Updated August 2019

Physical Restraint, Transport and Seclusion Documentation

Student: Date of Incident: School:
Grade: ☐Male ☐Female ☐ IEP ☐ 504 ☐ FIE ☐N/A

NCI= Nonviolent Crisis Intervention® CPI = Crisis Prevention Institute®

Seclusion – Location: Time In: Time Out: Duration:
Confinement of a student in a room from
which the student’s egress is restricted
NCI Physical Transport – ☐CPI Transport ☐CPI Interim Control Time Started: Time Ended: Duration:
Safely moving an individual who is ☐Other (Describe):
beginning to regain control
NCI Physical Restraint – ☐CPI Team Control ☐CPI Children’s Ctrl. Time Started: Time Ended: Duration:
Used to manage individuals who have ☐CPI Standing Hold ☐CPI Seated Hold
become dangerous to themselves or ☐ Other (Describe):
others; used as a last resort

List All Staff Members Involved (minimum first initial and last name):

Before Seclusion/Restraint/Transport (Check implemented items and describe when indicated with a colon)
Setting Events
(Events indirectly impacting the
behavioral outcome)
Location:
Subject:
Activity:
☐Conflict Prior to School
☐Conflict at School
☐Change in Routine
☐Difficulty in Previous Class
☐Homework Not Done
☐Missed Medication
☐Substitute Teacher
☐Academic Failure
☐Hunger
☐Fatigue
☐Illness
☐ Pain
☐Large Group Instruction
☐Small Group Instruction
☐Individual Instruction
☐Unstructured Time
☐Other:
Antecedents
(Immediate triggers or predictors of
the problem behavior)
☐Given Verbal Direction
☐Given Work/Activity
☐Unexpected Change in Routine
☐Presented w/Social Interaction
☐Told “No” by:
☐Denied Access to Item/Activity
☐ Preferred Activity Removed
☐Teacher Attending to Others
☐Given Correction/Redirection
☐With Specific Peer(s)
☐Work too Hard/Easy
☐Work Repetitive/too Long
☐Independent Work
☐Sitting for Extended Time
☐Approached by Adult
☐Scheduled Non-Preferred Activity
☐Waiting
☐Transition to: from:
☐Sensory:
☐Other:
Student Behavior
Immediately after
Antecedent
☐Anxious (Describe):
☐Defensive (Describe):
Behavior Leading to
Seclusion/Restraint/Transport
☐Physical Threats/Intimidation
☐Physical Aggression-Self
☐Physical Aggression-Others
☐Physical Aggression-Property
☐Weapon Possession
☐Elopement
☐Other (Describe):
Staff Response
(Calm & nonjudgmental actions taken to
de-escalate student behavior and avoid
seclusion/restraint)
☐Gave Redirections
☐Offered Coping Skill/Break, etc.
☐Planned Ignore
☐Gave Time to De-escalate
☐Gave Encouragement/Praise
☐Positive Reminders
☐Gave Support
☐Assignment Modified
☐Changed Instruction
☐Gave space
☐Visual Cues Used
☐Modeled Expected Behavior
☐Empathic Listening
☐Gave Choices
☐Time Out (Where):
☐Loss of Privilege/Reward
☐Set Limits (1st /Then, When/Then)
☐Called for Team Support
☐Remove Other Students
☐Other:

Additional Comments:

Possible Function/Purpose of Behavior (select at least one and describe when indicated with a colon)
Student may have been trying to gain- Student may have been trying to avoid-
☐Social Interaction- ☐Peer or ☐ Adult ☐Social Interaction- ☐Peer or ☐ Adult
☐Sensory Stimulation: ☐Sensory Stimulation:
☐Preferred Activity/Item: ☐Non-Preferred Activity/Task:
 Student: Date of Incident:

Student Actions and Debriefing After Incident
Student Actions
☐Crying
☐Calm
☐Talkative
☐Silent
☐Accepting Support
☐Sleeping
☐Following Directions
☐ Visited Nurse
☐Apologized for Actions
☐Worked Independently
☐Communicated with Caregiver
☐Restroom/Bodily Needs
☐Other (Describe):
Student Debriefing
☐Processing Activities (Describe):
☐Coping Skill Activity (Describe):
☐Expected Behavior Activity (Describe):
☐ Accepted Responsibility for Actions
(cleans up, etc.) (Describe):
☐Other (Describe):
Staff Actions After Incident
☐Empathic Listening (Supportive/Undivided Attention)
☐Used Restatements for Understanding/Clarification
☐Gave Wait Time
☐Allowed for Silence
☐Continued to Monitor
☐Assisted Student with Work Completion
☐Supported Student in Class
☐Assisted Student with Task Completion (cleaning up,
etc.)
☐Assisted with Coping Skill Activity
☐Followed Through on Prior Expectation
☐Assisted with Processing Activity
☐Switched Staff Roles
☐Assisted with Expected Behavior Activity
☐Other (Describe):

