Restrictive Procedurespost-Debriefing Form

Restrictive ProceduresPost-Debriefing Form

Student Name:

Staff Debrief

Signatures of staff attending debrief: ,
, ,
, ,
,
Date and time of debrief: Facilitator:
Does the student have a behavior intervention plan (BIP) in place? YES NO
Was it followed? YES NO
If no, document why not:

1. Was the physical holding or seclusion used in an emergency? YES NO

1. Was the physical holding or seclusion the least intrusive intervention that effectively responded to the emergency?YES NO

1. Was the physical holding or seclusion ended when the threat of harm ended and the staff determined that the child could safely return to the classroom or activity? YES NO

1. Did the staff directly observe the child while physical holding or seclusion was being used? YES NO
2. Was the documentation completed correctly?YES NO

1. Were the parents correctly notified?YES NO

1. Did any injuries occur prior to the use of the restrictive procedure? YES NO

1. Did any injuries occur during the use of the restrictive procedure? YES NO

What actions helped? What did not help?
Describe the procedure used to return the child to his/her routine activities, education setting, intervention, and/or site determined by the team, BIP and/or administrator:
Follow-up action plan (to prevent need for future restrictive procedures):
Have there been any restrictive procedures used on a separate day in the past 30 calendar days? YES NO
(If restrictive procedures are used on two separate school days within 30 calendar days or a pattern of use emerges and the child IEP or behavior intervention plan does not provide for using restrictive procedures in an emergency, the district must hold a meeting of the Individualized Education Program team within 10 calendar days of the second date.)
Does an IEP meeting need to be scheduled? YES NO
Has the district used restrictive procedures on the child on ten or more school days during the same school year?
YES NO
(If restrictive procedures are used on a child on ten or more school days during the same school year, the team, as appropriate, either must consult with other professionals working with the child; consult with experts in behavior analysis, mental health, communication, or autism; consult with culturally competent professionals; review existing evaluation, resources, and successful strategies; or consider whether to reevaluate the child.)
Does further action need to be taken? YES NO

File: Due Process File, Oversight Comm. Chair-2-September 2013