClGave Wait Time ?ialkative E1 1 ,DAllowed for Silence ,?D?ilent IflCoping Sic-(ill Activity (Describe) montinued to Monitor Mccepting Support EIAssisted Student with Work Completion DTired [:lWalked Student to Class [ESleeping DSupported Student in Class UFollowing Directions Behavior Activity ElAssisted Student with Task Completion (cleaning up, etc.) DReturned to Class {Describe} CICommunicated with Caregiver Name: Visited Nurse [:lFollowed Through on Prior Expectation DApologized for Actions EIAssisted with Processing Activity CICommunicated with Caregiver Name: Accepted Responsibility for Actions (cleans up, etc.) [:lMaintained Awareness of Proxemics, Kinesics, 8i. Para verbal Communication DPacing ElAssisted with Coping Skill Activity [:lWorked Independently EISwitched Staff Roles El Restroom/ Bod ily eeds El Other (Describe) ElAssisted with Expected Behavior Activity El Other (Describe) [:lOther Staff Debrieting and Future Approaches to Decrease or Eliminate Behavior from Reoccurring: etc.) Date: ClTeam Meeting (IEP, Learning Supports, El Parent Meeting Date: ClCollect ABC Data El Review ??evise Social Skill Instruction DComplete Competing Pathways Chart QConduct Functional Behavioral Assessment CIReview Replacement Behavior [3 Review Positive Behavior Supports %Consider Student DReview IEP Goals 8i. Data '?fievise Academic Support CIContact AEA Supports [JAccess Community Supports Other: - Describe any injuries to student, employees, others, or property damage: Communication Documentation Parent/guardian must be contacted on dav of incident. Name of person contacted: Date: I Time?z . Describe attempts to notify the parent/guardian if contact cannot be ntade on day of incident: Relationship: Method: I'Byi- Date sent: Written documentation must be sent to parent/guardian within 3 school clays. ., . 1 Sent by: El Mail (postmarked within 3 days of the occurrence) El Email upon written rquest of parent/guardian El Fax upon'written request of parent/guardian ?Hand Delivered In Person I Name of parent/guardian the documentation was sent to: tweet" - - . Emmett-reg . D. . . . . . "i?m?mh?t" Show mm" Restraint and Seciusion Documentation Student. Date of Incident: School: Grade: I i Seciusion - Location: Time In: Time Out: Duration: Confinement of a student in a room from v. a. ?1 a which the student?s egress is restricted ?1 (?Li Student Entered Seciusion by: Physical Transport Safely moving an individual who is beginning to regain control ElWalked on their own DOther (Please Describe): Time Started?eg/i Time End?iig?I g?DUrationii i?l?lii?i ?chpi Nineties-H- i NCI Physicai Restraint Team Control Time Started: Time Ended: Duration: Used to manage individuals who have Dcpi Children?s Contm) become dangerous to themselves or others; . . used as 3 East resort El Other (Please Describe). Staff Members involved: Before Seclusion/Restraint/Transport (Check Implemented Items) Setting Events Antecedents Student Behavior Staff Response (immediate triggers or predictors of the problem behavior.) (Events indirectly impacting the behavioral outcome) Immediately after Antecedent (Calm Er Nonjudgmental actions taken to de-escalate student behavior and avoid seclusion/restraint) ClLocation: UGiven Verbal Direction DAnxious (Describe): m?ave Redirections CISubject: iven Workactivity [JOffered Coping Skill/ break, etc. ETActivity: DUnexpected Change in Routine ?Planned Ignore EIConflict Prior to School EIPresented w/Social Interaction EIGave Time to De-escalate EIConflict at School EITold ?No? by: ClGave Encouragement/Praise DChange in Routine ?benied Access to ltemfActivity ?Defensive (Describe): Reminders (When/Then) DDifficuity in Previous Class Preferred Activity Removed EIGave Support Momework Not Done EITeacher Attending to Others 6.14% para EiAssignment