☐Returned to Prior Setting ☐Sent to office ☐Sent home by admin ☐Sent home by parent choice
Final outcome of incident:
☐Other (Describe):

Staff Debriefing and Future Approaches to Decrease or Eliminate Behavior from Reoccurring:
☐Team Meeting (IEP, Learning Supports, etc.) ☐Parent Meeting ☐Complete Brief FBA &Competing
Date: Date: Pathways Chart
☐Review FBA/BIP ☐Revise Social Skill Instruction ☐Review Positive Behavior Supports
☐Collect ABC Data ☐Review Replacement Behavior ☐Access Community Supports
☐Consider Student Strengths ☐Review IEP Goals & Data ☐Other (Describe):
☐Revise Academic Support ☐Contact AEA Supports

Injuries/Property Damage
Injuries to student/employees/others: ☐No ☐Yes (Describe; do not use names):

Property damage: ☐No ☐Yes (Describe):

Communication Documentation
Parent/guardian MUST be contacted ON DAY OF INCIDENT. *3 SEPARATE CONTACT ATTEMPTS SHOULD BE MADE ON DAY OF INCIDENT*
Name of person contacted: Relationship:
Date: Contacted by:
*List attempts to notify parents/guardians on day of incident (when contact is made, record in “Time of Parent Response” below)* -
Contact method: Time: Contact method: Time: Contact method: Time:
Time of Parent Response: Response method - ☐ Phone Call ☐ In-Person ☐ Text Message ☐ Email
Parent Response to Notification:

Parent requested Further Follow-up: ☐No ☐Yes (Describe):

Written documentation must be provided to parent/guardian within 3 school days (CANNOT BE SENT HOME WITH STUDENT).
Name of parents/guardians the documentation was provided to:
Date sent/provided: Sent/provided by:
☐ Mail (postmarked within 3 days of the occurrence) ☐ Email (upon written request of parent/guardian)
☐ Hand Delivered In-Person ☐ Text message (upon written request of parent/guardian)

Updated August 2019

 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 (all 4 columns) a minimum of every two minutes*
NOTE: For restraints and seclusions to exceed beyond each class period or every 45 minutes (consecutive OR non-
consecutive), obtain signature of administration indicating authorization.

Staff
Time Observed Actions of Student During Transport/Restraint/Seclusion Staff Response to Observed Actions
Initials

Administrator Signature (to go beyond every 45 minutes (consecutive or non-consecutive) or each class period)

☐In-person ☐Phone ☐Other (Describe):

Method of Approval Time of Approval Date of Approval

☐ I have reviewed this form.

☐ This form was entered in Infinite Campus.
Updated August 2019
Administrator Signature: ___________________________________
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 (all 4 columns) a minimum of every two minutes*
NOTE: For restraints and seclusions to exceed beyond each class period or every 45 minutes (consecutive OR non-
consecutive), obtain signature of administration indicating authorization.

Staff
Time Observed Actions of Student During Transport/Restraint/Seclusion Staff Response to Observed Actions
Initials

Administrator Signature (to go beyond every 45 minutes (consecutive or non-consecutive) or each class period)

☐In-person ☐Phone ☐Other (Describe):

Method of Approval Time of Approval Date of Approval

☐ I have reviewed this form.

☐ This form was entered in Infinite Campus.
Administrator Signature: ___________________________________ Updated August 2019
 Physical Restraint, Transport and Seclusion Parent Information Packet

This packet provides information on physical restraint, physical transport, and seclusion as utilized in the Cedar Rapids Community
School District (CRCSD). The following information is provided:

 District Policy on Student Restraint and Confinement/Detention (Regulation 604.7)

 State of Iowa “Top 10 Points about Chapter 103: Amended Administrative Rules on Corporal Punishment, Restraint, and
Physical Confinement and Detention”
 Glossary of terms appearing in Physical Restraint, Transport and Seclusion Documentation
 Visual depictions of physical interventions

District Policy on Student Restraint and Confinement/Detention

Student Restraint and Confinement/Detention

The Board of Education realizes that restraint and confinement/detention are, in some circumstances, appropriate as a means to maintaining a safe
and orderly school environment. They also expect that such measures comply with the Iowa Administrative Code 281 – Chapter 103.

Use of Reasonable Force

Any staff member may, within the scope of his/her employment, use and apply such force as is reasonable and necessary for self-defense, to protect
the safety of another person, to restrain a student from self-inflicted injury, to stop a fight between students, for the protection of property, to
obtain possession of weapons or other dangerous objects upon the person or within the control of a student; and to use reasonable force in other
circumstances as defined in 704.1 of the Code of Iowa.

Corporal Punishment
Corporal punishment is defined as the intentional physical punishment of a student. No employee shall inflict corporal punishment upon
a student.

