2015-2016
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1.
Minnesota Statutes ....................................................................................................... Pages 3 - 4
2.
District-Wide Teams and Roles
District Wide Restrictive Procedures and Oversight Committe Team ........................... Page 5
Crisis Response Teams ............................................................................................... Page 6-7
3.
New Prague Area Schools Restrictive Procedures Plan ............................................ Page 8-9
Minnesota Statues on Restrictive Procedures .............................................................. Page 8
Restrictive Procedures Not used in New Prague Schools ............................................ Page 8
Seclusion Rooms .................................................................................................... Page 8
Restrictive Procedures Used in New Prague Schools .................................................. Page 8
Physical Holding ..................................................................................................... Page 8
Prohibited Procedures include the Following ............................................................... Page 9
4. General Information ....................................................................................................... Page 9
What is considered an “Emergency” ............................................................................. Page 9
Restrictive Procedures: Basic Procedure ..................................................................... Page 9
Staff Training requirements ........................................................................................... Page 10
Authorized Staff ............................................................................................................ Page 10
Including Restrictive Procedures in IEPs or BIPs .......................................................... Page 10
Documentation Procedures .......................................................................................... Page 11
Post-Use Debriefings .................................................................................................... Page 11
Oversight Committee .................................................................................................... Page 11
Review Procedures ....................................................................................................... Page 11
5.
District 721 Staff Trainings ........................................................................................... Page 12
Current and Previous Trainings ..................................................................................... Page 12
Skills and Knowledge Areas .......................................................................................... Page 13
6.
Use of Restrictive Procedures Hot Sheet .................................................................... Pages 14
7.
Definitions ..................................................................................................................... Page 15
8.
Forms ............................................................................................................................. Page 16
Student Information Form ............................................................................................... Page 17-19
Restrictive Procedure Reporting Form ............................................................................ Page 20-21
Restrictive Procedure Staff Debriefing Form ................................................................... Page 22-28
Postvention Individual Debriefing Form ........................................................................... Page 29-30
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In accordance with Minn. Stat. §§ 125A.094 and 125A.0942 as amended effective
7/1/13, every school district is required to develop and make publicly accessible in an electronic format on a school or district website or make a paper copy available upon request a plan that discloses its use of restrictive procedures with special education students. The plan must list the restrictive procedures that the school district intends to use; describe how the school district will implement a range of positive behavior strategies and provide links to mental health services, describe how the school district will monitor and review the use of restrictive procedures, including post-use debriefings and convening an oversight committee to undertake a quarterly review of the use of restrictive procedures based on patterns or problems indicated by similarities in the time of day, day of the week, duration of the use of a procedure, the individuals involved, or other factors associated with the use of restrictive procedures, the number of times a restrictive procedures is used schoolwide and for individual children the number and types of injuries, if any, resulting from the use of restrictive procedures, whether restrictive procedures are used in nonemergency situations, the need for additional staff training, and proposed actions to minimize the use of restrictive procedures; and includes a written description and documentation of the training any staff members who will be using restrictive procedures have completed to show they have the skills set out in Minn. Stat. § 125A.0942, subd. 5.
:
Restrictive Procedures Plan: Schools that intend to use restrictive procedures shall maintain and make publicly accessible a restrictive procedures plan for children that includes at least the following: (1) the list of restrictive procedures the school intends to use; (2) how the school will monitor and review the use of restrictive procedures, including conducting post-use debriefings and convening an oversight committee; and
(3) a written description and documentation of the training staff completed under subdivision 5.
The New Prague Area School District promotes the use of positive approaches for behavioral interventions for all students. When restrictive procedures are employed in an emergency situation with any student the School
District will adhere to the standards and requirements of Minnesota Statutes 125A.094 Restrictive Procedures for Children with Disabilities.
Restrictive procedures may be used only by a licensed special education teacher, school social worker, school psychologist, behavior analyst certified by the National Behavior Analyst Certification Board, a person with a master’s degree in behavior analysis, other licensed education professional, paraprofessional under section
120B.363, or mental health professional under section 245.4871, subdivision 27, who has completed the training program under subdivision 5.
