Indiana School for the Blind and Visually Impaired

Physical Intervention Procedures

Policy O-46

▪ Physical restraint may only be used to the extent necessary to preserve the safety of students and others and may not be used as a form of punishment/discipline.

▪ Physical restraint is defined as holding a student or otherwise restricting his or her movements and includes only the use of specific, planned techniques.  It does not include momentary periods of physical restriction by direct person-to-person contact designed to prevent a student from completing an act that would result in potential harm to self/others/property.

▪ Use of physical restraint must adhere to the following guidelines:

· The student poses a physical risk to self or others.

· There is no medical contradiction to the use of physical restraint.

· It is not to be used when students display verbal threats, disrespect, or profanity unless the student also demonstrates a means of or intent to carry out the threat.

· Mechanical or chemical restraint is not permitted.

· If physical restraint is used on a student who communicates through sign language or an augmentative mode, their hands must be free for brief periods.

· Time limit- Student must be released from physical restraint immediately upon a determination by the staff that student is no longer in imminent danger of causing harm to self or others.

· The staff applying the restraint has been systematically trained and has received certification of completion or written evidence of participation in training.

▪ After a restraint, the attached form must be completed by the beginning of the next day and placed in the student’s education file. 

▪ The appropriate principal must be notified as soon as possible and no later than end of the school day in which a restraint has occurred. 

▪ Parents should receive written notice from the appropriate principal, within 24 hours, after a restraint occurred unless parents have waived notification requirement in writing.

· Notification must include student’s name, date of incident, description of intervention and name of contact person with telephone number.

Indiana School for the Blind and Visually Impaired

Physical Intervention Report

Student

Date

Start time of Restraint

End time of Restraint

Duration of Restraint

Total number of staff involved: ___________________

Staff who initiated physical intervention:

Name

Title

CPI trained-Yes/No

Other

Staff who assisted with physical intervention:

Name

Title

CPI trained-Yes/No

Other

Notifications:

	Date/Time	By Whom	Method	Response (if any)
Principal
Parent/Guardian (by appropriate  principal, must include-date, description of intervention, and contact person/number)
Superintendent
Intervention report placed in student’s temporary file
Other:

1. Description of incident:

a. Check and describe reason(s) below which caused restraint to be initiated

___To prevent child from injuring self____________________________________________

___To prevent child from injuring others__________________________________________

___To prevent child from causing significant property damage which could cause injury to

       self or others ____________________________________________________________

___To prevent child from leaving classroom or building when such action could cause injury

       to self or others__________________________________________________________

b. Location of Incident:

c. Were other students present? If yes, describe:

d. Describe what else was going on prior to/at the time the observed behavior occurred:

e. Describe the situation that led up to the behavior that caused the need for restraint (student and staff behavior):

f. Describe the behavior(s) the child was exhibiting that resulted in decision to physically intervene:

g. Describe other interventions staff attempted to prevent need for physical intervention:

2. Description of physical intervention:

a. Type of physical intervention:

_____Seated Basket

_____Standing Basket

_____Side or non straddle

_____Other:

b. Describe student’s behavior during physical intervention:

c. Describe condition following incident  of student, staff, property:

3. Discussions for after physical intervention:

a. Note any other conditions that may have affected the behavior (home issues, court date, medication, sleep, change in routine/schedule, social factors):

b. Describe your impression of what the student may have wanted to gain from the target behavior (attention, power, revenge, display on inadequacy, manipulate, escape accountability):

c. Describe the imposed or natural/logical consequences of the behavior:

d. Describe the preventative plan (student and staff actions) that will be implemented to prevent further incidents:

e. Resolution: Was the intervention completed? YES/NO

§ Isolate conversation, explore young person’s point of view, summarize and connect feelings and behavior, discuss alternatives, develop/practice plan, return to routine:

4. Follow up:

a. If restraint exceeded 15 minutes, list certified staff who evaluated situation for appropriateness of continuing, specific student needs, and possible alternatives.  Include the written documentation of such evaluation here:

b. How many restraints has this student had:

§ Today-

§ This week-

§ This month-

§ This semester-

§ This school year-

c. Review after first three restraints:

§ Conducted by:

§ Review of the effectiveness of the procedure:

§ Individual behavior plan:

§ Placed in temporary student record:

§ Consideration of need for alternative program:

d. Parents notified of restraint by principal:

e. Parents invited to review: