Report of Physical Intervention or Seclusion

Report of Physical Intervention or Seclusion
Student:

First NameLast Name
Does the student have an IEP?
Date and time of incident

MonthDayYear
Date
Hour MinutesAM/PM Option
Identify the student's disability type:
Teacher:

First NameLast Name
Building:
Principal:

First NameLast Name
Reason for implementing physical intervention or seclusion: (Describe the action that caused the student to be a danger to themselves or others.)
Is the report for a Handle With Care (HWC) physical intervention or seclusion (choose 1)?
Did you explain to the student reasons for implementation of a HWC physical intervention or seclusion, and discuss what behaviors the student would need to display for sufficient behavioral control?
Duration of the Incident:
A physical intervention shall not be used for longer than 5 minutes, and the need for continuation of a physical intervention shall be reassessed every 5 minutes.
Upon conclusion of the physical intervention or seclusion the student was able to: (check all that apply)
Were there injuries to student (self or other)?
Describe the student's injuries:
Were there injuries to staff?
Describe the injuries to staff:
Notation of any concerns:
Was an FBA created or revised?
Was a BIP created or revised?
Was the student suspended?
Was the student expelled?
Name of staff who implemented physical intervention or seclusion:

First NameLast Name
Name of Administrator in Charge:

First NameLast Name
Name of person submitting this report:

First NameLast Name
Your WCS email address:
example@example.com
Signature of Staff who implemented CPI Safe Hold or Seclusion

Signature of Administrator in Charge

Signature of Person Filling Out Report
Should be Empty: