The use of seclusion or restraint by SSD or the contracted private providers is limited to situations of conditions in which there is imminent danger of physical harm to self or others. Any student placed in seclusion or restraint shall be removed from seclusion or restraint as soon as the student is no longer in imminent danger of physical harm to self or others.
For all school years beginning on or after July 1, 2022, SSD or the contracted private provider shall not use any mechanical, physical, or prone restraint technique that
obstructs views of the student's face;
obstructs the student's respiratory airway, impairs the student's breathing or respiratory capacity, or restricts the movement required for normal breathing to cause positional or postural asphyxia;
places pressure or weight on or causes the compression of the student's chest, lungs, sternum, diaphragm, back, abdomen, or genitals;
obstructs the student's circulation of blood;
involves pushing on or into the student's mouth, nose, eyes, or any part of the face or involves covering the face or body with anything including, but not limited to, soft objects such as pillows, blankets, or washcloths;
endangers the student's life or significantly exacerbates the student's medical condition;
is purposely designed to inflict pain; or
restricts the student from communicating. If an employee physically restrains a student who uses sign language or an augmentative mode of communication as the student's primary mode of communication, the student shall be permitted to have the student's hands free of restraint for brief periods unless an employee determines that such freedom appears likely to result in harm to self or others.
All information required by DESE’s Model Policy on Restraint and Seclusion or Special School District’s Board Policy Regulation JGGA-R is indicated with an asterisk(*).
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Intro: Creating and Accessing a Restraint & Seclusion E-Form
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Login to the SSD Portal, go to the Finreporting and E-Forms application
Select EForm(s) – Author Listing
Select Add Seclusion and Restraint Form from the top banner
A new Seclusion and Restraint E-Form opens, with your name listed as assigned to:
Status is open
Incident # is the ticket number specific to this report
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Green notes on the E-Form are provided for guidance and will not print. |
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Section 1: General Information
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Enter the Student SSD# number and click Load Student Data
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Student name, MOSIS #, Student grade, LRE placement, Building and Eligibility auto-populate:
If any of the information is incorrect, correct it
Notify Student Data of the incorrect information by clicking the link to create a Student Data Support Desk ticket
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For Service type, check all the boxes that apply for this student.
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Select the appropriate option from Where did the incident began. If Other is selected, specify location in the text box.
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Enter the Incident date
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Select the Incident time
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The Name of person completing form is auto-filled with the creator of the E-Form.
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For Staff Involved, list staff members in First name and Last name fields:
Correct: Joe Johnson
Incorrect: Mr. Joe, J. Johnson, JJ, Mr. Johnson, The Teacher
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Select the Role from the list
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Select Yes or No to indicate if NCI Training was completed within the last calendar year
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Save changes
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Section II: Behaviors Demonstrated by Student Requiring Seclusion or Restraint
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Select all Behaviors demonstrated by student requiring Seclusion or Restraint that apply to this incident
Options:
Physical aggression towards peers
Physical aggression towards adults
Student elopement with risk of injury to self or others
Property destruction with risk of injury to self or others
Self-Injury
Other
If Other is selected, provide a detailed description of the behavior in the text box.
In the 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.
Save changes
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Other text boxes throughout the form have a 1,000 character limit. |
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Section III: Non-Physical Preventive/De-escalation Intervention Attempted by School Personnel
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Select at least one intervention attempted by staff prior to the seclusion or restraint occurring
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Describe Sensory Supports, leave blank if none
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Describe Environmental Modification, leave blank if none
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Save changes
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Section IV: Physical Crisis Strategies
You must complete at least 1 start and end time in at least one of the 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.
Examples:
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 AM and ending at 10:37 AM. The start times all fall within the same hour window, even though the events spanned more than 1 hour.
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. The start times are clearly not within the same hour time window.
Enter the start and end times for each type of crisis strategy used. As indicated in the examples, more than one type of Crisis Intervention can be documented on the same page as long as it is the same crisis incident and the onset of all crisis strategies are within the same hour.
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Describe the restraint and / or seclusion process and how each staff member intervened:
Enter the first and last name of the staff member who implemented the restraint
Enter the first and last name of the staff member monitoring the student for signs of distress during the restraint or seclusion
Indicate Which NCI Techniques Were Used during this crisis response in the text box
Enter a detailed description of the restraint or seclusion event in the text 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.
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.
Select Y/N for Was Law Enforcement Involved
If yes, indicate if they were district personnel or local police department
First name, last name and role of each should also be listed under Section I, Staff Involved
If the local Police Department were involved, their Event Number and Report Number should be listed on this form for FERPA purposes.
Save changes
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Section V: Monitoring
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Enter the first and last name of the Health Service Person or trained designee who checked the student’s physical condition after the crisis incident
Enter the time the student’s physical condition was checked
Enter the Level of Injury the student sustained during the incident
None
Minor
Major
Provide a description of the student’s Physical Status in the available text box
Select Y/N for Were any staff members were injured during the crisis with a detailed description if so in the text box
If any staff members were injured, complete the “Worker’s Injury Form” by the end of the school day on which the incident occurred
Select Y/N for Were any other students were injured during the crisis with a detailed description if so in the text box
If other students were injured, complete the “Student Incident Illness Form” by the end of the school day on which the incident occurred
Save changes
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Section VI: Student Post-Vention Procedures
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Select at least one post-vention procedure that was used during the establishment of therapeutic rapport
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Save changes
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Section VII: Resulting Action(s) of Today’s Incident
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Select at least one resulting action of the crisis event
For Other, provide a detailed description on any other results of the crisis event in the text box.
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Section VIII: Staff Post-Vention Procedures / Plan to Prevent the Need for Future Use of Crisis Strategies for Seclusion and Restraint
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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.
Enter the Team Meeting Date and time
Select Y/N for whether the student has a current Behavior Intervention Plan (documented in the IEP)
If yes, provide the date of the BIP
Based on the team’s debriefing discussion, document if there were Patterns of behavior detected for the student.
Indicate if a Functional Behavior Assessment of the student’s behaviors has ever been completed
If yes, note the hypothesized function of the behavior as identified by the FBA
Enter any other variables the team considered that have not been included elsewhere on this form in the text box
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.
Enter any additional actions to be taken as a result of this team debriefing
Save changes
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Section IX: Parent / Guardian (and Surrogate, if applicable) Notification
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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.
Enter the first and last name of the parent or legal guardian who was contacted in Name of person notified
Enter the Method of Notification (phone, in person, etc.)
Enter the first and last name of the staff member who contacted the parent / legal guardian in Person making notification
Indicate the date and time the parent / legal guardian were notified
This is NOT the date the paper report was provided to the parent
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Section X: E-Signatures
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PRIOR TO checking the box for your e-signature, review the entire form for accuracy and completeness. A closed / locked form cannot be edited.
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.
Save and return to View
Return to the TOP of the form and in the “AssignTo” field, select the name of SSD Supervisor for the building the student attends
*for related service providers and ABA staff, this may not be your direct supervisor
FINAL STEP: SSD Administrator reviews the form for accuracy and completeness. A closed / locked form cannot be edited.
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.
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.
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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:
For Partner Districts: SSD Director, SSD Special Education Coordinator, Partner District Building Principal, and Partner District Liaison
For SSD Buildings and Private Separate Settings: Building Principal and Executive Director of Schools and Programs
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Student Records also provides the required data to DESE via the Tiered Monitoring process online.
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