Student name:

Date of occurrence:

Start time of occurrence:

End time of occurrence:

Start time of use of physical restraint or seclusion:

End time of use of physical restraint or seclusion:

Employee names and titles who observed, were involved with or implemented physical restraint and/or seclusion during occurrence(including administrators who approved extended time if applicable):

Employee’s date of last training on use of physical restraint and seclusion:

Describe student actions before, during and after occurrence:

Describe employee actions before, during and after occurrence, including the reason for any of the following, if applicable:  use of non-approved restraint, use of non-designated seclusion rooms, any restraint or seclusion that lasted longer than necessary:

Describe any less restrictive means attempted as an alternative to physical restraint and seclusion or why those means would not be effective or feasible, or have failed:

Approval from administrator to continue physical restraint or seclusion past 15 minutes:

Administrator approving:

Time approved:

Reasons for length of incident:

Approval obtained from administrator to continue physical restraint or seclusion more than 30 minutes past last approval time:

Administrator approving:

Time approved:

Reasons for length of incident

If Administrator approval was not obtained at 15 minutes or every 30 minutes thereafter, or a student was not provided with breaks for bodily needs in incidents lasting longer than 15 minutes, explain why:

 

Parent/Guardian notification:

Parents/Guardians will be notified as soon as practicable once the occurrence is under control, but no more than one hour after, or the end of the school day, whichever occurs first. Space below for documenting multiple attempts to notify guardians is listed in case the guardian cannot be reached in the first attempt.

Employee attempting notification:

Parent/Guardian contacted:

Time and manner of attempted notification:

Was notification successful?

If Parent/Guardian notification requirements were not complied with, explain why:

Describe injuries sustained or property damaged by students or employees:

Describe future approaches to address student behavior including any consequences or disciplinary actions that may be imposed on the student:

This form has been reviewed and completed by the undersigned employee.  A written copy of this form has been sent to the student’s parent or guardian within three school days of the occurrence.  Unless the parent or guardian agrees to receive the report by email, fax or hand delivery, the report must be sent by mail and postmarked by the third day following the occurrence.  Enclosed with a copy of this form is an invitation for the parents or guardians to participate in the debriefing meeting scheduled in accordance with the law.

 

__________________________________________________________________
Employee

Date of form delivered to Parent/Guardian_______________________________

Method of Transmittal                                                                                              

 

Dear [Guardian],

Recently, your student [name]  was involved in an occurrence at school that required the physical restraint and/or seclusion of your student as defined by Iowa law.  A report related to this occurrence is enclosed with this letter.   The law requires debriefing meetings be held for such occurrences in the following circumstances:

            Following the first instance of seclusion or physical restraint during a school year;

            When any personal injury occurs as a part of the use of seclusion or physical   restraint;

            When a reasonable educator would determine a debriefing session is necessary;

            When suggested by a student’s IEP team;

            When agreed to by the guardian and school officials; and

            After seven instances of seclusion or physical restraint of the student.

This letter is intended to inform you that a debriefing meeting will be held on [date within 5 days of transmission of letter, time, place]  because of [reason from bulleted list above].  The following employees will be in attendance at this meeting:  [list names and titles of employees].  We are inviting you to attend this debriefing meeting to engage with us on topics related to this occurrence.   If you would like to reschedule the debriefing meeting, please contact me as soon as possible via email [email address] or telephone [telephone number], and at least one school day prior to the date and time listed for this debriefing meeting.  Your student is allowed to attend this meeting with your consent and you are welcome to bring a representative of your choosing if you wish.  If you plan to bring a representative to this meeting, please let us know at least one school day prior to the meeting so that we have an opportunity to make arrangements.  We look forward to working with you to foster the continued health, safety and educational growth of your student.

 

Administrator name, Title

Date

 

Enclosure:  Report related to student occurrence

 

[The following individuals must attend the debriefing meeting: employees who administered physical restraint or seclusion; an administrator or employee not involved in the occurrence; the administrator or employee who approved continuation of the physical restraint or seclusion; other relevant personnel designated by the school; if indicated by student’s behavior in occurrence, an expert in behavioral/mental health or other discipline.  The following individuals must be invited to attend the debriefing meeting:  the parent or guardian of the student, the student with guardian’s consent.]

