BEHAVIOR INCIDENT REPORT Emergency Seclusion-Restraint-Timeout Reporting Form Student Name:

Date:

Time In:

am pm

Time Out:

am pm

Staff Present:

Seclusion

Location of Incident: Transition Classroom Hall Cafeteria Playground

Total Time: Restraint

Break

Behavior(s): Gym Other:

________________________________ Activity: ________________________________

Danger to self Physical aggression Property destruction Other: Describe: _______________________________________________

________________________________

_______________________________________________

What precipitated the behavior?

Possible needs being meet through behavior:

Staff direction

Task avoidance Adult Attention Peer Attention Sensory Stimulation Power/Control Tangible Relief of Fear/Anxiety

Conflict with another student

Difficulty with assignments Unfamiliar person/task/place

Other: Describe:

Expression of anger/Frustration

Other: Student being monitored by: NEW PERSON EVERY 15 MINUTES BY LAW Name: Start Time: am pm Name: Start Time: am pm Name:

Start Time:

am pm

Name:

Start Time:

am pm

Procedures used by the teacher/staff to deescalate the student: Removal of other students from classroom Removal from classroom Provide choices Break offered Verbal redirection Reduce demands Reduce or eliminate verbal interaction Provide visual information Other: Was student able to return to the goals and objectives being worked on prior to the incident: Yes No Police/EMS Involvement

Does there need to be a change in the behavior plan? If so please indicate:

Signature of Teacher:

Signature of Witness:

Signature of Witness:

Signature of Witness:

Administrator Notification: Check the Box if you were a witness to all or part of the incident. Director ______________________ Student Advisor: __________________________ Principal _____________________ Social Worker: ________________________ Other: __________________________ __________________________________ Any Attached Documents: Parent/Guardian Signature:

Consequences:

Documents sent within 24 hours

Seclusion/Restraint/Timeout Student Debrief Documentation Sheet Date :

Student Signature:

 Procedures used to de-escalate the student prior to seclusion/restraint:_____________________________________

 Describe the behavior that led to seclusion/restraint: ________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________

 Extended Time rationale: _____________________________________________________________________________

 Describe behavior during seclusion/restraint:__________________________________________________________

 Describe behavior after seclusion/restraint:___________________________________________________________

 Was there any injury or damage?

Yes

 Is it anticipated that the behavior will re-occur?

No

If Yes, describe:

Yes

No

If Yes, actions implemented:

 Is other follow-up needed? (e.g. IEP meeting, additional evaluation, discussion with others)

Yes

No If Yes, specify:

 Person responsible for follow-up:____________________________  Who attended the debriefing meeting?_______________________________________________________________ Was parent/guardian contact made?

Yes

No

Who made the contact? If no contact made, please explain:

Date/Time:

Name of Teacher:

Signature:

Date:

Name of Witness:

Signature:

Date:

Seclusion/Restraint/Timeout ADULT Debrief Documentation Sheet Please only report of the area that you personally were a witness to ADULT Signature:

Date:

 Procedures used to de-escalate the student prior to seclusion/restraint:_____________________________________

 Describe the behavior that led to seclusion/restraint: ________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________

 Extended Time rationale: _____________________________________________________________________________

 Describe behavior during seclusion/restraint:__________________________________________________________

 Describe behavior after seclusion/restraint:___________________________________________________________

 Did you debrief with at least one member of the SAR team (who): When:_________________  What changes could have been made to help the student be successful: (adult prompts, lessons, environment, etc):