503.6E1 USE OF PHYSICAL RESTRAINT AND/OR SECLUSION DOCUMENTATION FORM

Code No.  503.6E1

Page 1 of 3

 

USE OF PHYSICAL RESTRAINT AND/OR SECLUSION DOCUMENTATION FORM

Student name:

Date of occurrence:

Start time of occurrence:

End time of occurrence:

Start time of use of physical restraint or seclusion:

End time of use of physical restraint or seclusion:

Employee names and titles who observed, were involved with or implemented physical restraint and/or seclusion during occurrence (including administrators who approved extended time if applicable):

Employee’s date of last training on use of physical restraint and seclusion:
   
   
   
   
   

Describe student actions before, during and after occurrence:
 
 
 
 

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:
 
 
 
 
 

 

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:
 
 
 
 
 
 

Approval from administrator to continue physical restraint or seclusion past 15 minutes:

Approval obtained from administrator to continue physical restraint or seclusion more than 30 minutes past last approval time:

Administrator approving: 

Administrator approving:

Time approved:

Time approved:

Reasons for length of incident:

Reasons for length of incident:

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:  

 

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.  

Employee attempting notification:

 

Parent/Guardian contacted:

Time and manner of attempted notification:

Was notification successful?

Employee attempting notification:

 

Parent/Guardian contacted:

Time and manner of attempted notification:

Was notification successful?

Employee attempting notification:

Parent/Guardian contacted:

Time and manner of attempted notification:

 

Was notification successful?

If Parent/Guardian notification requirements were not complied with, explain why:

 

Describe injuries sustained or property damaged by students or employees:
 
 
 

 

Describe future approaches to address student behavior including any consequences or disciplinary actions that may be imposed on the student:
 
 
 
 
 

 

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

Cross Reference:

402.03    Abuse of Students by School District Employees

503.05.   Corporal Punishment, Mechanical Restraint and Prone Restraint

Approved:   2/8/2021                          Reviewed:       05/13/2024                                 Revised:  05/13/2024

 
Uploaded Files: 
PDF icon 503.6e1_use_of_physical_restraint_andor_seclusion_documentation_form.pdf

503.6E2 DEBRIEFING LETTER

[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

Enclosure:  Report related to student occurrence

 

Cross References:

402.03    Abuse of Students by School District Employees

503.05    Corporal Punishment, Mechanical Restraint and Prone Restraint 

 

 

Approved:     2/8/2021                                    Reviewed:  05/13/2024                      Revised:  05/13/2024