2080 Citygate Drive • Columbus, OH 43219
p: 614.445.3750
│
f: 614.445.3767
www.escofcentralohio.o
CRITICAL INCIDENT FORM
STUDENT NAME: _______________________
D.O.B: _________________
SCHOOL BUILDING: _____________________
DATE OF INCIDENT: ___________
TIME OF INCIDENT: _____________A.M/P.M.
LOCATION OF INCIDENT: _______________________
TYPE OF BEHAVIOR THAT RESULTED IN RESTRAINT OR SECLUSION (check all that apply):
____ Physical aggression directed towards peers
____ Physical aggression directed towards staff
____ Physical aggression directed towards self (self-injurious behaviors)
____ Property damage that threatened safety of self/others
____ Leaving school building or property without permission that posed an immediate risk of harm
____ Other (specify): ___________________________________
Note: Physical intervention and seclusion may only be used when all other interventions have been
exhausted and when a student in an imminent danger to self or others.
BRIEF DESCRIPTION OF THE INCIDENT (Please clearly describe the incident in observable terms)
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
TYPE OF INTERVENTION:
___ Seclusion
___ Restraint
If seclusion was used, indicate the name(s) of the team member(s) who implemented the intervention,
and length of intervention:
____________________________________
_____________________________________
____________________________________
_____________________________________
Start time of intervention: __________ A.M/P.M.
End time of intervention: _________ A.M/P.M.
If restrained, indicate the CPI Nonviolent Physical Crisis Intervention technique used as a last resort to
ensure the care, welfare, safety, and security of all involved, and the length of intervention:
___ CPI Children’s Control Position
___ CPI Team Control Position
Start time of intervention: _________ A.M/P.M.
End time of intervention: _________ A.M/P.M.
Name(s) of team member(s) who implemented the physical intervention:
____________________________________
____________________________________
____________________________________
Name(s) of team member(s) who offered CPI’s CARE of the physical intervention:
___________________________________
____________________________________
Staff signature: ________________________________
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Did injuries occur? ____ Yes** ____ No
**If yes, please complete separate ESCCO non-critical incident form, and check with building/district
policy for further action required.
SETTING & ANTECEDENT (What happened before the behavior occurred):
Setting
Antecedent
___ Bus/ Transition
___ Attempt to gain attention (adult/peer) **
___ General Education Classroom
___ Attempt to gain preferred (item/activity) **
___ Intervention Classroom
___ Attempt to avoid directive
___ Hallway
___ Attempt to avoid (person, place, activity/task)
___ Cafeteria
___ Change in routine or schedule
___ Specials (Music, Art, P.E, Library) **
___ Transition between rooms
___ Recess
___ Transition between tasks
___ Restroom
___ Student appeared fatigued, sick, or in pain
___ Office
___ Social interaction or group activity with peers
___ Related Service (Speech, OT, PT) **
___ Student was given an earned consequence
___ Other (Please specify): _________________
______ Other (Please specify):________________
________________________________________ _________________________________________
**Please circle one item when multiple choices are given.
PREVENTATIVE INTERVENTIONS:
The Educational Service Center of Central Ohio’s policy indicates restraint and seclusion shall only be
used as a last resort, and focuses on prevention and a commitment to safety, therefore; please identify
proactive and/or less restrictive forms of intervention that were in place prior to or during the incident in an
effort to support appropriate behaviors and/or help the student regain control.
___ Break system
___ Choices given
___ Transition warning
___ Reduce audience
___ Meet with preferred staff
___ Awareness of nonverbal/
member
paraverbal communication
___Use of visuals
___ Use of sensory tools and/or
___ Active listening and verbal
relaxation techniques
de-escalation
___Review expectations
___ Academic assistance
___ Allow for verbal release
___Prepare for change in
___Positive reinforcement
___ CPI Personal Safety
schedule or routine
system
Technique(s)
RESTRAINT AND SECLUSION PROCEDURES WERE USED BECAUSE THE DANGER PRESENTED
DURING THE INCIDENT PREVAILED OVER THE RISK OF PHYSICAL INTERVENTION AND LEAST
RESTRICTIVE INTERVENTIONS WERE EXHAUSTED. ____YES ____ NO
POSTVENTION (De-briefing process that provides the opportunity to move towards behavioral
growth, and helps reduce the likelihood the incident will be repeated).
 COPING Model completed with student on ________ (date) at _____ (time).
 Name of team member reviewing COPING Model with student: _________________________


COPING Model conducted with team member on ________ (date) at _____ (time).
Name of team members involved in the COPING Model: _______________________________
The team plans to identify student triggers, and target proactive strategies to reduce the likelihood unsafe
incidents will be repeated and support positive behavior.
REPORTING AND CONTACTS MADE:
Building Administrator contacted and form submitted: ___ Yes ___ No
Time parent contact made via phone call: __________A.M./P.M.
Time parent contact attempted via phone call: __________A.M./P.M.
Police/Sheriff contact made: ____ Yes ____ No
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By: ______________________
By: ______________________
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