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“Physical holding” means physical intervention intended to hold a child immobile or limit a child’s movement and where body contact is the only source of physical restraint. The term physical holding does not mean physical contact that: 1) Helps a child respond or complete a task; 2) Assist a child without restricting the child’s movement; 3) Is needed to administer an authorized health-related service or procedure; or 4) Is needed to physically escort a child when the child does not resist or the child’s resistance is minimal.
The New Prague Area Schools Special Education Staff, Administration and Transportation Staff participate in
Nonviolent Crisis Intervention (CPI) training annually, which is considered an evidence-based program, to help de-escalate a situation before it becomes a crisis and to respond appropriately and safely when there is a crisis. The philosophy of CPI is to ensure the Care, Welfare, Safety, and Security of all.
Physical holding or seclusion may be used only in an emergency. A school that uses physical holding or seclusion shall meet the following requirements: 1) the physical holding or seclusion must be the least intrusive intervention that effectively responds to the emergency; 2) physical holding or seclusion must end when the threat of harm ends and the staff determines that the child can safely return to the classroom or activity; 3) staff must directly observe the child while physical holding or seclusion is being used; 4) each time physical holding or seclusion is used, the staff person who implements or oversees the physical holding or seclusion shall document, as soon as possible after the incident concludes, the following information: i) a description of the incident that led to the physical holding or seclusion; ii) why a less restrictive measure failed or was determined by staff to be inappropriate or impractical; iii) the time the physical holding or seclusion began and the time the child was released; and iv) a brief record of the child’s behavioral and physical status.
If a pupil who has an individual education plan is restrained or removed from a classroom, school building, or school grounds by a peace officer at the request of a school administrator or a school staff person during the school day twice in a 30day period, the pupil’s individual program team must meet to determine if the pupil’s individual education plan is adequate or if additional evaluation is needed.
New Prague Area School District uses restrictive procedures only in response to behavior that constitutes an emergency, even if written into a child’s IEP or BIP. “ Emergency ” means a situation where immediate intervention is needed to protect a child or other individual from physical injury. The intervention will be used as a last resort and will be considered the safest option for all. New Prague
Area Schools does not support the use of seclusion rooms and physical holding is the only conditional procedure that will be used.
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The District Wide team will meet quarterly each year (September, January, March & May) to evaluate and review the “Restrictive Procedures District Wide Plan” and review reported uses of restrictive procedures.
Amy Johnson ......................................................................................... Special Education Director
Will Remmert .......................................................................................... Eagle View Elementary Principal
Erik Garnass ........................................................................................... High School Assistant Principal
Rick Bell ................................................................................................. Middle School Assistant Principal
......................................................... Darrin Sawchuk
......................................................................................... Jon Shriver
....................................................................................... Amy Hennen
Sharon Drazenovich ............................................................................. ECSE
Mary Kay Bachel ................................................................................... Raven Stream Elementary
Nicole Sattzer, Jill Grensteiner .............................................................. Falcon Ridge Elementary
Megan Melzer, Melissa Giles ................................................................ Eagle View Elementary
Katie Challberg...................................................................................... Middle School
Dawn Thielen, Shannon Tupy ............................................................... High School
Colleen Traxler ...................................................................................... ELL
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Principal ............................... Will Remmert ....................... x6001 ........................ (cell: 952-381-5936)
School Nurse ........................ Teresa Skluzacek ................. x6006
Building Secretary ................ Darcy Chlan ......................... x6002
Social Worker ....................... Renee Meyer ........................ x6025
EBD Program ....................... Megan Meyer ....................... x6032
First Aid ................................ Terry Skluzacek .................... x6006
Principal ............................... Dave Giesen ........................ x160 .......................... (cell: 952-210-9475)
School Nurse ........................ Amie Wollin .......................... x1606
Building Secretary ................ Julie Martin ........................... x1602
Social Worker ....................... Amy Hennen ........................ x1613
DCD/ASD Program ............... Nicole Saatzer ...................... x1656
............................................. Jill Grensteiner ..................... x1629
First Aid ................................ Amie Wollin .......................... x1606
Principal ............................... Pat Pribyl .............................. x1501 ........................ (cell: 952-292-6017)
School Nurse ........................ Teresa Francis ..................... x1506
Building Secretary ................ Candy Gareis ....................... x1502
Social Worker ....................... Polli Edberg .......................... x1525
Autism Program .................... Mary Kay Bachel .................. x1532
First Aid ................................ Teresa Francis ..................... x1506
Principal ............................... Brad Gregor ......................... x1401 ........................ (cell: 952-292-6014)
Assistant Principal ................ Rick Bell ............................... x1408 ........................ (cell: 952-220-6849)
School Nurse ........................ Angie Sirek ........................... x1406
Building Secretary ................ Cindy Perkinson ................... x1402
Social Worker ....................... Aliina Peterson ..................... x1428
DCD Program ....................... Nancy Sackett ...................... x1424
Resource Program ............... Katie Challberg ..................... x1423
First Aid ................................ Angie Sirek ........................... x1403
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th
Educational Services Director .......... Tony Buthe ........................... x1767.........................(cell: 952-292-6018)
Special Services Director .................. Amy Johnson ........................ x1724.........................(cell: 952-923-0424)
District Nurse .................................... Cheryl Kollasch ..................... x1760.........................(cell: 952-217-1090)
School Nurse .................................... Jan Sirek-Meyer .................... x1706
Building Secretary ............................ Julie DeGross ....................... x1768
ALC/HS Setting 3 EBD ..................... Aliina Peterson ...................... x1428
Transition ......................................... Sue Kratochvil ....................... x1755
First Aid ............................................ Jan Sirek-Meyer .................... x1706
Principal ........................................... Lonnie Seifert........................ x1201.........................(cell: 952-292-6012)
Assistant Principal ............................ Erik Garnass ......................... x1209.........................(cell: 952-210-0393)
Police Liaison ................................... John Madigan ....................... x1330.........................(cell: 952-367-6081)
School Nurse .................................... Lisa Tisdel ............................ x1206
Building Secretary ............................ Ann Marie Simon .................. x1202
Social Worker ................................... Andy Dimick .......................... x1212
DCD Program ................................... Michelle Thelen ..................... x1335
Autism Program ................................ Dawn Thielen ........................ x1248
First Aid ............................................ Lisa Tisdel ............................ x1206
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New Prague Area Schools is committed to using positive behavioral intervention and supports as defined in
Minnesota Statute #125A.0941 (d). This involves incorporating environmental changes and skill building strategies proactively in order to maintain a supportive and safe learning environment. In the event that a student’s challenging behavior should escalate to an emergency situation, New Prague staff may use procedures which are considered restrictive under Minnesota Statute #125A.0942 in order to maintain a safe environment when lesser restrictive procedures are ineffective. In accordance with Minnesota Statute
#125A.0942, Subd. 1, New Prague Area School discloses the following on use of restrictive procedures:
1. Restrictive Procedures: Minnesota Statute #125A.0941 (e) includes physical holding and seclusion as restrictive procedures.
2. Prohibited Procedures: New Prague Area School will never use any of the procedures designated as prohibited under Minnesota Statute #125A.0942, Subd. 4(1-9).
3. Emergency: Minnesota Statute #125A.0941 (b) states that a restrictive procedure may only be utilized in an emergency situation. An emergency is defined as a situation where immediate intervention is needed to protect a student or others from physical injury.
Seclusion Rooms: Seclusion means confining a student alone in a room from which egress is barred. This does not include removing a child from an activity to a location where the child cannot participate or observe the activity. New Prague Area School does not currently use any room for the sole purpose of seclusion.
