ࡱ> '`  bjbj$$ .FFhhhhhhh|@@@8@A\|e[BHHHH-L$QNDOZZZZZZZ$O\h^Z]hQuK-LQQZhhHH[TTTQXhHhHZTQZTThhTHB `G@QT(Ut5[0e[T[_R[_T[_hTT9P0iP"TPP9P9P9PZZ|TX9P9P9Pe[QQQQ|||D"'|||'|||hhhhhh PROVIDENCE PUBLIC SCHOOLS CRISIS INTERVENTION/PHYSICALRESTRAINT REPORT  Date of incident_ FORMTEXT      _____________ Date of report__ FORMTEXT      ______________ STUDENT NAME___ FORMTEXT      ___________________ School _ FORMTEXT      ______________ Person completing report___ FORMTEXT      ____________ ____ FORMTEXT      _____________________ Name Title/position Person(s) who administered restraint ___ FORMTEXT      _________________ _____ FORMTEXT      ____________ Name Title/position ___  FORMTEXT      ______________ ________ FORMTEXT      ___________ Name Title/position Duration of physical restraint: Began _ FORMTEXT      _____ Ended__ FORMTEXT      _______ Total time _ FORMTEXT      _____ Administrator informed ___ FORMTEXT      _______________ ____ FORMTEXT      ____________ Name Title/position Observers/Witnesses ______ FORMTEXT      ___________ __ FORMTEXT      ___________________ Location of restraint____ FORMTEXT      ______________________________________ Activity in which student was involved prior to restraint_____ FORMTEXT      _______________ Location of other students during the restraint__ FORMTEXT      __________________________________ Location of other staff during the restraint__ FORMTEXT      __________________________________________ CHECK TRIGGERS/BEHAVIOR PROMPTING RESTRAINT: TRIGGERDESCRIPTION FORMCHECKBOX Academic challenge FORMTEXT       FORMCHECKBOX Arguing with adults FORMCHECKBOX Arguing with peers FORMCHECKBOX Before school incident FORMCHECKBOX Bus incident FORMCHECKBOX Challenges of routine FORMCHECKBOX Consequence FORMCHECKBOX Continuation of previous CI FORMCHECKBOX Demand FORMCHECKBOX Denied request FORMCHECKBOX Discomfort FORMCHECKBOX Environmental stimulus FORMCHECKBOX Extreme emotion FORMCHECKBOX Fatigue FORMCHECKBOX Hunger FORMCHECKBOX Ignored FORMCHECKBOX Illness FORMCHECKBOX Natural consequence FORMCHECKBOX Negative social interaction FORMCHECKBOX Praise FORMCHECKBOX Peer in crisis FORMCHECKBOX Positive social interaction FORMCHECKBOX Report of home crisis FORMCHECKBOX Other CHECK DE-ESCALATION EFFORTS AND INTERVENTION ALTERNATIVES ATTEMPTED PRIOR TO HOLDING  FORMCHECKBOX Choices FORMCHECKBOX Proximity control FORMCHECKBOX Change in intervening staff FORMCHECKBOX Quiet/time out room FORMCHECKBOX Conflict resolution FORMCHECKBOX Reality therapy FORMCHECKBOX Escort FORMCHECKBOX Redirection FORMCHECKBOX Exclusion FORMCHECKBOX Reminder FORMCHECKBOX Hurdle helping FORMCHECKBOX Solution Center FORMCHECKBOX Limit setting FORMCHECKBOX Verbal/nonverbal prompts FORMCHECKBOX Parental contact FORMCHECKBOX Other FORMCHECKBOX Peer mediation FORMCHECKBOX Other CHECK SPECIFIC BEHAVIORS DEMONSTRATED THAT NECESSITATED THE HOLD  FORMCHECKBOX Learning disruption FORMCHECKBOX Property destruction FORMCHECKBOX Leaving supervision FORMCHECKBOX Self-abuse FORMCHECKBOX Physical aggression FORMCHECKBOX Suicidal ideation FORMCHECKBOX Physical acting out FORMCHECKBOX Verbal aggression FORMCHECKBOX Other  FORMCHECKBOX Other   JUSTIFICATION FOR INITIATING PHYSICAL RESTRAINT  FORMTEXT        HOLD UTILIZED: _ FORMCHECKBOX _ one person children s control position _ FORMCHECKBOX __ team control position _ FORMCHECKBOX __ transport position _ FORMC46\  0 2 4 > @ ^ v | ~ ʺҨʘҨʈҨ~yi~j\hhIW>*U h>*jh>*UjhhIW>*UjthhIW>*U#jhh>*UmHnHujhhIW>*Uhh>*jhh>*Uh hO;5 h 5jh 5UmHnHuh %4^ " 6 " ^ : `,h.d 6$If @ ^@ `dh$a$֚   8 X Z n p r | ~ Z   ^ f h | ~ ٹ٩ٙىyjhhIW>*UjhhIW>*Uj,hhIW>*UjhhIW>*UjDhhIW>*UjhhIW>*U h>*hh jh>*Ujh>*UmHnHu/ X .0DFHRTnɹѧ梒梂rbjbhhIW>*UjhhIW>*UjvhhIW>*UjhhIW>*U h>*#jhh>*UmHnHujhhIW>*Uhh>*jhh>*Uhh jh>*Ujh>*UmHnHu&zJ`bvxz@PRfhjtvzj& hhIW>*UjhhIW>*Uj:hhIW>*UjhhIW>*UjNhhIW>*Ujh>*UmHnHujhhIW>*U h>*hh jh>*U0 8:VXZJLhjl*ѻխѢїьсvjXhUj9hUjhUj hUj hUjhUmHnHuj hIWUjG hIWUhjhU h 5h jh>*Ujh>*UmHnHu,68\~xxx$Ifkd $$IflFj*. 206    4 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  _______________________________ RATIONAL ______ FORMTEXT      _____ STUDENT BEHAVIOR DURING HOLD____ FORMTEXT      _______________________________ HOW RESTRAINT ENDED_____ FORMTEXT      ___________________________  FOLLOW UP ACTIONS _ FORMCHECKBOX __Behavior intervention plan (development or modification) _ FORMCHECKBOX __Crisis counseling __ FORMCHECKBOX _In-house suspension __ FORMCHECKBOX _Processing sheet _ FORMCHECKBOX __Reparative contract __ FORMCHECKBOX _Referral to evaluation team __ FORMCHECKBOX _Suspension  DESCRIPTION OF MEDICAL ATTENTION NEEDED Did an injury occur as a result of this restraint? _ FORMCHECKBOX _Yes _ FORMCHECKBOX _No If yes, name of student _ FORMTEXT      _____or staff ___ FORMTEXT      ________injured. 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J K L ^ t u v   % & 8 T f z {   * 3 4 F U g w x  ! 3 9 :    % 9 K ] ^ p  "@hm49hhXPPPPPPP,@PPUnknownG: Times New Roman5Symbol3& : Arial3z Times 1hff§&dW )dW )!4d2qHX?td2PROVIDENCE PUBLIC SCHOOLS Sue HartsonProvidence Public SchoolsOh+'0 , L X d p|PROVIDENCE PUBLIC SCHOOLS Sue Hartson Normal.dotProvidence Public Schools3Microsoft Office Word@ @]@@@dW՜.+,0 hp  Providence Public Schools) ' PROVIDENCE PUBLIC SCHOOLS Title  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|~Root Entry FPNData WK1Table}[_WordDocument.SummaryInformation(DocumentSummaryInformation8CompObjq  FMicrosoft Office Word Document MSWordDocWord.Document.89q