5144.1 - Use of Physical Force

5144.1(a)

Students

Use of Physical Force

Physical Restraint(s)/Seclusion

The Board of Education believes that maintaining an orderly, safe environment is conducive to learning and is an appropriate expectation of all staff members within the district. To the extent that staff actions comply with all applicable statutes and Board policy governing the use of physical force, including physical restraint of students, staff members will have the full support of the Board of Education in their efforts to maintain a safe environment.

The Board recognizes that there are times when it becomes necessary for staff to use reasonable restraint to protect a student from harming himself/herself or to protect others from harm. (Alternative language: “to use reasonable restraint to provide a safe environment for students.”) Physical restraint means any mechanical or personal restriction that immobilizes or reduces the free movement of a person’s arms, legs or head. Excluded from this definition is the use of helmets, or other protective gear used to protect a person from injuries due to a fall, mitts and similar devices used to prevent special education students from hurting themselves if their use is documented in their Individualized Education Program (IEP), pursuant to Connecticut’s special education laws and is the least restrictive means available to prevent self-injury.

Reasonable restraint is defined as immobilization of the individual’s opportunity for movement by staff member(s) through direct contact using devices and techniques designed to control acute or incidental aggressive behaviors or to control involuntary movements or lack of muscular control due to organic causes or conditions. Such constraint will not be used except as necessary to ensure a student’s safety and that of others, and then only for as long as is necessary for control of the situation. Such restraint is not to be used as a disciplinary measure. Restraint includes “aversive techniques” which are defined as deliberate activities designed to establish a negative association with a specific behavior. Prohibited is any physical restraint or hold of a person that restricts the flow of air into a person’s lungs, whether by chest compression or any other means.

Restraint does not include briefly holding a person in order to calm or comfort the person; restraint involving the minimum contact necessary to safely escort a person from one area to another; or medical devices, including but not limited to, supports prescribed by a health care provider to achieve proper body position or balance.

Seclusion is defined as the confinement of an individual in a room, with staff supervision, in a manner that prevents the person from leaving, provided such seclusion does not include any confinement of a person at risk in which the person is physically able to leave the area of confinement, including, but not limited to, in-school suspension and time-out. Time-out is not considered seclusion. Involuntary seclusion is permitted in accordance with the student’s IEP or in an emergency to prevent immediate or imminent injury to the person or others, so long as it is the least restrictive alternative.

Physical restraint may be used on a person at risk only as an emergency intervention to prevent immediate or imminent injury to the person or others. It may not be included as a behavior modification strategy in the IEP of a special education student.

Physical restraint may be used by staff members to:

In the case of students with disabilities, any restraint used beyond the specific situations listed above shall be identified on the student’s Individual Education Plan (IEP) as a form of intervention. All less restrictive alternatives must be explored prior to using physical restraint. The student being restrained must be constantly monitored through direct observation or through video monitors within physical proximity sufficient to provide aid as may be needed.

Such acts shall not be construed to constitute corporal punishment within the meaning and intent of this policy.

Staff using such constraint shall be subject to the following:


District personnel who transport special education students to and from off-campus facilities and consider the use of a physical restraint device to control physical activity or aggression of a special education student shall follow these guidelines:

a) the purpose/goal for utilization of the device;

b) the specific type and model number of the restraint device to be used;

c) the specific times it is to be used;

d) a method of assessing the effectiveness of its use.

In the case of an emergency involving the threat of immediate and significant harm to the special education student or to other persons in the proximity of the student, a district employee may use a restraint device prior to receiving the above required approval, provided that such use is only for the minimum time required until the threat of immediate and significant harm is removed. The student’s parent/guardian, principal and the Superintendent must immediately be notified of the reason for the use of the device and the length of time the student was in restraint.

An act of a staff member shall not be considered child abuse if the act was performed in good faith and in compliance with Board policies and procedures. Such acts shall not be construed to constitute corporal punishment.

Seclusion may be used for a person at risk only as an emergency intervention to prevent immediate or imminent injury to the person or others or in a non-emergency situation if (1) it is specified in the student’s IEP and (2) other less restrictive, positive behavior interventions appropriate to the behavior exhibited by the person at risk have been implemented but were ineffective.

Generally, the seclusion may not exceed the time necessary to allow the person at risk to compose himself/herself and return to the educational environment. It may not exceed one (1) hour unless extended through the written authorization of a building principal or designee in order to prevent immediate injury to the person at risk or others.

A room is required for seclusion which fulfills the following regulatory requirements:

Reporting/Notification Requirements

Regular Education Students

A student not eligible for special education and is not being evaluated for eligibility is not covered by this policy. CGS 53a-18 permits a teacher or other person entrusted with the care and supervision of a minor for school purposes to use reasonable physical force upon such minor when and to the extent he/she reasonably believes such to be necessary to (1) protect himself/herself from immediate physical injury; (2) obtain possession of a dangerous instrument or controlled substance; (3) protect property from physical damage; or (4) restrain such minor or remove such minor to another area to maintain order.

(cf. 4148/4248 - Employee Protection)

(cf. 5141.23 - Students With Special Health Care Needs)

(cf. 5144 - Use of Physical Force)


Legal Reference: Connecticut General Statutes

10-76b State supervision of special education programs and services.

10-76d Duties and powers of boards of education to provide special education programs and services.

46a-150 Definitions. (as amended by PA 07-147)

46a-152 Physical restraint, seclusion and use of psychopharmacologic agents restricted. Monitoring and documentation required.

46a-153 Recording of use of restraint and seclusion required. Review of records by state agencies. Reviewing state agency to report serious injury or death to Office of Protection and Advocacy for Persons with

Disabilities and to Office of Child Advocate.

53a-18 Use of reasonable physical force or deadly physical force generally.

53a-19 Use of physical force in defense of person.

53a-20 Use of physical force in defense of premises.

53a-21 Use of physical force in defense of property.

PA 07-147 An Act Concerning Restraints and Seclusion in Public Schools.

State Board of Education Regulations Sections 10-76b-5 through 10-76b-11.


Policy adopted: March 28, 2013 WINDSOR LOCKS PUBLIC SCHOOLS

  Windsor Locks, Connecticut




5144.1

Form 1

Windsor Locks Public Schools

Physical Restraint Report Form

Note: This report is required to be submitted to the Director of Special Education as soon as practicable after an incident involving physical restraint, but in no event later than 24 hours after the incident.

Physical Restraint: Any mechanical or personal restriction that immobilizes or reduces the free movement of a person’s arms, legs or head. The term DOES NOT INCLUDE: (A) Briefly holding a person in order to calm or comfort the person; (B) restraint involving the minimum contact necessary to safely escort a person from one area to another; (C) medical devices, including, but not limited to, supports prescribed by a health care provider to achieve proper body position or balance; (D) helmets or other protective gear used to protect a person from injuries due to a fall; or (E) helmets, mitts and similar devices used to prevent self injury when the device is part of an Individualized Education Program (“IEP”).

STUDENT INFORMATION:

Name of Student: ___________________________________ Date of Restraint: _____________

Date of Birth: ___________ Age: _________ Gender: M/F _______ Grade Level: ___________

Does student currently receive special education services or is the student being evaluated for

eligibility for special education services? Yes:___ No: ___ School: _______________________

Date of this report: ___________________ Site of physical restraint: ______________________

This report prepared by: __________________________________ Position: ________________

Staff administering restraint:

Name: ___________________________________ Title: _______________________________

Name: ___________________________________ Title: _______________________________

Name: ___________________________________ Title: _______________________________

Staff monitoring restraint:

Name: ___________________________________ Title: _______________________________

Name: ___________________________________ Title: _______________________________

Administrator who was verbally informed following the restraint:

Name: ___________________________________ Title: _______________________________

Reported by: ______________________________ Title: _______________________________




5144.1

Form 1

(continued)

PRECIPITATING ACTIVITY:

Description of activity in which the restrained or other students were engaged immediately preceding emergency use of physical restraint:



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



Description of other steps, including attempts at verbal de-escalation, to prevent the emergency necessitating use of restraint:



DESCRIPTION OF PHYSICAL RESTRAINT:


Justification for initiating physical restraint (check all that apply):

□ Non-Physical interventions were not effective

□ To protect student from immediate or imminent injury

□ To protect other student/staff from immediate or imminent injury

Type of Protective Hold Used:

□ Side by side parallel hold

□ Lifted and carried (full security hold)

□ Held in chair (reverse cradle transport)

□ Floor control

□ Other (describe)


Regular evaluation of the student being restrained for signs of physical distress:

Time: _______ Evaluation:____________________________________________________________________________

Time: _______ Evaluation:____________________________________________________________________________

Time: _______ Evaluation:____________________________________________________________________________

Time: _______ Evaluation:____________________________________________________________________________

Time: _______ Evaluation:____________________________________________________________________________


Time restraint began:_______________________ Time restraint ended:____________________

Total time (in minutes): ____________________



5144.1

Form 1

(continued)

CESSATION OF RESTRAINT:

How restraint ended (check all that apply):

Determination by staff member that student was no longer a risk to himself/herself or others

Intervention by administrator(s) to facilitate de-escalation

Law enforcement personnel arrived

Staff sought in-house assistance

Community emergency personnel arrived

Other (describe):

Description of any injury to student and/or staff and any medical or first aid care provided:

Time medical staff checked injured person:__________________________________________________________________

Medical staff actions:_________________________________________________________________________________________

Medical staff name: __________________________________________________________________________________________

Incident report was filed with the following school district official:

_______________________________________________________________________________________________________________

Date:______________


FURTHER ACTION TO BE TAKEN: (Attach separate page if necessary)

The school will take the following actions (check all that apply)

Review incident with student to address behavior that precipitated the restraint

Debrief staff regarding incident

Consider whether follow-up is necessary for students who witnessed the incident

Further contact with parents (describe):



Convene Crisis Team Meeting

Convene PPT to review/revise behavior intervention plan and/or IEP

Convene PPT to discuss functional behavior assessment



5144.1

Form 1

(continued)

PARENT/GUARDIAN NOTIFICATION (required for all restraints):

Parent who was verbally informed of this restraint:

Name: ____________________________________________________ Telephone Number: ______________________________

Date: ______________________________ Time: ______________________________

Called by: ______________________________ Title:______________________________

Notice mailed to Parent: Yes_____ No_____

Mailed by: Title:

Reviewed by:_____________________________________________ Date:______________________________

(Program Administrator/ Team Leader)


Reviewed by:_____________________________________________ Date: ______________________________

(Director of Special Education)


FOR DIRECTOR OR DESIGNEE USE ONLY

Reviewed physical restraint report

Reviewed behavior plan, if applicable

In considering the effect of the restraint on the student’s established behavioral support of educational plan, I find the following: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________




5144.1

Form 2

Windsor Locks Public Schools

Seclusion Report Form

Note: This report is required to be submitted to the Director of Special Education as soon as practicable after an incident involving the seclusion of a student, but in no event later than 24 hours after the incident.

Seclusion: The confinement of a person in a room, whether alone or with supervision by a Board of Education employee, in a manner that prevents the person from leaving the room.