Should New Prague Area Schools determine the need for such a space, the room would meet the requirements listed under Minnesota Statute #125A.0942, Subd. 3 and would be registered with the state of
Minnesota. In the event that an emergency situation should unexpectedly occur and use of physical holding is deemed unsafe, staff may remove others and themselves from the current room while barring egress in order to prevent injury as use of reasonable force under Minnesota Statutes #125A.582; 609.06, Subd.1; and
609.379. Should such an event occur the student will be monitored and seclusion will terminate immediately when safe to do so. Such use will be documented and monitored as if a designated seclusion room had been used.
Physical Holding: Physical holding means physical intervention intended to hold a child immobile or limit a child’s movement and where body contact is the only source of physical restraint. New Prague Area Schools
Special Education Staff, Administration and Transportation Staff complete mandatory training on appropriate use of physical restraints through CPI (Crisis Prevention Institute) on an annual basis.
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Corporal Punishment which include conduct involving:
1. Hitting or spanking a person with or without an object; or 2) unreasonable physical force that causes bodily harm or substantial emotional harm.
2. Requiring the student to assume and maintain a specified physical position, activity, or posture that induces physical pain.
3. Presenting an intense sound, light or other sensory stimuli using taste, smell, substance, or spray as punishment.
4. Denying or restricting the student’s access to equipment and devices such as wheelchairs, hearing aids or communication boards that facilitate the student’s functioning except when temporarily removing the equipment or device is needed to prevent injury to the student or others or serious damage to the equipment or device, in which case the equipment or device shall be returned to the student as soon as possible.
5. Interacting with a student in a manner that constitutes sexual abuse, neglect, or physical abuse under section 626.556.
6. Totally or partially restricting a student’s senses as punishment.
7. Withholding regularly scheduled meals or water.
8. Denying the student access to bathroom facilities, and/ or; physically holding that restricts or impairs a student’s ability to breathe.
9. Use of tasers or threatened use of tasers.
An emergency is a situation where immediate intervention is needed to protect a child or other individual from physical injury.
● Jumping in front of a bus IS an emergency.
● A student not responding to verbal intervention during a fight MAY BE an emergency.
● Screaming obscenities in the hallway is NOT an emergency.

Can be used ONLY in an emergency, it must be the safest option and the last resort.

Must be the least intrusive effective intervention

Must end when the threat of harm ends

Must be documented EVERY time

Parent notification is required the same day a restrictive procedures is used on a child

A post-use debriefing must occur within 24 hours of the procedure

A Procedure Reporting Form must be completed and submitted to the Director/Supervisor of Special
Education, the Building Principal, and a copy must be placed in the student file.
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Staff Training Requirements: All New Prague Area School staff receive training on the skills and knowledge content areas in accordance with Minnesota Statute #125A.0942, Subd. 1(3) and Subd. 5. (see attached training information)
All Special Education staff were required to attend CPI training prior to August 1, 2011 and continue to participate in refresher CPI training annually. Newly hired staff are required to attend CPI training prior to the start of the school year. Staff who design and use behavioral interventions will complete training in the use of positive approaches as well as restrictive procedures. Training records will identify the content of training, attendees, and training dates.
Authorized Staff: Staff who are trained and current with their CPI training and who are authorized to use restrictive procedures include:
● Building administration
● Licensed school social workers
● School psychologists
● Licensed special education teachers
● Other certified/ registered educational professionals
● Special education paraprofessionals
Including Restrictive Procedures in IEPs or BIPs: The requirement that physical holding only be used in an emergency situation continues to apply even when restrictive procedures are included in the IEP and BIP.
When physical holding is included in the IEP or BIP, the IEP team must:
1.
Insure that an FBA has been completed. Use the FBA information along with the present level of performance, needs, goals, and objectives to develop a BIP.
2.
Include positive behavior supports, de-escalation procedures, instruction in appropriate behavior, and other preventative measures in the BIP.
3.
Document which restrictive procedure is being included and why it is the least restrictive effective intervention. The BIP must identify the frequency and severity of target behaviors for which the restrictive procedure is being considered; and anticipated criteria for returning the students to the routine activities and regular education environment if the intervention is used.
4.
Indicate how the parent wants to be notified when a restrictive procedure is used.
5.
The team is expected to debrief after every restrictive procedure within 24 hours and complete the
Restrictive Procedure Reporting Form and the Restrictive Procedure Staff Debrief Form.
6.
The IEP team can include restrictive procedures in the IEP or BIP but they can only be used in response to an emergency, and you still have to have an IEP meeting if they are used twice in 30 days
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Documentation Procedures: Following each use of restrictive procedures, staff members involved will complete the Restrictive Procedures Reporting Form which meets the documentation requirements under
Minnesota Statute #125A.0942, subd. 3(4) (see attached).
The School District shall make reasonable efforts to notify the parent on the same day by the parents preferred method when a restrictive procedure is used in an emergency. If the school is unable to provide same-day notice, notice will be sent by written or electronic means or as otherwise indicated by the parent. If used twice within 30 days or when a pattern emerges, and it’s NOT already included in student’s IEP or BIP, the district must hold a meeting of the team to conduct a review of the Functional Behavior Assessment data and consider developing or revising the behavioral interventions and supports.
The use of restrictive procedures in emergency situations will be documented on the Restrictive Procedure
Reporting Form . This form should be completed as soon as possible after an incident has occurred, no later than 24 hours after the incident has occurred. Once completed, the form will be sent to the Director/Supervisor of Special Education and a copy of the form should be placed in the student’s special education file as well as a copy given to the building principal. A Restrictive Procedure Reporting Form must be completed every time a restrictive procedure is used.
Post-Use Debriefings: Each time a restrictive procedure is used, the staff person will conduct a post-use debriefing with the staff members involved in the use of such procedures within 24 hours. The post-use debriefing will review the requirements for use of restrictive procedures to ensure that staff has implemented them according to the standards in Minnesota Statute #125A.0942, the form was completed correctly, staff is able to talk through their feelings surrounding the incident, and action-plans are generated. Should the postuse debriefing indicate that uses of restrictive procedures were not used appropriately, New Prague Area
School staff will contact the Building Principal and Director/Supervisor of Special Education immediately.
Within 24 hours the staff members who were involved in the restrictive procedure are expected to debrief after every restrictive procedure and complete the Restrictive Procedure Staff Debriefing Form . The School
Social Worker will be the lead staff member during a de-briefing meeting (when available). An administrator should be invited to the meeting and should attend when possible.
Oversight Committee: Quarterly, the District Oversight Committee will convene and review reported uses of restrictive procedures. This team will review aggregate data, monitor implementation of restrictive and proactive interventions, and provide additional resources if necessary (i.e. training, staff support, materials).
Review Procedures: The District will monitor and review the use of restrictive procedures. This includes postuse debriefings with those involved, meetings each trimester between the Director/Supervisor of Special
Education and all principals to review completed forms and data, and the convening of a District Wide
Restrictive Procedures committee quarterly. In the case of a student with a disability, due process and documentation requirements will be followed a minimum of one time per year during annual IEP meetings.
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Current and Previous Trainings
Presenter: .................................................... MRVSEC Staff
Date: ............................................................ June 23-24, 2011
District Attendance: ...................................... Melissa Giles and Megan Melzer
(Focused on the ten points of the required restricted procedures training)
Presenter: .................................................... MRVSEC Staff
Date: ............................................................ June 14-15, 2011
District Attendance:
Administration: ............................................ Tony Buthe
ECSE: ......................................................... Sharon Drazenovich, Amy Vandenberg
Eagle View: ................................................. Megan Melzer, Melissa Giles
Falcon Ridge: .............................................. Kellie Frey
Middle School ............................................. Jeff Bruder, Jake Frey
High School: ............................................... Dawn Thielen, Shannon Tupy
Presenter: .................................................... Tony Buthe
Presenter: .................................................... Amy Johnson
Presenter: .................................................... Katie Challberg
Presenter: .................................................... Megan Melzer and Melissa Giles
Presenter: .................................................... Megan Melzer and Melissa Giles
To meet all of the requirements of 125A.0942 subd 1(3), staff who use restrictive procedures complete training in the following 12 skills and knowledge areas each year. CPI Training is completed each year and all staff members are certified. Training Components for Restrictive Procedures were initially completed prior to
August 1, 2011. Annual training for the “Standards” for use of Restrictive Procedures will be updated yearly.
Each School Principal provides additional training to the staff regarding Positive Behavioral supports during staff and team meetings throughout the school year. Buildings review behavioral data 3 to 4 times a year. Each building also provides anti-bullying training to staff and students.
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1. Positive Behavioral Interventions
2. Communicative Intent of Behavior
3. Relationship Building
4. Alternatives to Restrictive Procedures (including techniques to identify events and environmental factors that may escalate behavior)
5. De-escalation methods
6. Standards for using restrictive procedures
7. Obtaining Emergency Medical Assistance
8. Psychological/ Physiological Impact of Restraint and Seclusion
9. Monitoring and responding to a child’s physical signs of distress during restraint
10. Recognizing symptoms of Asphyxia during restrain
11. District policies and procedures for timely reporting and documenting each incident involving use of a restricted procedure;
12. School wide programs on positive behavior strategies
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1. Select the least intrusive intervention possible to reasonably react to the emergency situation.
2. Ensure that a staff member directly monitors the student to ensure that the student is safe.
3. End the intervention when the threat of harm ends and staff determine that the student can safely return to the classroom, activity, intervention and/or site determined by the team, BIP, and/ or administrator.
4. We are not using any form of seclusion as an intervention in the New Prague Area Schools District. A student may choose to take a break in a quiet or calming room.
5. Complete the Restrictive Procedure Reporting Form every time a restrictive procedure is conducted. a. A copy of the Restrictive Procedure Reporting Form is available on the district webpage under Restrictive Procedures and is included in this manual.
6. Conduct a debriefing within 24 hours of the incident a. A copy of the Restrictive Procedure Staff Debriefing f Form is available on district webpage under Restrictive Procedures and is included in this manual. b. The debriefing process should involve all members of the team that were involved in the restrictive procedure.
7. Provide copies of the Restrictive Procedure Reporting Form to the Director/Supervisor of Special
Education, the building principal, and the student Special Education file.
8. Notify the parents the same day a restrictive intervention is used using the preferred method of contact that was specified by the parent at the start of the school year (see Student Information Form ).
Provide written or electronic notice within two days if unable to notify parents the same day.
9. Hold a team meeting when a restrictive intervention is used twice in 30 days or when a pattern of behavior emerges. a. In the case of a nondisabled student, the team should develop an intervention plan b. In the case of a student with an IEP, conduct or review a functional behavioral analysis, review data, consider developing additional or revised behavior interventions and supports, consider actions to reduce the use of restrictive procedures, and consider modifying the IEP or BIP.
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Emergency – A situation where immediate intervention is needed to protect a child or other individual from physical injury.
Physical Holding – Physical intervention intended to hold a child immobile or limit a child’s movement and where body contact is the only source of physical restraint. The term physical holding does not mean physical contact that:

Helps a child respond or complete a task;
 Assist a child without restricting the child’s movement

Is needed to administer an authorized health-related service or procedure; or

Is needed to physically escort a child when the chil d does not resist or the child’s resistance is minimal
Positive Behavioral Interventions and Supports – Interventions and strategies to improve the school environment and teach children the skills to behave appropriately. A comprehensive list of district-wide interventions and strategies are listed on the District website under Restrictive Procedures.
Restrictive Procedures – The use of physical holding or seclusion in an emergency.
Seclusion – Confining a child alone in a room from which egress is barred. Removing a child from an activity to a location where the child cannot participate in or observe the activity is not seclusion. A student who selfinitiates going to a “quiet area” to calm down is NOT considered being in seclusion.
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Forms
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Please bring this completed form back to your child’s Case Manager
Student Name: ___________________________________Date:______________________
Parent/ Guardian Name: ______________________________________________________
Grade Entering: _____________________________________________________________
Preferred Method of Communication:
Home Phone Number: ________________________________________________________
Cell Phone Number: __________________________________________________________
Email Address: ______________________________________________________________
Other: _____________________________________________________________________
Does your child have any allergies? If so, what are they?
___________________________________________________________________________
___________________________________________________________________________
What are typical behaviors your child may demonstrate?
___________________________________________________________________________
___________________________________________________________________________
What tends to trigger these behaviors?
___________________________________________________________________________
___________________________________________________________________________
What has proven to be successful in order to work through these behaviors?
___________________________________________________________________________
___________________________________________________________________________
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What motivates your child?
___________________________________________________________________________
___________________________________________________________________________
Is your child sensitive to any sensory input, such as sounds or lights?
___________________________________________________________________________
___________________________________________________________________________
May pictures of your child be used for the special education classroom website?
______ Yes ______No
May pictures be used in social skills books or pictures with other children in his/her group?
______Yes ______No
What have you liked that previous teachers have done that you would like to see implemented this year?
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Is there anything in the past that you think hasn’t worked well?
____________________________________________________________________________
____________________________________________________________________________
What is the biggest goal you have for your child this year?
____________________________________________________________________________
____________________________________________________________________________
What can I do to help support you with this goal?
__________________________________________________________________________
__________________________________________________________________________
What methods of communication have you used in the past with your child’s teacher? (notebook, email, planner, phone calls, etc.)
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___________________________________________________________________________
___________________________________________________________________________
Have there been any changes over the past year or since the last IEP Team Meeting that you feel the school should be aware of?
___________________________________________________________________________
___________________________________________________________________________
Please list any questions or comments you have for y our child’s case manager below:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
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Student Name: _______________________________________________ Date: __________
Building: ____________________________________ Room Number: _________________
Name of Person Completing the Form: ___________________________________________
Name of all persons involved in using the restrictive procedure:
____________________________________________________________________________
Definition of Emergency:
New Prague A rea Schools uses restrictive procedures only in emergency situations. “Emergency” means a situation where immediate intervention is needed to protect the child or other individuals from the physical injury.
Description of Emergency Situation:
Intervention was used to protect a child or staff from physical injury
Intervention was used to protect child from physical injury to self
Yes ____ No ____
Yes ____ No ____
Please list all positive and least restrictive interventions tried before use of restrictive procedure:
(Examples: redirection, safe place to relax, visual supports, verbal or nonverbal de-escalation).
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Please list a description of physical holding and the student’s behavioral and physical status.
_________________________________________________________________________
Was it the least intrusive intervention to effectively respond to the emergency? Explain. Include why a less restrictive measure failed or was determined by staff to be inappropriate or impractical.
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Did the physical holding end when the threat of harm ended and staff determined that the student could safely return to the classroom or activity? Yes ____ No _____
Explain: __________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
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Time intervention began: __________ Time intervention ended: __________
Total Time: _________________________________
Description of physical/ behavior status: ________________________________
Follow-Up
When an emergency situation occurs and a restrictive procedure is implemented, the parents,
Director/Supervisor of special education, and the principal must all be notified within twenty-four hours. The
School District shall make reasonable efforts to notify the parent on the same day by phone when a restrictive procedure is used in an emergency. If the school is unable to provide same-day notice, notice will be sent by written or electronic means or as otherwise indicated by the parent.
Parent/ Guardian Notified (date): ______________________ (time): _____________________
Method used: _________________________________________________________________________
Parent comments (optional):
____________________________________________________________________________
Director of Special Education sent report: Date _______________________
Principal informed: Date _______________
Debriefing Meeting took place on ________________________ at ________________.
