Eden Prairie School Restrictive Procedures Staff Debrief Form printable pdf download

Eden Prairie School Restrictive Procedures Staff Debrief Form

Eden Prairie School Districts 272

(Sept 2011‐ Purple)

Restrictive Procedures Staff Debrief Form

Date of Debriefing Meeting: ____/____/_____

Time of Meeting:____________

STAFF MEMBERS PRESENT AT DEBRIEFING MEETING

Person overseeing the restrictive procedure(s)

Building Administrator

Signature, title

Student DOES have an IEP

Student DOES NOT have an IEP

1. Does the student have a current IEP?

How many times have restrictive procedures been used in the

last 30 calendar days? ________

2. How many restrictive procedures have been using in the

last 30 calendar days? __________

Describe if any current interventions, supports or processes

** If 2 or more restrictive procedures has occurred and are

are in place:

not written in the IEP then the team needs to meet.

 social worker  PBIS Specialist  Washburn

3. Does the IEP team need to meet?  yes  no

 Primary Project  child study team

4. If an IEP team meeting occurred as a result of the incident,

what date did it occur? ________________

Other:________________________________________________________________

TEAM REFLECTION

Was the procedure the least restrictive?

Was it an emergency?

The physical holding or seclusion ended when (what was observed‐timeline):

Follow up Action Plan:

Where the staff trained? yes no

Was law enforcement contacted? yes no

NOTIFICATION

Who notified the parent/guardian?___________________________ Who was contacted?____________________________________________

How were the parent/guardian notified? ☐email written note phone call Other:______________________

*Parent/Guardians must be notified within 24 hours.

Brief summary of discussion:

Outcome of call:

Eden Prairie School Restrictive Procedures Staff Debrief Form