STUDENT INFORMATION:

Name of Student: _____________________________________________________________ Date of seclusion: ______________________

Date of Birth: ___________ Age: _________ Gender: M/F _______ Grade Level: _________

Does student currently receive special education services or is the student being evaluated for eligibility for special education services? Yes: ___ No: ___ School: _____________________________________________________________

Date of this report: ___________________ Site of seclusion: _____________________________________________________________

This report prepared by: ___________________________________________________ Position: ____________________________________________


Staff placing student in seclusion:

Name: __________________________________________________ Title: __________________________________________________

Name: __________________________________________________ Title: __________________________________________________

Name: __________________________________________________ Title: __________________________________________________

Staff monitoring seclusion:

Name: __________________________________________________ Title: __________________________________________________

Name: __________________________________________________ Title: __________________________________________________

Administrator who was verbally informed following the seclusion:

Name: __________________________________________________ Title: __________________________________________________

Reported by: ___________________________________________  Title: __________________________________________________


PRECIPITATING ACTIVITY/DESCRIPTION OF SECLUSION:

Does the student’s IEP include the use of seclusion? Yes ____ No ____

If No: Description of the risk of immediate or imminent injury to the student secluded or others that required use of seclusion.


If Yes or No: Description of other steps, including attempts at verbal de-escalation, to prevent the use of seclusion:



MONITORING OF SECLUSION

Regular evaluation of the student being secluded for signs of physical distress:

Time: _______ Evaluation:___________________________________________________________________________

Time: _______ Evaluation:___________________________________________________________________________

Time: _______ Evaluation:___________________________________________________________________________

Time: _______ Evaluation:___________________________________________________________________________

Time: _______ Evaluation:___________________________________________________________________________

Time: _______ Evaluation:___________________________________________________________________________

Time: _______ Evaluation:___________________________________________________________________________

Time: _______ Evaluation:___________________________________________________________________________

Time: _______ Evaluation:___________________________________________________________________________

Time seclusion began:_____________________ Time seclusion ended:____________________

Total time (in minutes): ____________________


CESSATION OF SECLUSION:

How seclusion ended (check all that apply):

Determination by staff member that student was no longer a risk to himself/herself or others

Intervention by administrator(s) to facilitate de-escalation

Law enforcement personnel arrived

Staff sought in-house assistance

Community emergency personnel arrived

Termination per instruction in IEP/behavior plan

Other (describe):


Description of any injury to student and/or staff and any medical or first aid care provided:



Time medical staff checked injured person: ___________________________________________________________________________

Medical staff actions: __________________________________________________________________________________________________

Medical staff name: ____________________________________________________________________________________________________

Incident report was filed with the following school district official:

_________________________________________________________________________________________________________________________

Date:______________


FURTHER ACTION TO BE TAKEN: (Attach separate page if necessary)

The school will take the following actions (check all that apply)

Review incident with student to address behavior that precipitated the seclusion

Debrief staff regarding incident

Consider whether follow-up is necessary for students who witnessed the incident

Further contact with parents (describe):



Convene Crisis Team Meeting

Convene PPT to review/revise behavior intervention plan and/or IEP

Convene PPT to discuss functional behavior assessment


PARENT/GUARDIAN NOTIFICATION (required for all seclusions):

Parent who was verbally informed of this seclusion:

Name: ________________________________________________ Telephone Number: _____________________________________________

Date: ________________________________________________   Time: _____________________________________________

Called by: _____________________________________________ Title:_____________________________________________

Notice mailed to Parent: Yes_____ No_____

Mailed by: _____________________________________________Title: _____________________________________________

Reviewed by:__________________________________________ Date:

(Program Administrator/ Team Leader)

Reviewed by:_____________________________________________ Date:

(Director of Special Education)


FOR DIRECTOR OR DESIGNEE USE ONLY

Reviewed seclusion report

Reviewed behavior plan, if applicable

In considering the effect of the seclusion on the student’s established behavioral support of educational plan, I find the following:




5144.1

Form 3

(STATE INCIDENT REPORTING FORM)

Report of Seclusion or Restraint

Incident Report

School District: ________________________________________________ School: __________________________________________________

Address: _______________________________________________________ Address: ________________________________________________

Phone: _________________________________________________________ Phone: __________________________________________________

Name and Title of Person Preparing the report: _________________________________________________________________________

Incident: Seclusion ________________________________________________ Restraint ____________________________________________

Name of Student: _________________________________________________ Student Disability: ___________________________________

Birth Date of Student: _____________________________________________ Male/Female Race: __________________________________

Describe the nature and use of seclusion: (Identify the emergency that necessitated the use of seclusion and how long the student was in seclusion. Was the use of seclusion included in the student’s IEP?)

