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*All information required by DESE’s Model Policy on Seclusion and Restraint and / or SSD’s Board Policy Regulation JGGA-R is indicated with an asterisk * |
Staff should contact their administrator with questions about how to complete this form. The Technology Help Desk should only be contacted if the form is malfunctioning. All process and data entry questions please direct to the building supervisor and/or your administrator.
Form Intro: Creating and Accessing a Seclusion and Restraint E-Form
Log-in to the SSD Portal and go to the Finreporting and E-Forms application.
Select EForm(s) – Author Listing.
Click on “Add Seclusion and Restraint Form” located in the top banner.
A new Seclusion and Restraint EForm will open,
With your name listed as Assigned to.
Status will be Open.
An Incident Number will be assigned, which is the ticket number specific to this report.
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Once a form is open you will see a list of ‘Data Entry Issues’ in red. These are required fields. The Data Entry Issues will disappear as you complete the required fields and save the form. Data Entry fields are not errors with the application. Once you are finished with the form, if there are still Data Entry Issues noted at the top, you must review the form to identify and complete any required field. If you have any questions, contact your administrator. |
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A Help button is available at the top of the form. Clicking this link will send the user to the Technology Services Knowledge Center support site to this documentation. |
Section 1: General Information
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Notes on the E-Form in green font are provided as guidance to staff completing the form. They will not print on the final report. |
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This form must be used when a student is involved in a situation that presents an imminent danger to himself/herself or others and requires a crisis intervention. Multiple incidents occurring within one hour should be documented on this form. IMPORTANT: This form needs to be completed within 4 school days of the incident occurring |
*Enter the student’s SSD ID number and click Load Student Data. by clicking Load Student Data student demographic information will auto-populate.
*The student’s name, MOSIS ID, grade level, LRE placement, building and eligibility will auto-populate.
If any of the information is incorrect, you can type over it to change it.
If you change any information, 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. Continue to complete the form even if you make updates with Student Data. Submit a ticket for Student Data here.
Indicate if the student receives ABA services by checking the box if they do.
For Service Type, check all the boxes that apply for this student.
*From the drop-down menu, select where the incident began. If selecting “Other,” specify location in the box provided.
*Document the date the incident occurred.
*Select the time frame the incident occurred from the available drop down.
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).
*For the Staff Involved section, all staff members should be listed including their first names and last names.
Correct: Joe Johnson.
Incorrect: Mr. Joe, J. Johnson, JJ, Mr. Johnson, The Teacher.
*For each Staff Involved team member, select their role from the drop-down list.
*For each Staff Involved team member, indicate whether or not they have completed NCI training within the last calendar year.
Click Save changes. Staff should save this form frequently so that they do not lose data. After saving changes you will not lose your place on the form.
Section II: Behaviors demonstrated by student requiring Seclusion or Restraint
*Select all student behaviors that apply to this incident.
There are new behavior options, ‘student elopement..’ and ‘property destruction…’ have been added as additional behavior options.
If you select Other, a detailed description of the behavior should be provided in the text box (max character count of 1,000).
*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). This text box is required to describe events that led up to the physical intervention, regardless of what the student behavior is.
Reminder: save your progress.
Section III: Non-Physical Preventive / De-escalation Intervention Attempted by School Personnel
*From the available options, select all interventions attempted by staff prior to the seclusion or restraint occurring.
For Sensory Supports, describe any supports provided. Leave blank if none.
For Environmental Modification, describe any modifications that were provided. Leave blank if none.
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.
Section IV: Physical Crisis Strategies
*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.
See 5 examples of documenting multiple restraints.
Document the start and end times for each type of crisis strategy used.
Reminder: save your progress.
Describe the restraint and / or seclusion process and how each staff member intervened:
*First and Last Name(s) of the staff member(s) who implemented the Restraint. Separate multiple staff names with a comma.
*First and Last Name(s) of the staff member(s) monitoring the student for signs of distress during the Restraint or Seclusion.
*In the appropriate box, list the NCI techniques that were used during this crisis response (max character count 1,000).
*In the second text box of this section, provide a detailed description of the Restraint or Seclusion event (max character count 1,000).
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.
If the student is transported to the hospital for suicidal evaluation, that information should be included in this section. The next section on “Monitoring” is in regard to student physical status during and after the event.
Indicate if Law Enforcement was involved.
If yes, indicate if they were district personnel or local police department.
First and Last Names and roles 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.
Reminder: save your progress.
Section V: Monitoring
*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. It is recommended that a nurse monitor or check the physical status of the student. When a nurse is not available, another staff member may be the trained designee, who will typically be an administrator.
*Document the time the student’s physical condition was checked.
*Document the Level of Injury the student sustained during the incident using the definitions provided on the form. Contact your administrator if you have questions about these definitions.
*Provide a description of the student’s physical status in the available box (max character count of 1,000).
Document if any staff members were injured during the incident, with a detailed description if so (max character count of 1,000).
If any staff members were injured, complete the Worker’s Injury Form by the end of the school day on which the incident occurred.
Document if any other students were injured during the incident, with a detailed description if so (max character count of 1,000).
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.
Section VI: Student Postvention Procedures
Conduct COPING (Control, Orient, Pattern, Investigate, Negotiate, Giving). Process for Student as specified in Non-Violent Crisis Intervention training.
*Document at least one postvention procedure that was used during the establishment of therapeutic rapport.
Note that ‘Hassle log’ has been changed to ‘Think Sheet,’ and ‘Community Circles,’ and ‘Restorative Practices,’ have been added as options.
In the space for “Other,” provide a detailed description of any other postvention procedures that were utilized.
Reminder: save your progress.
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Section VII: Resulting Action(s) of today’s Incident
*Of the options available, check all that apply to indicate the results of the crisis event.
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.
Section VIII: Staff Postvention 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. “Clicking on the JGGA-R link will direct users to the SSD public site. Enter in the code JGGA-R and click submit to view the most up to date policy.” |
*Document the Team’s Meeting Date and Time.
*Indicate if 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 the student’s behavior detected.
*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.
In the box provided, document any other variables the team considered that have not been included elsewhere on this form.
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.
Document any additional actions to be taken as a result of this team debriefing.
Reminder: save your progress.
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. Do not wait until this section of the form to notify the parent/guardian. In accordance with JGGA-R, the parent/guardian must be notified of the crisis event through verbal or electronic means as soon as possible but no later than one hour after the end of the school day of the event. The staff member must also inform the parent/guardian that they will receive a written report of the crisis event within 5 school days. |
*Document the First and Last Name of the parent or legal guardian who was contacted.
*Document the Method of Notification (phone, in person, etc.).
*Document the First and Last Name of the staff member who contacted the parent / legal guardian.
*Indicate the date and time the parent / legal guardian was notified of the restraint or seclusion event.
This is NOT the date the paper report was provided to the parent. Student Records will send the report to families after staff complete this form.
Reminder: save your progress.
Section X: E-Signatures.
PRIOR TO checking the box for your e-signature, review the entire form for accuracy and completeness. Once all required fields are completed and signed by the author and the supervisor, this form automatically closes and can no longer 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.
The Author e-signs the form (by checking the box next to their name in Section X) and click Save changes.
DO NOT click Save and return to view. Please click the Save Changes button above section X.
Return to the TOP of the form and in the AssignTo field, select the name of SSD Supervisor for the building the student attends.
If you do not see the supervisor in the drop-down list, then check the box, to add all supervisors. This will reload the page and allow you to select any SSD supervisor.
For related service providers and ABA staff, the supervisor your select may not be your direct supervisor.
Click Save and return to View.
Supervisor is emailed within 10 minutes after a form is assigned to them.
FINAL STEP: SSD Administrator reviews the form for accuracy and completeness. Remember, a closed 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, and then click SAVE. 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.
Emails are generated after 5 days, if you have an open form assigned to you.
Once a form has been closed, it is accessed the following school day by Student Records to be sent home to the parent. Student Records sends a copy of the completed form with the cover letter to the following:
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.
Student Records also provides the required data to DESE via the Tiered Monitoring process online.
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