Restrictive Procedures Post-Debriefing Form
Student Name:
Staff Debrief
Signatures of staff attending debrief:
,
,
,
,
,
,
Date and time of debrief:
Facilitator:
Does the student have a behavior intervention plan (BIP) in place? YES
Was it followed? YES
NO
NO
If no, document why not:
1.
Was the physical holding or seclusion used in an emergency? YES
2.
Was the physical holding or seclusion the least intrusive intervention that effectively responded to the emergency?
YES
NO
3.
Was the physical holding or seclusion ended when the threat of harm ended and the staff determined that the child
could safely return to the classroom or activity?
YES
NO
4.
Did the staff directly observe the child while physical holding or seclusion was being used? YES
5.
Was the documentation completed correctly?
6. Were the parents correctly notified?
YES
YES
NO
8. Did any injuries occur during the use of the restrictive procedure?
What actions helped? What did not help?
-1-
NO
NO
7. Did any injuries occur prior to the use of the restrictive procedure?
File: Due Process File, Oversight Comm. Chair
NO
YES
NO
YES
NO
September 2013
Describe the procedure used to return the child to his/her routine activities, education setting, intervention, and/or site
determined by the team, BIP and/or administrator:
Follow-up action plan (to prevent need for future restrictive procedures):
Have there been any restrictive procedures used on a separate day in the past 30 calendar days? YES
NO
(If restrictive procedures are used on two separate school days within 30 calendar days or a pattern of use emerges and the child IEP
or behavior intervention plan does not provide for using restrictive procedures in an emergency, the district must hold a meeting of
the Individualized Education Program team within 10 calendar days of the second date.)
Does an IEP meeting need to be scheduled?
YES
NO
Has the district used restrictive procedures on the child on ten or more school days during the same school year?
YES
NO
(If restrictive procedures are used on a child on ten or more school days during the same school year, the team, as appropriate,
either must consult with other professionals working with the child; consult with experts in behavior analysis, mental health,
communication, or autism; consult with culturally competent professionals; review existing evaluation, resources, and successful
strategies; or consider whether to reevaluate the child.)
Does further action need to be taken?
YES
File: Due Process File, Oversight Comm. Chair
NO
-2-
September 2013