CC: Director/Supervisor of Special Education
Building Administrator
Special Education Student File
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Restrictive Procedures Postvention: Debriefing
Person leading the debriefing session: _________________________________ Date: __________________
Persons in attendance:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Date of incident: _____________________________
Brief description of the incident:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Are all staff members who were involved in this incident present for this debriefing session?
________________________________________________________________________________________
________________________________________________________________________________________
If no, who is absent?
________________________________________________________________________________________
________________________________________________________________________________________
How will their input be provided?
________________________________________________________________________________________
________________________________________________________________________________________
__________________________________________________________
**All staff should have completed their incident reports before this debriefing session. If they have not, please allow time for this before beginning.
For the purposes of this debriefing session the Crisis Prevention Institute COPING Model will be utilized as an outline to follow throughout the discussion. Discussion points have been provided for reference if needed, but the leader of the session may or may not use each one. The debriefing process is meant to provide an opportunity for staff to acknowledge any feeling they may be having in a supportive, nonjudgmental atmosphere. This will allow all those involved an opportunity to openly share their recollection of the incident which may increase the identification of possible triggers and alternative interventions.
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· What were staff feelings and concerns during the procedure?
· How are those who were involved with the incident feeling at this point (fear, anger, confusion, powerless)?
. Do staff members feel like they are in need of additional support to better deal with a similar situation should one arise? If so, what support is requested?
Summary:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
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· Describe the incident in chronological order without interruption.
· Review the reports that were written prior to this session
· Describe what happened using the 5 “w” questions: What? Who” To Whom?
Where? When?
· Are there any precipitating factors that have been identified:
Summary: (Note areas of agreement as well as disagreement)
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
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· Did everyone know who the team leader was? Did the team leader give clear directives?
· Did only one person speak to the acting out person?
· IF a physical restraint was used, was it was necessary: How was the “last resort” determined
·
What other interventions were attempted prior to the restrictive procedure?
· How did staff members respond to the actingout person’s behavior?
· Were staff members able to depersonalize the situation and remain rationally detached?
· Did staff members do anything they may have escalated the acting-out person?
· How is data regard ing this student’s behavior being collected?
· What were team members thinking and feeling during the crisis?
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· What additional measures or training may be necessary?
· Is there a need for further debriefing or counseling for the team or individual members?
·
Consider role playing to assist in this stage.
·
Focus on the function of behavior and staff responses, not the form.
Sometimes it helps to identify when the two are
happening.
Summary:
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· Refer to
to assist in this stage.
https://specialedandme.wordpress.com/2007/10/02/questions-to-ask-yourself-whenaddressing-behavior-problems-part-1-of-4/
·
How will we adapt the environment to reduce or eliminate the setting events and antecedents?
· What new skills will be taught to replace the challenging behavior?
· How will the staff respond in order to support positive behavior and reduce the challenging behavior?
· How will staff receive the additional resources, support, and training they may need:
Summary:
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· How can staff members give each other support and encouragement?
· How can staff begin to collect data and track the effectiveness of the new plan?
Summary:
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Staff Name: _______________________________________ Date: ______________________
Student Involved: ______________________________________________________________
Other staff present: ____________________________________________________________
Please fill out this record to the best of your knowledge of the incident. This will help you during the group debriefing process. You may not have witnessed all of the incident or have all of the information and that is ok; please provide the information that you can contribute.
Brief timeline of the incident as you saw it.
1. Setting events (mood before incident, student characteristics, lack of meds, precipitating factors)
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2. Perceived trigger(s). Are there any patterns you have noticed about triggers?
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3. Staff interventions prior to physical hold (redirecting, removing others, warnings, choices, giving space, etc.)
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4. Reaction of student to interventions.
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5. Perceived usefulness/appropriateness of the intervention.
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6. Student actions that were determined to be harmful to self or others.
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7. Was a physical hold used during this intervention? If yes, please describe.
(length of hold, persons involved, physical condition of student/staff throughout, location )
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8. Duration/conclusion of crisis:
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9. Ideas to improve next time or staff training necessary:
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10. Please provide any information that wasn’t included above.
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