Report of Physical Intervention or Seclusion

Report of Physical Intervention or Seclusion
Student:*

First NameLast Name
Does the student have an IEP?*

YesNo
Date and time of incident*

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

AutismOrthopedic ImpairmentDeaf-BlindnessOther Health ImpairmentDeafnessSpecific Learning DisabilityEmotional DisturbanceSpeech or Language ImpairmentHearing ImpairmentTraumatic Brain InjuryIntellectual DisabilityVisual ImpairmentMultiple DisabilitiesN/A
Teacher:*

First NameLast Name
Building:*

HolmesDenverWMSWHS
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)?*

Primary Restraint Technique (PRT)Seclusion
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?*

YesNo
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)*

Demonstrate safe behaviorProcess the issueReturn to ClassComplete AssignmentsMaintain Student in a Small Group Setting
Were there injuries to student (self or other)?*

YesNo
Describe the student's injuries:*
Were there injuries to staff?*

YesNo
Describe the injuries to staff:*
Notation of any concerns:
Was an FBA created or revised?*

YesNo
Was a BIP created or revised?*

YesNo
Was the student suspended?*

YesNo
Was the student expelled?*

YesNo
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: