ࡱ> pro bjbjcTcT .|>>@@8d,GGGGG*!!!!GGAAA!XGGA!AAAG)59YyA0Ap"=p"Ap"AL0"A$@j!!!!p"@ I: PROVIDENCE PUBLIC SCHOOLS CRISIS INTERVENTION/PHYSICALRESTRAINT REPORT  Date of incident_____________________________ Date of report________________________ STUDENT NAME______________________________________ School ________________________ Person completing report_______________________________ __________________________________ Name Title/position Person(s) who administered restraint _____________________________ ____________________________ Name Title/position _____________________________ ____________________________ Name Title/position Duration of physical restraint: Began ____________ Ended_____________ Total time _____________ Administrator informed _____________________________ ____________________________ Name Title/position Observers/Witnesses _______________________________ ______________________________ Location of restraint_________________________________________________________________________ Activity in which student was involved prior to restraint____________________________________________ Location of other students during the restraint____________________________________________________ Location of other staff during the restraint_______________________________________________________ CHECK TRIGGERS/BEHAVIOR PROMPTING RESTRAINT: TRIGGERDESCRIPTIONAcademic challengeArguing with adultsArguing with peersBefore school incidentBus incidentChallenges of routineConsequenceContinuation of previous CIDemandDenied requestDiscomfortEnvironmental stimulusExtreme emotionFatigueHungerIgnoredIllnessNatural consequenceNegative social interactionPraisePeer in crisisPositive social interactionReport of home crisisOther CHECK DE-ESCALATION EFFORTS AND INTERVENTION ALTERNATIVES ATTEMPTED PRIOR TO HOLDING ChoicesProximity controlChange in intervening staffQuiet/time out roomConflict resolutionReality therapyEscortRedirectionExclusionReminderHurdle helpingSolution CenterLimit settingVerbal/nonverbal promptsParental contactOtherPeer mediationOther CHECK SPECIFIC BEHAVIORS DEMONSTRATED THAT NECESSITATED THE HOLD Learning disruptionProperty destructionLeaving supervisionSelf-abusePhysical aggressionSuicidal ideationPhysical acting outVerbal aggressionOther Other   JUSTIFICATION FOR INITIATING PHYSICAL RESTRAINT_________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________  HOLD UTILIZED: ______ one person childrens control position ______ team control position ______ transport position ______ interim control position ______ emergency temporary position (please describe)___________________________________________ RATIONAL _____________________________________________________________________________ _________________________________________________________________________________________ STUDENT BEHAVIOR DURING HOLD_____________________________________________________ _________________________________________________________________________________________ HOW RESTRAINT ENDED________________________________________________________________ _________________________________________________________________________________________ FOLLOW UP ACTIONS _____Behavior intervention plan (development or modification) _____Crisis counseling _____In-house suspension _____Processing sheet _____Reparative contract _____Referral to evaluation team _____Suspension  DESCRIPTION OF MEDICAL ATTENTION NEEDED Did an injury occur as a result of this restraint? _____Yes _____No If yes, name of student __________________________or staff ___________________________injured. Nature of injury ____________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ Medical care provided To whom ______________________________________ By whom ________________________________ Nature of care_____________________________________________________________________________ ________________________________________________________________________________________ School nurse initials ________________ ADDITIONAL INFORMATION __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ PARENTAL NOTIFICATION Parent/guardian of the student was informed about the restraint on: Date________________________ Time____________________________ By_______________________________________ Position_________________________________ Method of notification: _____Phone conversation with ______________________________________ _____Letter _____Conference CC: Principals file Office of Special Populations: Physical Restraint Coordinator Mailed/given to parent or guardian __________________ (Date)     APPENDIX A .AHIJL y 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