Notes on the EForm in green font are provided to …. They for guidance and will not print.

1. Log-in to the SSD Portal and go to the Finreporting and E-Forms application

2. Select “EForm EForm(s) – Author Listing”Click on “Add Listing

3. Select Add Seclusion and Restraint Form” located in Form from the top banner

4. A new Seclusion and Restraint EForm will open, with your name listed as “Assigned assigned to.”:

   1. Status will be “Open”Incident Number will be assigned, which is open

   2. Incident # appears and is the ticket number specific to this report

Under Section 1: General Information

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1. Enter the student’s SSD ID Student SSD# number and click “Load Data” Load Student Data

2. The student’s name, MOSIS ID#, grade levelStudent Grade, LRE placement, building and eligibility Eligibility will auto-populate

   1. If any of the information is incorrect, you can type over it to change it

   2. You must also notify Student Data of the incorrect information by clicking the link provided on the form to create a Student Data Support Desk ticket

3. Indicate if the student receives ABA services by checking the box

4. For Service Typetype, check all the boxes that apply for this student

5. Indicate if the student receives ABA services by checking the box if they do

6. From the drop down menu, select where Select from the drop-down in Where did the incident began.  If selecting “Other Other is selected, ” specify location in the box provided.

7. Document the date the incident occurred

8. Select the time frame the incident occurred from the available drop-down

9. Name of person completing the form should be auto-filled (will reflect the name of the person who created the E-Form , and cannot be changed)

10. For the Staff Involved section, all staff members should be listed including their first names and last names

    1. Correct: Joe Johnson

    2. Incorrect: Mr. Joe, J. Johnson, JJ, Mr. Johnson, The Teacher

11. For each Staff Involved team member, select their role Role from the drop-down list

12. For each Staff Involved team member, indicate whether or not they have completed NCI training choose Yes or No to indicate if NCI Training was completed within the last calendar year

13. Click “Save Save changes.”

Under Section II: Behaviors demonstrated by student requiring Seclusion or Restraint

1. Select all student behaviors that apply to this incident

   1. Options available:

      1. Physical aggression towards peers

      2. Physical aggression towards adults

      3. Student elopement with risk of injury to self or others

      4. Property destruction with risk of injury to self or others

      5. Self-Injury

      6. Other

         1. If you select Other, a detailed description of the behavior should be provided in the text box (max character count of 1,000)

         2. In the available text box, “Further describe the behavior necessitating the use of a crisis intervention,” provide a detailed description of the student’s behaviors and events leading up the crisis intervention (max character count of 1,000)

Under Section III: Non-Physical Preventive / De-escalation Intervention Attempted by School Personnel

1. From the available options, select all interventions attempted by staff prior to the seclusion or restraint occurring

2. For Sensory Supports, describe any supports provided.  Leave blank if none

3. For Environmental Modification, describe any modifications that were provided.  Leave blank if none

4. For Other, provide a detailed description of any other interventions or supports that were attempted prior to the seclusion or restraint occurring (max character count of 1,000)

 *Reminder: save your progress

Under Section IV: Physical Crisis Strategies

1. You must complete at least 1 start and end time in at least one of the following sections.  If multiple crisis events start within one hour, document them on the same form.  Use separate forms if more than one hour passes between the start of separate crisis events.

   1. Use one Form: student first restrained starting at 9:30 AM and ending at 9:35 AM.  Student restrained again at 9:45 AM and ending at 9:50 AM.  Seclusion began at 9:51 and ending at 10:37 AM.

      1. The start times all fall within the same hour window, even though the events spanned more than 1 hour

   2. i.e., Use separate Forms: student first restrained starting at 9:00 AM and ending at 9:05 AM.  Student restrained again at 2:00 PM and ending at 2:15 PM

      1. The start times are clearly not within the same hour time window

2. Document the start and end times for each type of crisis strategy used.  As illustrated in the example above (8.a.i), more than one type of Crisis Intervention can be documented on the same page so long as it is in regards to the same crisis incident and the onset of all crisis strategies are within the same hour timeframe. 

3. Describe the restraint and / or seclusion process and how each staff member intervened:

   1. First and Last Name of the staff member who implemented the Restraint

   2. First and Last Name of the staff member monitoring the student for signs of distress during the Restraint or Seclusion

   3. In the appropriate box, list the NCI techniques that were used during this crisis response (max character count 1,000)

   4. In the second text box of this section, provide a detailed description of the Restraint or Seclusion event (max character count 1,000)

      1. In the appropriate box, provide specific details of the restraint or seclusion event, including a description of the student’s physical and psychological status, as well as the safety of the environment based on the Monitor’s observations

      2. If the student is transported to the hospital for suicidal evaluation, that information should be included in the description of the student’s observable physical and psychological distress. 

   5. Indicate if Law Enforcement was involved

      1. If yes, indicate if they were district personnel or local police department

      2. First and Last Names and roles should also be listed under Section I, Staff Involved

      3. If the local Police Department were involved, their event number and report number should be listed on this form for FERPA purposes

*Reminder: save your progress

Under Section V: Monitoring

1. Document the first and last name of the health service personnel or trained designee who checked the student’s physical condition after the crisis incident

2. Document the time the student’s physical condition was checked

3. Document the Level of Injury the student sustained during the incident

   1. None

   2. Minor

   3. Major

4. Provide a description of the student’s physical status in the available box (max character count of 1,000)

5. Document if any staff members were injured during the incident, with a detailed description if so (max character count of 1,000)

   1. If any staff members were injured, complete the “Worker’s Injury Form” by the end of the school day on which the incident occurred

6. Document if any other students were injured during the incident, with a detailed description if so (max character count of 1,000)

   1. If other students were injured, complete the “Student Incident Illness Form” by the end of the school day on which the incident occurred

Reminder: save your progress

Under Section VI: Student Postvention Procedures

1. Document at least one postvention procedure that was used during the establishment of therapeutic rapport

2. In the box available, document any other postvention procedures that were utilized

Under Section VII: Resulting Action(s) of today’s Incident

1. Of the options available, check all that apply to indicate the results of the crisis event

2. In the space for “Other,” provide a detailed description on any other results of the crisis event (max character count of 1,000)

*Reminder: save your progress

Under Section VIII: Staff Postvention Procedures / Plan to Prevent the need for future use of crisis strategies for Seclusion and Restraint

NOTE: Per SSD Board and DESE policies, a debriefing meeting shall be held as soon as possible but no later than 2 school days of the crisis event.  Teams shall refer to Regulation JGGA-R for points that should be considered in the debriefing process and in planning for possible future occurrences.

1. Document the Team’s Meeting Data and Time

2. Indicate if the student has a current Behavior Intervention Plan (documented in the IEP)

   1. If yes, provide the date of the BIP

3. Based on the team’s debriefing discussion, document if there were patterns of the student’s behavior detected

4. Indicate if a Functional Behavior Assessment of the student’s behaviors has ever been completed

   1. If yes, note the hypothesized function of the behavior as identified by the FBA

5. In the box provided, document any other variables the team considered that have not been included elsewhere on this form

6. Based on the team’s debriefing discussion, indicate if the student’s Behavior Intervention Plan is in need of revision, as well as a projected date to revise

7. Document any additional actions to be taken as a result of this team debriefing

*Reminder: save your progress

Under Section IX: Parent / Guardian (and Surrogate, if applicable) Notification

NOTE: This section is to document the notification to the parent / legal guardian the day of the incident, which should be completed no later than 1 hour after the end of the school day

1. Document the First and Last Name of the parent or legal guardian who was contacted

2. Document the Method of Notification (phone, in person, etc.)

3. Document the First and Last Name of the staff member who contacted the parent / legal guardian

4. Indicate the date and time the parent / legal guardian were notified

   1. This is NOT the date the paper report was provided to the parent

*Reminder: save your progress

Under Section X: E-Signatures

1. PRIOR TO checking the box for your e-signature, review the entire form for accuracy and completeness.  A closed / locked form cannot be edited.

2. The person completing the form must check the box by their name to “e-sign” the form.  The date the box was checked will be listed on the printed version of this form.

3. The Author e-signs the form (by checking the box next to their name in Section X), and saves

4. Return to the TOP of the form and in the “AssignTo” field, select the name of SSD Supervisor for the building the student attends

   1. *for related service providers and ABA staff, this may not be your direct supervisor

5. FINAL STEP: SSD Administrator reviews the form for accuracy and completeness.  A closed / locked form cannot be edited.

6. Once the SSD Administrator has reviewed the form AND ANY NEEDED CHANGES HAVE BEEN MADE, the SSD Administrator will check the box by their name to “e-sign” the form.  This will automatically change the status of the form to CLOSED and no other edits can be made.

   1. If an error is recognized on a form after it has been closed, a new form will need to be completed to correct the error.

Once a form has been locked, it is accessed the following school day by Student Records to be sent home to the parent.  A copy of the completed form with the cover letter is provided to the following people:

1. For Partner Districts: SSD Director, SSD Special Education Coordinator, Partner District Building Principal, and Partner District Liaison

2. For SSD Buildings and Private Separate Settings: Building Principal and Executive Director of Schools and Programs 

Student Records also provides the required data to DESE via the Tiered Monitoring process online.