Modified EIMissed Medication EIGiven Correction/Redirection CIChanged instruction EISubstitute Teacher ElPeople too Close Used Proxemics/Kinesics DAcademic Failure [3 Loud Noises/Room Behavior Leading to ElPara Verbal Communication EIHunger EIBright Lights Seciusion/ Restraint CIUsed Supportive Stance ClFatigue DWith a Specific Peer(s) EIVerbal Aggression EIVisual Cues Used Dlilness EIWork too Hard/Easy EIVerbal Threats/Intimidation DModeled Expected Behavior EILarge Group Instruction DWork Repetitive/too Long Physical Threats/Intimidation Empathic Listening EISmaii Group instruction Ellndependent Work El Physical Aggression/Self NGave Choices Ellndividuai Instruction Elln Pain Aggression/Others Out (Where): EIUnstructured Time DSitting For Extended Time Physical Aggression/Property Loss of Privilege/ Reward prroached By Adult DWeapon Possession DSet Limits (15t fThen, When/Then) DScheduled Non Preferred Activity Cl Elopement EICalled for Team Support DWaiting I may EIOther (Please Describe): IZIRemove Other Students MTransition DOther: DOther: El Additional Comments: Possible Function/Purpose of Behavior Student may have been trying to gain: Student may have been trying to avoid: EISociai interaction CiPeer or Cl Adult DSocial Interaction EIPeer or EJAdult CISensory Stimulation CISensory Stimulation 4 a CI Preferred Activity/item ENon-Preferred Activity/Task {mm I A 8 a a - Playrsreal lites-trend Seeiasran "i?re'eansentetran I Student. . 1 I Date at ineident: During Record actions of the student and staff during physical restraint, transport, and/or seclusion. Students must be monitored constantly and documentation completed at a minimum of every two minutes. NQTE: For restraints and seciusions to exceed beyond each class period or every 60 minutes, obtain signature of administration indicating authorization. Staff Initials 'i?irne Gaseraed Aetiens at the Student uring Seeiusian/Restraint Staff Reseanse ta Gbsewed Actiens i Administratar Signature (to go beyend every 60 minutes or each class period) Time Date titre-teal} Restraint and Sedation 'Diaearnentation I Bate at incident: I Student:~ Betting Record actions of the student and staff during physical restraint, transport, and/or seciusion. Students must be monitored constantly and documentation completed at a minimum of every two minutes. NQTE: For restraints and seclusions to exceed beyond each class period or every 60 minutes, obtain signature of administration indicating authorization. Staff initials ?Fime Sta-it Reseanse to Observed Actions Qbsereed Actions at the Student During Seclasion/ Restraint F. \?sm we 9. Administrator Signature (to en beyond every 60' minutes or each class period) Time Date was? - I phvg?caf Regtramt 3mg Documentation I. Date ofincident. Student Actions and Debriefing After incident Staff Actions After incident Student Actions Student Debriefing DSupportive/ Undivided Attention DCrying El Processing Activities (Describe) El Empathic Listening Ekalm DUsed Restatements for Understanding/Clarification DRationai EGBVE Wait Time DTalkative EIAliowed for Silence DSiient DCoping Skill Activity (Describe) DContinued to Monitor HAccepting Support DAssisted Student with Work Completion bTired ?Waiked Student to Class DSieeping EISupported Student in Ciass ElFollowing Directions Expected Behavior Activity DAssisted Student with Task Completion (cleaning up, etc.) )iiRetumed to ciass (Describelvt?yi (M46, DCommunicated with Caregiver Name: C) Visited Nurse High DLLV EIFoliowed Through on Prior Expectation DApologized for Actions Kis?i?r ?1 A QE?ejVQy?n?] DAssisted with Processing Activity UCommunicated with El Accepted Responsibility for ElMaintained Awareness ofProxemics, Kinesics, 8: Caregiver Name: Actions (cieans up, etc.) Para verbal Communication UPacing EIAssisted