WEST CLERMONT LOCAL SCHOOL DISTRICT
WEST CLERMONT LOCAL SCHOOL DISTRICT
PHYSICAL SAFE HOLD REPORT
Student: ____________________________ ID #:_________________ Time and Date of Incident_____________________________
Teacher: __________________________________________________Principal: __________________________________________
Recorder:____________________________________________________________________________________________________
Nurse/Heath Aide: ________________________________________ Time of physical assessment_____________________________
Parent:______________________________________________________________________________________________________
Parent Contact Number: ________________________________________________________________________________________
Time of Parent Contact: ________________________________________________________________________________________
Notice Sent Home: ____________________________________________________________________________________________
Disability Code: _______________ Student Ethnicity: ________________ Was the Student Suspended from this incident? ________
Parent MUST be notified of the physical safe hold procedure and intervention used with the student.
Reason for implementation of the physical safe hold:
(Describe the action that caused the student to be a danger to themselves or others?)
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
What type of CPI physical safe hold was used?:
□ Children’s Control Position □ Team Control Position □ Transport Position □ Interim Control Position
Less restrictive intervention attempted first: (What P ositive B ehavior S trategies were implemented?)
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Did you explain to the student reasons for implementation of a CPI physical safe hold and discuss what behaviors the student would need to display for sufficient behavioral control:
? YES ? NO Duration of Incident : _____________________________________________________________
(A Physical Safe Hold shall not be used for longer than 5 minutes, and the need for continuation of a safe hold shall be reassessed every 5 minutes.)
Upon conclusion of the physical safe hold the student was able to: (check all that apply)
□ Demonstrate safe behavior
□ Process the issue
□ Return to Class
□ Maintain Student in a Small Group Setting
□Complete assignments
Nurse / Health Aide Assessment Results: __________________________________________________________________________
___________________________________________________________________________________________________________
Notation of any concerns: ______________________________________________________________________________________
___________________________________________________________________________________________________________
Staff who implemented CPI Physical Safe Hold Signature: ____________________________________________________________
Building Administrator in Charge Signature: _______________________________________________________________________
Recorder’s Signature: _____________________________________________________________________________________
Health Aide/Nurse Signature: ___________________________________________________________________________________
Other Signature: _____________________________________________________________________________________________
Supervisor Signature: _____________________________________________ Date of Review: ______________________________
(Copies must be sent to the principal, health aide, and the Director of Special Education)
Please fill out the information requested below, tear off Parent/Guardian reporting slip and send home with student .
Parent and or Guardian: __________________________________________________ Date: ____________
School Building Administrator: ____________________________________________
Regarding: Physical Safe Hold Incident
This is a follow up notice regarding the implementation of a Physical Safe Hold. A phone call was made on __________ at _______ pm/am to
Date Time inform you that ______________________________ was acting in a manner that threatened the safety of themselves or others. In order to keep
Student’s Name your child, his/her peers and staff members safe, a physical safe hold was implemented by trained Crisis Prevention Intervention (CPI) staff member
or members. If you have any further questions please contact your child’s principal.