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Describe the nature and use of restraint: (Identify the emergency that necessitated the use of restraint, time in restraint and type of restraint used.)

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Was the parent contacted within twenty-four hours of the use seclusion or restraint as an emergency intervention to prevent immediate or imminent injury to the person or others?

Yes ______ No ______ If “No”, did the parent receive a copy of the incident report no later than five days from the date of the incident? Yes _____ No______

Was the student injured during the emergency use of restraint or seclusion?

Yes___ No ____ If “Yes”, complete and attach a Report of Injury.



ED 636: Seclusion/Restraint Report




5144.1

Appendix A

RESTRAINT AND SECLUSION LAWS IN CONNECTICUT

The following sets forth Connecticut law related to the physical restraint and seclusion of persons at risk, which can be found in Public Act 07-157, amending Connecticut General Statutes Sections 46a-150 through 46a-153, 10-76b, and 10-76d. The [_______] Board of Education mandates compliance with these laws at all times.

I. The following definitions apply to these procedures:

II. Procedures for Physical Restraint of Persons at Risk

No provider or assistant shall under any circumstance use a life-threatening physical restraint on a person at risk.

No provider or assistant shall use involuntary physical restraint on a person at risk EXCEPT as an emergency intervention to prevent immediate or imminent injury to the person at risk or to others.

Physical restraint of a person at risk shall never be used as a disciplinary measure or as a convenience.

Providers and assistants must explore all less restrictive alternatives prior to using physical restraint for a person at risk.

Providers and assistants must comply with all regulations promulgated by the Connecticut State Board of Education in their use of physical restraint with a person at risk.

Monitoring

A provider or an assistant must continually monitor any person at risk who is physically restrained. The monitoring must be conducted by direct observation of the person at risk.

A provider or an assistant must regularly evaluate the person being restrained for signs of physical distress. The provider or assistant must record each evaluation in the educational record of the person being restrained.

Documentation and Communication

A provider must notify the parent or guardian of a person at risk of each incident that the person at risk is physically restrained.

The Director of Special Education must be notified of the following:

a. each use of physical restraint on a person at risk;

b. the nature of the emergency that necessitated its use; AND

c. if the physical restraint resulted in physical injury to the person at risk.

After a physical restraint occurs, the following information must be documented in the educational file of the person at risk who was physically restrained:

a. in the case of an emergency use, the nature of the emergency and what other steps, including attempts at verbal de-escalation, were taken to prevent the emergency from arising if there were indications that such an emergency was likely to arise;

b. a detailed description of the nature of the restraint;

c. the duration of the restraint; AND

d. the effect of the restraint on the person’s established behavioral support or educational plan.

III. Procedures for Seclusion of Persons at Risk

No provider or assistant shall use involuntary seclusion on a person at risk EXCEPT as follows:

1. as an emergency intervention to prevent immediate or imminent injury to the person at risk or to others; OR

2. as specifically provided for in the IEP of the person at risk.

Seclusion of a person at risk shall never be used as a disciplinary measure or as a convenience.

Providers and assistants must explore all less restrictive alternatives prior to using seclusion for a person at risk. If an Individualized Education Program Team (“IEP

Team”) incorporates the use of seclusion into a child’s IEP, the IEP Team shall consider the use of less restrictive alternatives to determine whether seclusion is a necessary part of a child’s IEP.

Providers and assistants must comply with all regulations promulgated by the Connecticut

State Board of Education in their use of seclusion for a person at risk.

Monitoring

A provider or an assistant must frequently monitor any person at risk who is placed in seclusion. The monitoring must be conducted by direct observation of the person at risk.

A provider or an assistant must regularly evaluate the person in seclusion for signs of physical distress. The provider or assistant must record each evaluation in the educational record of the person who is in seclusion.


Documentation and Communication

A provider must notify the parent or guardian of a person at risk of each incident that the person at risk is placed in seclusion.

The Director of Special Education must be notified of the following:

a. each use of seclusion on a person at risk;

b. the nature of the emergency that necessitated its use; AND

c. if the seclusion resulted in physical injury to the person at risk.

After seclusion occurs, the following information must be documented in the educational file of the person at risk who was placed in seclusion:

a. in the case of an emergency use, the nature of the emergency and what other steps, including attempts at verbal de-escalation, were taken to prevent the emergency from arising if there were indications that such an emergency was likely to arise;

b. a detailed description of the nature of the seclusion;

c. the duration of the seclusion; AND

d. the effect of the seclusion on the person’s established behavioral support or educational plan.

IV. Responsibilities of the Director of Special Education

The Director of Special Education, or his or her designee, must compile annually the instances of physical restraint and seclusion within the District and the nature of each instance of physical restraint and seclusion.

The Director of Special Education, or his or her designee, may report to the Connecticut State Department of Education any instance of physical restraint or seclusion that resulted in physical injury to the person at risk.

The Director of Special Education, or his or her designee, must, at each initial IEP Team meeting for a child, inform the child’s parent, guardian, or surrogate parent, or the student if such Student is an emancipated minor or eighteen years of age or older, of the laws relating to physical restraint and seclusion as expressed through this regulation, and of the laws and regulations adopted by the Connecticut State Board of Education relating to physical restraint and seclusion.


V. Responsibilities of the Connecticut State Board of Education

The State Board of Education may review the annual compilation of each local and regional board of education that provides special education for children and may produce an annual summary report identifying the frequency of use of physical restraint or seclusion on such children.

The State Board of Education and the Commissioner receiving a report of serious injury or death resulting from a physical restraint or seclusion shall report the incident to the Director of the Office of Protection and Advocacy for Persons with Disabilities and, if appropriate, the Child Advocate of the Office of the Child Advocate.

The State Board of Education may regulate the use of physical restraint and seclusion of special education students in the public schools.

The State Board of Education shall adopt regulations concerning the use of physical restraint and seclusion in public schools.




5144.1

Appendix B

WINDSOR LOCKS PUBLIC SCHOOLS-PROTECTIVE MEASURES

[General Statute 46a-150]


The Windsor Locks Public School System strives to provide a safe and productive learning environment for all students and school personnel.

Every student served by Windsor Locks Public Schools will be free from unreasonable use of protective measures and seclusion. Protective measures shall be used only in an emergency situation, only after all other alternatives have been exhausted and or deemed inappropriate.

Seclusion and Protective measures are never used to punish or discipline a child. They are appropriate, only in the cases where immediate or imminent harm is threatened either to the student himself or to others. In such cases, they should be limited to the amount of time necessary for the student to regain self-control, and should not be extended beyond that point for any reason.

If protective measures or seclusion are used on a child more than once, the district will conduct a FBA to determine the causes of the behaviors and to recommend alternative approaches including a written behavior intervention plan.




5144.1

Appendix C

Windsor Locks Public Schools

Protective Measures Procedures

Staff Training: A core group of educators within each school building have been trained in the principles and philosophy of Physical & Psychological Management Training. (PMT) These staff members are appropriately trained in de-escalation techniques as well as safe and effective protective measures.

_____________ Public Schools mandates that alternative strategies and techniques must be exhausted prior to implementation of a protective measure including but not limited to:

If a student is not able to regain self-control following all attempts by the staff to deescalate the student’s behavior and the safety of the student and/or the safety of others is in question, the following procedures should be enacted:

STEP 1:

Immediately notify the office:

The office will notify the appropriate team members and the principal and send them to the room or environment in question. The student should remain under constant supervision to assure that he/she is safe. At least two TEAM members must be present during the intervention. 