Code of Iowa: 280.21 Iowa Administrative Code: Chapter 103, Section 281
704.1

Top 10 Points about Chapter 103: Amended Administrative Rules on Corporal Punishment, Restraint, and Physical
Confinement and Detention (Effective Nov. 12, 2008)
1. Add a training requirement
 Understand the law – Chapter 103 and Employers policies
 Positive behavior interventions and supports
 Disciplinary options to seclusion and restraint
 Crisis prevention, crisis intervention, crisis de-escalation techniques
 Student and staff debriefing
o Everyone who might need to implement seclusion or restraint should have the professional development described above. With
supplemental information added regarding your district policies, the accompanying PPT presentation will serve the needs of this group.
 Safe, effective use of restraint and confinement and detention
o All staff who definitely use seclusion and/or restraint should be trained in depth regarding holds, restraint, and seclusion (e.g. Mandt, CPI)
2. Corporal Punishment is banned in Iowa. The definition of corporal punishment is “The intentional physical punishment of a student, “including
“the use of unreasonable or necessary physical force, or physical contact made with the intent to harm or cause pain.”
3. No mechanical restraints may be used. This includes misusing physical devices that are meant for safety, therapy, or another purpose (E.g.
you may not use Rifton chair to discipline a child)
4. You can still use necessary and reasonable force. Necessary and reasonable are defined by the context of the event. (E.g. restraining
someone for tearing up a paper is unreasonable and unnecessary force)
5. If using seclusion (or physical confinement), the room must be of adequate size, sufficient light, adequate ventilation, and temperature
similar to the rest of the building
6. Period of time for confinement should be reasonable and allow for bodily needs.
7. If confinement extends past 60 minutes or 1 period (whichever is shorter), an administrator must authorize the continued confinement.
8. Adequate and continuous adult supervision is necessary.
9. Material restraints cannot be used to maintain confinement. Door latches must be nonlocking and allow for easy exit if pressure is released.
May not be disabled by duct tape or chairs. No keyed locks!
10. Notice to parents: if restraint or seclusion is used with a student, parents must be notified that day and in writing within 3 days. Share
documentation with parents. Documentation includes:
 Name of student involved,
 Name of employees involved, including the administrator authorizing further confinement
 Date, time & duration of incident Updated August 2019
Abbreviations Listed on the Seclusion and Restraint Documentation Form
CPI Crisis Prevention Institute NCI Nonviolent Crisis Intervention
More information can be found here: www.crisisprevention.com Practical skills for safely managing and preventing difficult behavior – proprietary
language from CPI.
FBA Functional Behavior Assessment BIP Behavior Intervention Plan
A systemic way to figure out what triggers problem behavior. The information is used in A plan that includes positive strategies, program modifications and supplementary
designing a plan to address problem behaviors and prevent them from happening in the future. aids and supports that address a student’s disruptive behaviors.
IEP Individualized Education Plan FIE Full Individualized Evaluation
The IEP is written document that describes the educational plan for a student with a An initial evaluation to determine if a student is a child with a disability and the
disability. The IEP talks about the student’s disability, what skills he/she need to learn, educational needs of the student. The FIE determines eligibility for special education.
what the student is doing in school this year, what services the school will provide, and CPC Competing Pathways Chart
where learning will take place. A chart utilized along with an FBA to help identify appropriate replacement behavior
504 Individualized Plan of Accommodations PBS Positive Behavior Supports
A plan that lists the accommodations a school will provide, such as audiobooks, note- Supports that reinforce appropriate behaviors and make challenging behavior less
taking aids or extend time to complete tests, so that a student with a disability has equal desirable to engage in.
access to the general education curriculum. (Accommodations are tools or procedures Replacement Behavior
that provide equal access to instruction and assessment for students with disabilities.)
RB
A replacement behavior is an alternative that allows a student to meet the same need or
BFBA Brief Functional Behavior Assessment achieve a similar outcome as the undesired behavior they are currently using.
Checklists and questionnaires that help determine the function/purpose of problem behavior ABC Data – Antecedent- Behavior- Consequence Data:
ABC
ABC data is collected through direct observation to gather information about the
AEA Area Education Agency
events that are occurring within a student’s environment. “A” refers to the
Educational service agencies that ensure all students have access to high-quality
antecedent, or the event/activity that immediately precedes a problem behavior. “B”
educational opportunities and resources. AEA staff work as educational partners with
refers to observed behavior, and “C” refers to the consequence, or the event that
public and accredited, nonpublic schools to improve the learning outcomes and well-
immediately follows the response.
being of all children and youth. AEAs also provide tools for educators to grow
professionally and reach students. https://www.gwaea.org

NCI Physical Restraint

Seated Hold

Standing Hold Team Control

Children’s Control NCI Physical Transport

Updated August 2019