with Coping Activity EIWorked independently EISwitched Staff Roles DRestroom/Bodiiy Needs El Other (Describe) ElAssisted with Expected Behavior Activity Other (Describe) XiOther Staff Debriefing and Future Approaches to Decrease or Eliminate Behavior from Reoccurring: UTeam Meeting Learning Supports, EIParent Meeting Date: DColiect ABC Data etc.) Date: Ci Review Mevise Social Skili Instruction EiCompiete Competing Pathways Chart DConduct Functional Behavioral Assessment Eliteview Replacement Behavior DReview Positive Behavior Supports monsider Student DReview Goals 8: Data EIAccess Community Supports KRevise Academic Support El Contact AEA Supports DOther: - Describe any injuries to student, employees, others, or property damage: Communication Documentation Parent/guardian be contact-an an den mt inridnnt I Na me of person contacted: I ?Relationship: Date: If; . Time: Method: I By: _Describelattempts to notifythe parent/guardian rr com-act cannot be made on day of incident: Let-Jr meagre; Written documentation musgbe sent to parent/guardian within 3 school davs. Date sent: Sent by: Mail (postmarked within 3 days of the occurrence) El Email upon written request of parent/guardian {El Fax upon'written request of parent/guardian El Hand Delivered In Person Name of parent/guardian the documentation was sent to: I a I I . . .1. . Cedar Rapid; Commnm?gd?m'mm Physical Restraint and Seclusion Documentation Student: Date of Incident: School: - I Grade: IEP: Seciusion Location: Time In: Time Out: Duration: Confinement of a student in a room from . . L, which the student?s egress is restricted b0 Student Entered Seclusion by: MCI Physical Transport Safer moving an individual who is beginning to regain control DWalked on their own DOther (Please Describe): ECPI Transport DCPI Interim Control Time Started: il 300 Time Ended: Duration: 2 NCI Physical Restraint DCPI Team Control Time Started: Time Ended: Duration: Used to manage individuals who have Dcpi Children?s Control - become dangerous to themselves or others; . used as a last resort El Other (Please Staff Members Involved: Before (Check Implemented Items) Setting Events Antecedents Student Behavior Staff Response (Events igdirectly impacting the (Immediate triggers or predictors of mmediatew after (Calm 3t Nonludgmental actions 13an to behavioral outcome the roblem behavior. de'escalate ?Udent baby-?0" and ?Old Antece?ient seclusionlrestraint) Location: WGiVen Verbal Direction EIAnxious (Describe): ElGave Redirections USUbjEct: ElGiven Work/Activity MOffered Coping Skill/ break, etc. KlActivity: ?ame DUnexpected Change in Routine XPlanned Ignore DConflict Prior to School Presented xiv/Social Interaction MGave Time to De?escalate Con?ict at School DTold "No" by: EGave Encouragement] Praise DChange in Routine El Denied Access to Item/Activity Defensive (Describe): ?Positive Reminders (When/Then) DDif?culty in Previous Class Preferred Activity Removed bane}? nq cal?; un?i- ClGave Support DHom ework Not Done MTeacher Attending to Others thU?Q Elk-newts, ElAssignment Modi?ed DMissed Medication UGiven Correction/Redirection diam: DChanged Instruction DSubstitute Teacher DPeople too Close I El Used Proxemics/Kinesics [:lAcademic Failure DLoud Noises/Room Behavior Leading to WPara Verbal Communication DHunger Bright Lights Seclusion/ Restraint ElUsed CPI Supportive Stance ElFatigue ClWith a Speci?c Feeds) IEVerbal Aggression ClVisual Cues Used too Hard/Easy KlVerbal Threats/intimidation DModeled Expected Behavior ?Large Group on ClWork RepetitiVe/too Long EPhysical Threats! Intimidation pathic Listening DSmall Group Instruction Independent Work Physical Aggression/Self MGave Choices Instruction In Pain Physical Aggression/Others El'lime Out (Where): [:lUnstructured Tlme [:lSitting For Extended Time Cl Physical