Pre-approved protective measures as indicated within the PMT training manual

Escort: Protective Hold:


Protective measures lasting longer than 5 minutes must be approved by an administrator or designee. Holds must be approved each additional 5 minutes up to 20 minutes. Protective measures are not to exceed 20 minutes.

STEP 2:

Administrator will notify parent.

_________________ Public Schools may seek an individual waiver for students who present a high risk of frequent, dangerous behavior that may require the frequent use of protective measures. Parent(s)/guardian(s) may withdraw consent to such waiver at any time without penalty. Protective measures that result in serious injury to a student or program staff member must be reported as described above regardless of any individual waiver.

STEP 3:

Complete Paperwork

o To be completed before the close of the school day

o To be completed no later than the following school day


Reports of these incidents should be submitted to the principal no later than the following school day, with copies sent to the pupil services office.

The principal or his/her designee shall maintain an on-going record of all reported instances of protective measures, which shall be made available for review by the Department of Education, upon request.

The following documentation regarding individual waiver of reporting requirements will be maintained on-site in the student’s file and will be made available for inspection to the

Department of Education upon request:

a. Informed written consent of parent(s)/guardian(s) to the waiver, which shall specify those reporting requirements listed above that the parent(s)/guardian(s) agrees to waive; and 

b. Specific information regarding when and how the parent(s)/guardian(s) will be informed regarding the administration of all protective measures to the individual student.


Windsor Locks Public Schools Protective Measures Documentation

5144.1

Appendix D

Windsor Locks Public Schools

Windsor Locks, Connecticut

Protective Measure Report

Date: _____________________ Time (begin): ______________ Time (end): _______________

Name of Staff Person(s) Administering Protective measures:________________

Name of Observer(s): ________________________________________________________

Administrator Notified: ______________________________________________________

1. Description of the activity of all parties involved prior to the use of the protective measure.



2. The student’s behavior which prompted the protective measure.



3. Describe the de-escalation efforts.



4. Justification of the protective measure and a description of the administration of the protective measure.



5. Other information and/or related information.




Date:_____________ Time:________________ Location:____________________

Student:_________________________ Parent Notification:______________________

Antecedents to the Incident:

Demand: ______

Environmental: ______

Denied Access: ______

See Attached: _______

Describe Environment or Activity:

___________________________________

___________________________________

___________________________________

Alternatives to Protective Measure:

Ignoring:

Environmental Manipulation:

Contingency: ____

Physical Redirection: ____

Severity of Behavior Prevents: ____

Other:

Justification for Protective Measure

______ Safety of Student

______ Safety of Others

Protective Hold/Escort Utilized:

Escort: _____Guide-a-long

_____Lower Figure Four

Protective Hold: _____Limited Security Hold (1)

_____Full Security Hold (1)

_____Seated Full Security Hold (1)

_____Kneeling Full Security Hold (2)

_____PMT Floor Control

Staff Implementing Protective Hold:

Staff 1 Signature: ___________________________ Init: ______

Staff 2 Signature: ___________________________ Init: ______

Staff 3 Signature: ___________________________ Init: ______

Immediate Notification:

Staff: ________

Time: ________

Admin: _______

_____________________

5-min. Notification

Staff: ________

Time: ________

Admin: _______

_____________________

20-min. Notification

Admin: _______

Total Duration: ______

Reason for Release:

Student Specific Criteria: __

Unsafe Protective Hold: __

Physiological Factors: __

Supervisor Directive: __

Monitoring:

Staff____________________

Skin Color ____

Breathing ____

Body Position ____

Reestablish

Therapeutic Rapport:

(follow up actions)

Classroom Teacher Review: __________________________ Date: _____

School Principal Review: __________________________ Date: _____

Special Education Administrator Review: __________________________ Date: _____

Nurse (if necessary) __________________________ Date: _____