7:190-E3 Behavior Intervention Documentation
Note: Copy of form must be sent to Student Services Office c/o Director of Student Services on the day of the incident.
This form should be completed by school staff for any behavioral incident requiring the use of physical restraint or isolated time-out for any student, general ed or special education, or forced physical guidance (physically moving a student from one location to another) .
| Student |
____________________________ |
School | ______________ |
| Date of Incident | ______________ | Check if Student has IEP | ____ | Start Time of Incident |
_____ |
| Location of Incident | _____________ | Stop Time of Incident | __________ |
| Describe behavior that required physical restraint, isolated time-out, or forced physical guidance.
|
| Describe antecedents to the behavior:
|
| Describe interventions attempted prior to use of physical restraint, isolated time-out, or forced physical guidance.
|
| Was physical restraint or isolated time-out or forced physical guidance used in this situation? (circle one) Describe the intervention used and the student’s behavior while using this procedure.
|
| What staff were involved in responding to the incident?
What staff were involved in the use of physical restraint, isolated time-out, or forced physical guidance?
|
| Describe any injuries to student and/or staff and any property damage that occurred during the behavioral incident or use of physical restraint, isolated time-out or forced physical guidance.
|
| What was the student’s response and the outcome of the behavioral intervention?
|
| What is the plan for dealing with similar behavior in the future, including strategies for avoiding the use of physical restraint, isolated time-out, or forced physical guidance?
|
| When was the parent notified about the need to use the behavior intervention procedure and by whom?
|
| Has either physical restraint or isolated time-out been used 3 or more times this school year? ____
# of times ____ |
| If ‘yes’ to previous question, when is review meeting scheduled?
|
Date Adopted: 04/05/2013
