West Clermont Local School District

WEST CLERMONT LOCAL SCHOOL DISTRICT

PHYSICAL SAFE HOLD REPORT

Student: ______Time and Date of Incident______

Teacher: ______

Principal:______

Recorder:______

Nurse/Heath Aide: ______Time of physical assessment______

Parent:______

Parent Contact Number: ______

Time of Parent Contact: ______

Notice Sent Home: ______

Parent MUST be notified of the physical safe hold procedure and intervention used with the student.

Reason for implementation of the physical safe hold: (Describe the action that caused the student to be a danger to themselves or others?)

______

What type of CPI physical safe hold was used?:

□ Children’s Control Position □ Team Control Position □ Transport Position □ Interim Control Position

Less restrictive intervention attempted first: (What Positive Behavior Strategies were implemented?)

______

Did you explain to the student reasons for implementation of a CPI physical safe hold and discuss what behaviors the student would need to display for sufficient behavioral control:

? YES ? NO Duration of Incident: ______

(A Physical Safe Hold shall not be used for longer than 5 minutes, and the need for continuation of a safe hold shall be reassessed every 5 minutes.)

Upon conclusion of the physical safe hold the student was able to: (check all that apply)

□ Demonstrate safe behavior □ Process the issue □ Return to Class □Complete assignments

□ Maintain Student in a Small Group Setting

Nurse / Health Aide Assessment Results: ______

______

Notation of any concerns: ______

______

Staff who implemented CPI Physical Safe Hold Signature: ______

Building Administrator in Charge Signature: ______

Recorder’s Signature: ______

Health Aide/Nurse Signature: ______

Other Signature: ______

Supervisor Signature: ______Date of Review: ______

(Copies must be sent to the principal, health aide, and the Director of Special Education)

Please fill out the information requested below, tear off Parent/Guardian reporting slip and send home with student.

Parent and or Guardian: ______Date: ______

School Building Administrator: ______

Regarding: Physical Safe Hold Incident

This is a follow up notice regarding the implementation of a Physical Safe Hold. A phone call was made on ______at ______pm/am to

Date Time

inform you that ______was acting in a manner that threatened the safety of themselves or others. In order to keep

Student’s Name

your child, his/her peers and staff members safe, a physical safe hold was implemented by trained Crisis Prevention Intervention (CPI) staff member

or members. If you have any further questions please contact your child’s principal.