Fillable South East Consortium for Special Education

Fill Online, Printable, Fillable, Blank South East Consortium for Special Education Form

Use Fill to complete blank online OTHERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

South East Consortium for Special Education

On average this form takes 14 minutes to complete

The South East Consortium for Special Education form is 4 pages long and contains:

  • 1 signature
  • 6 check-boxes
  • 49 other fields

Country of origin: OTHERS
File type: PDF

BROWSE OTHERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
South East Consortium for Special Education
3434 Marten Ave.
San Jose, CA 95148
Phone: 408.223.3771 / Fax: 408.532.9311
Guidelines for Completing the Behavioral Emergency Intervention Report
Districts must document and record all instances of emergency behavioral restraints and/or seclusion incidents
involving students for annual reporting purposes to the state of California. Documentation is required for students
in general education, students with Section 504 plans, and students with exceptional needs (Assembly Bill 2657).
The SELPA Behavioral Emergency Intervention Report will assist school districts in properly documenting
behavioral emergency interventions. One must be completed by staff with involvement and/or knowledgeable of
events leading to the emergency behavioral intervention. Please note that emergency interventions, including
behavioral restraint and/or seclusion “may only be used to control unpredictable, spontaneous behavior which
poses clear and present danger of serious physical harm to the individual with exceptional needs, or others, and
that cannot be immediately prevented by a response less restrictive than the temporary application of a technique
used to contain the behavior” [Education Code § 56521.1(a)].
Below are definitions of what constitutes a behavioral restraint and seclusion (Education Code § 49005):
“Mechanical restraint” means the use of a device or equipment to restrict a pupil’s freedom of movement.
“Mechanical restraint” does not include the use of devices by trained school personnel, or by a pupil, prescribed
by an appropriate medical or related services professional, if the device is used for the specific and approved
purpose for which the device or equipment was prescribed, which shall include, but not be limited to, all of the
following:
-Adaptive devices or mechanical supports used to achieve proper body position, balance, or alignment to
allow greater freedom of mobility than would be possible without the use of such devices or mechanical
supports.
-Vehicle safety restraints when used as intended during the transport of a pupil in a moving vehicle.
-Restraints for medical immobilization.
-Orthopedically prescribed devices that permit a pupil to participate in activities without risk of harm.
“Physical restraint” means a personal restriction that immobilizes or reduces the ability of a pupil to move his or
her torso, arms, legs, or head freely. “Physical restraint” does not include a physical escort, which means a
temporary touching or holding of the hand, wrist, arm, shoulder, or back for the purpose of inducing a pupil who
is acting out to walk to a safe location.
“Seclusion” means the involuntary confinement of a pupil alone in a room or area from which the pupil is
physically prevented from leaving. “Seclusion” does not include a timeout, which is a behavior management
technique that is part of an approved program, that involves the monitored separation of the pupil in a non-locked
setting, and is implemented for the purpose of calming.
Please visit the California Department of Education or the California Legislative Information websites for more
information.
BEHAVIORAL EMERGENCY INTERVENTION REPORT CHECKLIST
Directions: Complete all steps below for any incident involving a behavioral restraint and/or seclusion.
Items #5 and #6 only applies to individuals with exceptional needs.
1. The parent and/or legal guardian shall be notified within one school day when an emergency intervention
is used. /
Staff initials date
2. The Behavioral Emergency Intervention report shall immediately be completed by staff involved in the
intervention/incident. /
Staff initials date
3. The Behavioral Emergency Intervention report shall immediately be forwarded to and reviewed by the
designated responsible administrator. /
Staff initials date
4. Place a copy of the Behavioral Emergency Intervention report in student’s file.
/
Staff initials date
5. If the Behavioral Emergency Intervention Report is completed for an individual with exceptional needs
who does not have a behavioral intervention plan, the designated responsible administrator shall, within
two days, schedule an IEP to determine whether a Functional Behavioral Assessment (FBA) should be
conducted and/or an interim Behavior Intervention Plan (BIP) be developed, or to revise an existing BIP.
Parent notice is given and consent must be obtained prior to commencement If an FBA is not conducted
and/or an interim Behavior Intervention Plan is not developed, the IEP team shall documents the reasons
for such decisions. of a Functional Behavioral Assessment. /
Staff initials date
6. If the Behavioral Emergency Intervention report is completed for an individual with exceptional needs
who has a positive behavioral intervention plan, an incident involving a previously unseen serious
behavior problem, or where a previously designed intervention is ineffective, shall be referred to the IEP
team to review and determine if the incident constitutes a need to modify the positive behavioral
intervention plan. /
Staff initials date
7. The responsible administrator will forward a copy of the Behavioral Emergency Intervention report to the
Special Education Director and site administrator. /
Staff initials date
8. The responsible administrator will ensure the incident is documented in the local student information
system. /
Staff initials date
South East Consortium for Special Education
3434 Marten Ave.
San Jose, CA 95148
Phone: 408.223.3771 / Fax: 408.532.9311
BEHAVIORAL EMERGENCY INTERVENTION REPORT
*To be completed after a behavioral emergency intervention involving the use of a behavioral restraint
and/or seclusion occurs (see guidelines.
Report Date: Report Completed by: School Site: ____________________________
Pupil’s Name: Birth Date: Age:
Date of Incident: Time Incident Began: Time Incident Ended:
Setting: Location of Incident:__________________________________
District of Residence: _________________________________________________________________________
Describe events leading to the behavioral emergency incident, positive behavioral supports used, and/or the
implementation of any current behavior plan strategies:
Describe emergency behavior and interventions utilized to contain the unexpected behavioral emergency:
Name(s) of staff involved:_____________________________________________________________________
District utilizes the following de-escalation and restraint program:
Indicate if any of the below behavioral emergency intervention(s) used, including the number of such
interventions if more than one:
▢ Seclusion ▢ Mechanical Restraint ▢ Physical Restraint ▢ Other: ________________________
Injuries sustained by student as a result of the incident:
Injuries sustained by others (including other students and staff):
Description of any property damage:
Other pertinent information:
The following two check boxes apply only to individuals with exceptional needs (check one):
Student does not have a current Behavior Intervention Plan (BIP): Within two days of the behavioral
emergency, the designated responsible administrator shall schedule an IEP meeting to review the emergency
report, to determine the necessity for a Functional Behavioral Assessment and to determine the need for an
interim Behavior Intervention Plan. If an FBA is not conducted and/or an interim BIP is not developed, the IEP
team shall documents the reasons for such decisions. The IEP team will make a concerted effort to hold an IEP
meeting as soon as possible.
Student has an existing Behavior Intervention Plan (BIP): When an incident involving a previously
unseen serious behavior problem occurs or where a previously designated intervention is not effective, student
shall be referred to the IEP team to review and determine if the incident constitutes a need to modify the plan.
COPIES OF BEHAVIORAL EMERGENCY INCIDENT REPORTS WERE SENT TO:
POSITION NAME DATE
Site Administrator
Parent, Guardian or Residential Care Provider**
District of Residence*
Student’s File*
Special Education Director
*California Education Code requires that an “emergency intervention report shall be immediately be completed
and maintained in the individual’s file”.
**California Education Code requires parent or guardian or residential provider shall receive a report within one
school day. The report may be verbal or in writing.
Signature of Person Completing this Report:
Title:
Date:
Revised 11/17/20
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

South East Consortium for Special Education

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 7 May 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document