Student name:

Date of occurrence:

Date of debriefing meeting:

Time of debriefing meeting:

Location of debriefing meeting:

Names of individuals attending the debriefing meeting(must include the employees involved and at least one employee who was not involved):

Job title of employee and/or relation to student:

Documentation reviewed during meeting (must include at least the occurrence report; and BIP, IHP, IEP and/or safety plan if applicable):

Identification of patterns of behavior and proportionate response, if any, in the student and employees involved:

Possible alternative responses, if any, to the incident/less restrictive means, if any:

Additional resources, if any, that could facilitate those alternative responses in the future:

Plans for additional follow up actions, if any:

This form has been reviewed and completed by the undersigned employee.  A written copy of this form has been sent to the student’s guardian within three school days of the debriefing meeting.

__________________________________________________________________
Employee

Date of delivered to Parent/Guardian______________________________

Method of Transmittal                                                                                  

 

The school district will comply with Iowa law regarding the use of physical restraint and seclusion with students, including, but not limited to:

• Physical restraint and seclusion will be used only by employees who have been trained in accordance with applicable law unless a trained employee is not immediately available due to the unforeseeable nature of the occurrence.
• As soon as practical after the situation is under control, but within one hour after either the occurrence or the end of the school day, whichever occurs first, the school district will attempt to contact the student’s parent or guardian using the school district’s emergency contact system.
• The seclusion or physical restraint is used only for as long as necessary based on research   and evidence to allow the student to regain control of their behavior to the point that the threat or behavior necessitating the use of the seclusion or physical restraint has ended, or when a medical condition occurs that puts the student at risk of harm.  Unless otherwise provided for in the student’s written approved IEP, BIP, IHP or safety plan, if the seclusion or physical restraint continues for more than 15 minutes:
• The student will be provided with any necessary breaks to attend to personal and bodily needs, unless doing so would endanger the child or others.
• An employee will obtain approval from an administrator or administrator’s designee to continue seclusion or physical restraint beyond 15 minutes.  After the initial approval, an employee must obtain additional approval every 30 minutes thereafter for the continuation of the seclusion or physical restraint.
• The student’s parent or guardian and the school may agree to more frequent notifications than is required by law.
• The school district and school district employees must document and explain in writing the reasons why it was not possible for the employees to obtain approval, notify parents, or take action within prescribed time limits.
• The school district and school district employees who begin and then end use of nonapproved restraints will document and explain in writing the reasons why they had no other option but to use this type of behavioral intervention.
• The area of seclusion will be a designated seclusion room that complies with the seclusion room requirements in accordance with law, unless the nature of the occurrence makes the use of the designated seclusion room impossible, clearly impractical, or clearly contrary to the safety of the student, others, or both; in that event, the school district must document and explain in writing the reasons why a designated seclusion room was not used.
• An employee must continually visually monitor the student for the duration of the seclusion or physical restraint.
• If an employee restrains a student who uses sign language or an augmentive mode of communication as the student’s primary mode of communication, the student shall be permitted to have the student’s hands free of physical restraint, unless doing so is not feasible in view of the threat posed.
• Seclusion or physical restraint shall not be used:  as punishment or discipline; to force compliance or to retaliate; as a substitute for appropriate educational or behavioral support; to prevent property damage except as provided in law; as a routine school safety   measure; or as a convenience to staff.
• The superintendent or the superintendent’s designee will investigate any complaint or allegation that one or more employees violated any provisions of Iowa law.  If the   school district determines a violation has occurred, corrective action will be taken up to and including termination of the employees involved.  If the allegation or complaint involves a specific student the school district will notify the parents or guardian of the involved student about the results of the investigation.  If any allegation or complaint is also defined as abuse in Iowa law, the procedures set out in applicable Iowa law will apply.
• The school district must comply with and implement the requirements in Iowa law whether or not a parent consents to the use of physical restraint or seclusion.