Aggression/Property DLoss of Privilege/Reward DApproached By Adult UWeapon Possession DSet Limits (1It fThen, When/Then) Non Preferred Activity KlElopement 'h?ienl to leave mCalled for Team Support UWaiting DOther (Please Describe): Remova Other StudenE DT'ransition to: from: DOther: DOther: El Additional C0mm?ni5= Jones to leaye bulldima? Fund/feel ordcd?ri SCerched as ?tried in bile Possible Function] Purpose of Behavior Student may hava been trying to gain: Student may have been trying to avoid: my _I:lSocial Interaction ClPeer or El Adult DSocial Interaction UPeer or ElAdult ElSensory Stimulation DSensory Stimulation referred Activity/ Item Non?Preferred Activiwa ask e" Communws?d?m?mm Potteteet Reettein?t end Seeteeton Boeomentetton IStodent: I. Batting-w Record actions of the student and staff during physical restraint, tranSport, and/or seciusion. Students. must be monitored constantly and documentation compieted at aminimum of every two minutes. MGTE: For restraints ono' seciusions to exceed beyond each class period or every 60 minutes, obtain signature of administration indicating authorizationwed Aettene of the Student Du ring ft Response to Qbeewed Aettone Ingialg Administrator Signature (to go beyond even; 63 minutee or each eiees period) Time Date 4t Cedar Rapids itCommun'ws?fhm'o?m Physical Restraint and Sectosron Documentation I Student: I Date of incident: Student Actions and Deprie'iing After incident Staff-Actions After incident 41 "Student Actions Student Debrie?ng KISupportive/ Undivided Attention El Crying Processing Activiti es (Describe) El Empathic Listening ECalm A isms.st 8.05?qu ?Used Restatements for Understanding/Clari?cation [:lRational I ElGave Wait Time DTalkative CIAllowed for Silence CISilent KlCoping Skill Activity (Describe) [:lContinued to Monitor UAccepting Support Plan as [:lAssisted Student with Work Completion ?3 I or (Ll/clad (1.9.24 mWalked Student to Class - [:lSleeping twee/k: 4?1 W41 ESupported Student in Class Cl Following Directions Expected Behavior Activity CIAssisted Student with Task Completion (cleaning up, etc.) EReturned to Class (Describe) [:lCornmunicated with Caregiver Name: Visited Nurse [:lFollowed Through on Prior Expectation UApologiZed for Actions CIAssisted with Processing Activity DCommunicated with Accepted ReSponsibility for ?Maintained Awareness of Proxemics, Kinesics, 8L Caregiver Name: Actions (cleans up, etc.) Para verbal Communication [:lPacing DAssisted with Coping Skill Activity BWorked independently EISwitched Staff Roles DRestroom/Bodily Needs QOther (Describe) we in 4-3 CIAssisted with Expected Behavior Activity @Other (Describe) 03+? 8 re E. Bother Staff Debriefing and Future Approaches to Decrease or Eliminate Behavior from Reoccurring: DTeam Meeting Learning SUpports,_ etc.) Date: [:lParent Meeting Date: CI Collect ABC Data EReview D?Revise Social Skill Instruction ElComplete Competing Pathways Chart DConduct Functional Behavioral Assessment CI Review Replacement Behavior HReview Positive Behavior Supports El Consider Stu dent UReview Goals Data CIAccess Community Supports Cl Revise Academic Support CIContact AEA Supports CI Other: Describe any injuries to student, employees, others, or property damage: A - Communication Documentation Parentlguardian must be contacted on day of incident. Name of person contacted: _aiationship: Date: i I Time: '1 Method: 014mm, I By: to notify the parent/ guardian if contact cannot be rhade on day of incident: Written documentation must be sent to pa rent/gua rdian within 3 school days. Date sent: Sent by: El Mail {postmark?d within 3 days of the occurrence) El Email upon written request of parent/guardian El Fax upon written request of parent/guardian El Hand Delivered in Person I Name of parentLguardian the documentation was sent to: