539E1 - Use of Physical REstraint and/or Seclusion Documentation Form
539E1 - Use of Physical REstraint and/or Seclusion Documentation FormSTUDENT PERSONNEL
Series 500
Policy Title: Use of Physical Restraint and/or Seclusion Documentation Form
Code No: 539.E1
Page 1 of 3
USE OF PHYSICAL RESTRAINT AND/OR SECLUSION DOCUMENTATION FORM
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Student Name: |
Date of occurrence: |
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Start time of occurrence: |
End time of occurrence: |
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Duration of restraint: |
Duration of seclusion: |
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Check all that apply: |
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Employee Name: |
Employee Title: |
Observed Restraint |
Involved Restraint |
Imple- mented Restraint |
Observed Seclusion |
Involved Seclusion |
Imple- mented Seclusion |
Date of last Chapter 103 training: |
Date of last CPI training: |
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Administrator Signature:
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15 min time: initials: |
30 min time: initials: |
30 min time: initials:
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30 min time: initials: |
30 min time: initials: |
30 min time: initials: |
30 min time: initials: |
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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: |
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Describe the incident; must include the antecedent (what happened before the behavior) and the behavior (what the student did). |
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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: |
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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. |
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Employee attempting notification: |
Parent/Guardian contacted: |
Time and manner of attempted notification:
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Was notification successful? |
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Employee attempting notification: |
Parent/Guardian contacted: |
Time and manner of attempted notification: |
Was notification successful? |
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If Parent/Guardian notification requirements were not complied with, explain why: |
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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: |
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Describe injuries sustained or property damaged by students or employees: |
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Describe future approaches to address student behavior including any consequences or disciplinary actions that may be imposed on the student: |
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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
539E2 - Debriefing Letter To Guardian Of Student Involved In An Occurrence
539E2 - Debriefing Letter To Guardian Of Student Involved In An Occurrence
Series 500
STUDENT PERSONNEL
Policy Title: Debriefing Letter To Guardian Of Student Involved In An Occurrence
Code No. 539.E2
WHERE PHYSICAL RESTRAINT AND/OR SECLUSION WAS USED
[This letter and the enclosed report may be transmitted electronically via email or fax, picked up in person, or mailed. If the district and the guardian do not agree on how to transmit this letter, it must be mailed via postage prepaid, first class mail to the guardian within 3 school days of the occurrence.]
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 281 Iowa Administrative Code Ch. 103. 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.
Code No. 539.E2
Pg. 2 of 2
We look forward to working with you to foster the continued health, safety and educational growth of your student.
___________________________________
[Administrator name], title
___________________________
Date
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 delivered to Parent/Guardian
______________________________
Method of Transmittal
Date of Adoption/Review/Revision:
February 2021
November 2023
539E3 Debriefing Meeting Document
539E3 Debriefing Meeting Document
Series 500
STUDENT PERSONNEL
Policy Title: Debriefing Letter To Guardian Of Student Involved In An Occurrence
Code No. 539.E2
WHERE PHYSICAL RESTRAINT AND/OR SECLUSION WAS USED
[This letter and the enclosed report may be transmitted electronically via email or fax, picked up in person, or mailed. If the district and the guardian do not agree on how to transmit this letter, it must be mailed via postage prepaid, first class mail to the guardian within 3 school days of the occurrence.]
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 281 Iowa Administrative Code Ch. 103. 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
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 delivered to Parent/Guardian
______________________________
Method of Transmittal
Date of Adoption/Review/Revision:
February 2021
November 2023