Restraint Injury Report

Select Schools

If run at the district level, choose one of the following:

• Select Multiple Schools – Select schools to include in the report. To select a single school, click that school. To select multiple schools, use Ctrl+Click and select each school to be included.
• All Schools – Run the report for the entire district.

If run at the school level, the report includes all records associated with the current school that meet the selection criteria. To change the current school, click School at the top of the page and choose the appropriate school from the list.

Select Students*

Indicate which students to include in the report by selecting one of the following options:

• The selected [number] students only – Run the report for students in the current student selection from the currently selected schools.
• All students – Run the report for all students who meet the selection criteria in the currently selected school(s).

Note: If running the report for a single student, or group of students, select the students prior to running the report.

Report State Date*

Enter the report start date.

Report End Date*

Enter the report end date.

Include Logs created in District Office*

Choose Yes or No to indicate whether or not to include Restraint Injury Logs created in the District Office.

Logs required by 603 CMR 46.06(2) will be submitted with this report*

Choose Yes or No to indicate whether or not to include Logs required by 603 CMR 46.06(2).

Processing Options

Choose a time to run the report from the pop-up menu:

• In Background Now (Recommended) – Execute the report immediately in the background.
• ASAP – Execute the report in the order it is received in the Report Queue.
• At Night – Execute the report during the next evening.
• On Weekend – Execute the report during the next weekend.
• On Specific Time – Execute the report on the date and time specified.

Specific Date/Time

Enter a date using the format mm/dd/yyyyor mm-dd-yyyyin order to run the report on a specific day. The incorrect format displays an alert and the date field is submitted as a blank entry.

Use the pop-up menus to schedule the report to be run at a specific hour and minute.

Example: 7/29/2008 @ 10:05 AM.

Name of School District, Charter School, Educational Collaborative or Approved Private Special Education Program

The state assigned LEA ID assigned to this district.

[S_MA_LOG_Restraint_X]OODAgencyName

or

[Prefs]Value where [Prefs]Name = DistrictName

Alpha-numeric

Name of School

The name of the school where the restraint injury took place.

[Schools]Name if log created at school

or

[Prefs]Value where [Prefs]Name = DistrictName if log created at district

Alpha-numeric

60

Address

The address of the school or district depending on where the log was created.

[Schools]Address, [Schools]City, [Schools]schoolState, [Schools]schoolZip if created at school

[Prefs]districtaddress, [Prefs]districtcity, [Prefs]districtstate, [Prefs]districtzip if created at district

Alpha-numeric

Name(s) of Injured

The names of the staff and/or student injured.

[S_MA_LOG_Restraint_X]personInjuredType=1 (Student), 2 (Staff), 3 (Both)

[S_MA_LOG_RestraintPersonRole_C]personLastFirst where [S_MA_LOG_RestraintPersonRole_C]personrole=2

Alpha-numeric

Name of Student Restrained

The student’s name.

Note: If populated, the student's legal name overrides the student's preferred name.

Concatenate [StudentCoreFields]PSCore_Legal_First_Name, [StudentCoreFields]PSCore_Legal_Middle_Name,[StudentCoreFields]PSCore_Legal_Last_Name

OR [Students]LastFirst

OR concatenate [Students]First_Name, [S_MA_STU_Demographic_X]LongMiddleName or [Students]Middle_Name, [Students]Last_Name

Alpha-numeric

130

Date of Restraint

The date the student was restrained.

[S_MA_LOG_Restraint_X] RestraintDate

Or

[Log]entry_date

Alpha-numeric

10

Student Date of Birth

The student’s date of birth.

[Students]dob

Alpha-numeric

10

Age

The student’s age.

Calculated

Alpha-numeric

2

Gender

The student’s gender.

Note: If populated, the student's legal gender overrides the student's preferred gender.

[StudentCoreFields]PSCore_Legal_Gender

[Students]Gender

[S_MA_STU_Demographic_X]NonBinary_Gender_TF

Alpha-numeric

1

Grade Level

The student’s grade level.

[Students]Grade_Level

Alpha-numeric

2

Does student currently receive special education services?

Indication if the student currently receives special education services.

[S_MA_LOG_Restraint_X]IEPIND=1 (Yes), 0 (No)

Alpha-numeric

1

Date of this report

The report run date.

mm/dd/yyyy HH24:MI:SS

Alpha-numeric

20

Specific location of Restraint

The location where the restraint took place.

[Schools]Name if log created at school

or

[Prefs]Value where [Prefs]Name = DistrictName if log created at district

and

 [S_MA_LOG_Restraint_X]restraintSite

Alpha-numeric

N/A

This report prepared by:

The name of the person completing the form.

[S_MA_LOG_Restraint_X]

PersonCompletingFormName

Numeric

100

Position

The title of the person completing the form.

[S_MA_LOG_Restraint_X] PersonCompletingFormTitle

Address

The address of the school or district depending on where the log was created.

[Schools]Address, [Schools]City, [Schools]schoolState, [Schools]schoolZip if created at school

[Prefs]districtaddress, [Prefs]districtcity, [Prefs]districtstate, [Prefs]districtzip if created at district

Alpha-numeric

Telephone

The telephone of the school or district depending on where the log was created.

[Schools]schoolPhone

Or

[Prefs]districtPhone

Alpha-numeric

10

Person 1 Involved: Name

The name of the first person listed as involved in administering the restraint.

Note: The person involved information is pulled from the information entered into the People Involved section of Student Setup - Log Entries > Massachusetts State Information (Log Type = Restraint).

[S_MA_LOG_RestraintPersonRole_C] PersonLastFirst where [S_MA_LOG_RestraintPersonRole_C] PersonRole = 3 (Person Involved in Administering Restraint)

Alpha-numeric

100

Person 1 Involved: Title

The title of the first person listed as involved in administering the restraint.

[S_MA_LOG_RestraintPersonRole_C] PersonTitle where [S_MA_LOG_RestraintPersonRole_C] PersonRole = 3 (Person Involved in Administering Restraint)

Alpha-numeric

50

Person 2 Involved: Name

The name of the second person listed as involved in administering the restraint.

Note: The person involved information is pulled from the information entered into the People Involved section of Student Setup - Log Entries > Massachusetts State Information (Log Type = Restraint).

[S_MA_LOG_RestraintPersonRole_C] PersonLastFirst where [S_MA_LOG_RestraintPersonRole_C] PersonRole = 3 (Person Involved in Administering Restraint)

Alpha-numeric

100

Person 2 Involved: Title

The title of the second person listed as involved in administering the restraint.

[S_MA_LOG_RestraintPersonRole_C] PersonTitle where [S_MA_LOG_RestraintPersonRole_C] PersonRole = 3 (Person Involved in Administering Restraint)

Alpha-numeric

50

Person: 3 Involved: Name

The name of the third person listed as involved in administering the restraint.

Note: The person involved information is pulled from the information entered into the People Involved section of Student Setup - Log Entries > Massachusetts State Information (Log Type = Restraint).

[S_MA_LOG_RestraintPersonRole_C] PersonLastFirst where [S_MA_LOG_RestraintPersonRole_C] PersonRole = 3 (Person Involved in Administering Restraint)

Alpha-numeric

100

Person 3 Involved: Title

The title of the third person listed as involved in administering the restraint.

[S_MA_LOG_RestraintPersonRole_C] PersonTitle where [S_MA_LOG_RestraintPersonRole_C] PersonRole = 3 (Person Involved in Administering Restraint)

Alpha-numeric

50

Restraint prevention/Behavior Support

Indication if the staff person administering restraint has restraint prevention training.

[S_MA_LOG_Restraint_X]hasRestraintPreventionTraining=1 (Yes), Null or 0 (No)

Alpha-numeric

1

In-Depth Restraint administration

Indication if the staff person administering restraint has

[S_MA_LOG_Restraint_X]hasInDepthRestraintTraining=1 (Yes), Null or 0 (No)

Alpha-numeric

1

Name of restraint methodology:

The type of hold used on the student.

 [S_MA_LOG_Restraint_X] HoldUsed

Alpha-numeric

N/A

Observers: Name

The name of the observer.

Note: The observer information is pulled from the information entered into the People Involved section of Student Setup - Log Entries > Massachusetts State Information (Log Type = Restraint).

[S_MA_LOG_RestraintPersonRole_C] PersonLastFirst where [S_MA_LOG_RestraintPersonRole_C] PersonRole = 1 (Observer)

Alpha-numeric

100

Observer: Title

The title of the observer.

[S_MA_LOG_RestraintPersonRole_C] PersonTitle where [S_MA_LOG_RestraintPersonRole_C] PersonRole = 1 (Observer)

Alpha-numeric

50

Administrator Notification:

Name

The name of the administrator who was informed following the restraint.

[S_MA_LOG_Restraint_X]adminInformedName

Alpha-numeric

100

Administrator Notification:

Title

The title of the administrator who was informed following the restraint.

[S_MA_LOG_Restraint_X] adminInformedTitle

Alpha-numeric

50

Reported by:

Name

The name of the person who verbally reported the restraint.

[S_MA_LOG_Restraint_X]verbalReporterName

Alpha-numeric

100

Reported by:

Title

The title of the person who verbally reported the restraint.

[S_MA_LOG_Restraint_X] verbalReporterTitle

Alpha-numeric

50

Date of verbal notification

The date the administrator was informed the restraint verbally.

[S_MA_LOG_Restraint_X] adminInformedVerbalNotifyDate

Date of written notification

The date the administrator received written notification of the restraint.

[S_MA_LOG_Restraint_X] adminInformedWrittenNotifyDate

Description of Injuries

A description of the nature and extent of any injuries sustained, the medical care provided and any follow-up medical attention which may be needed.

[S_MA_LOG_Restraint_X] InjuryDescription

Alpha-numeric

500

Precipitating Activity

A description of the activity that the restrained student, or others involved, were engaged in prior to use of physical restraint.

[S_MA_LOG_Restraint_X] AntecedentActivity

Alpha-numeric

500

Behavior that prompted and justified the restraint:

A description of the student’s behavior that justified the use of restraint.

[S_MA_LOG_Restraint_X] JustifyingBehavior

Alpha-numeric

500

Thorough description or efforts made to prevent escalation of behavior and alternatives to restraint that were attempted:

A description of any alternative or de-escalation techniques used or attempted to try to prevent the escalation of the situation.

[S_MA_LOG_Restraint_X] DeescalationTechnique

Alpha-numeric

500

Description of Physical Restraint:

Justification for initiating physical restraint (check all that apply):

• Non-physical interventions were not effective
• To protect student from imminent, serious, physical harm
• To protect other student/staff from imminent, serious, physical harm

[S_MA_LOG_RestraintJustify_C]JustifyCode=1

Or

[S_MA_LOG_RestraintJustify_C]JustifyCode=2

Or

[S_MA_LOG_RestraintJustify_C]JustifyCode=3

Describe holds used:

A description of why the restraint hold was chosen.

[S_MA_LOG_Restraint_X] ChosenHoldExplanation

Alpha-numeric

500

Student’s behavior and reaction during restraint:

A description of the student’s behavior and reactions during the restraint, how the restraint ended, and how the student’s well-being was monitored.

[S_MA_LOG_Restraint_X] DemeanorDescription

Alpha-numeric

500

Time restraint began:

The time that the restraint started.

Parsed from:

[S_MA_LOG_Restraint_X] RestraintStartTime

Alpha-numeric

2

Time restraint ended:

The hour that the restraint ended.

Parsed from:

[S_MA_LOG_Restraint_X] RestraintEndTime

Alpha-numeric

2

If restraint lasted more than 20 min, name of administrator who approved continuation of restraint:

The name of the person informed or the person who approved the extended restraint time if the restraint was applied for more than 20 minutes.

[S_MA_LOG_Restraint_X] ExtendedTimeApproverName

Alpha-numeric

100

Additional restraints/Other information:

The description of additional restraints used or other pertinent information.

[S_MA_LOG_Restraint_X]injOtherInfoOrRestraint

Alpha-numeric

500

Cessation of Restraint:

How restraint ended (check all that apply):

• Determination by staff member that student was no longer a risk to himself or others.
• Intervention by administrator(s) to facilitate de-escalation.
• Law enforcement personnel arrived
• Staff sought medical assistance
• Other (describe)

[S_MA_LOG_RestraintCessation_C] cessationCode=1

[S_MA_LOG_RestraintCessation_C] cessationCode=2

[S_MA_LOG_RestraintCessation_C] cessationCode=3

[S_MA_LOG_RestraintCessation_C] cessationCode=4

[S_MA_LOG_RestraintCessation_C]cessationDescription if  [S_MA_LOG_RestraintCessation_C] cessationCode=0

Further Action to be Taken:

The school will take the following action and/or disciplinary sanctions (check as many as apply):

• Review incident with student to address behavior that precipated the restraint.
• Review incident with staff to discuss whether proper restraint procedures were followed.
• Consider whether to follow-up is necessary for students who witnessed the incident.
• Conduct a local investigationof any complaint regarding this restraint (describe investigation procedures):
• Disciplinary action/sanctions taken against student or staff by the program (describe):
• Contact with parents, responsible school district, other state agency (describe):

[S_MA_LOG_RestraintFutureAct_C] futureActionCode=1

[S_MA_LOG_RestraintFutureAct_C] futureActionCode=2

[S_MA_LOG_RestraintFutureAct_C] futureActionCode=3

[S_MA_LOG_RestraintFutureAct_C] futureActionCode=4

[S_MA_LOG_RestraintFutureAct_C] futureAction4Description if applicable

[S_MA_LOG_RestraintFutureAct_C] futureActionCode=5

[S_MA_LOG_RestraintFutureAct_C] futureAction5Description if applicable

[S_MA_LOG_RestraintFutureAct_C] futureActionCode=6

[S_MA_LOG_RestraintFutureAct_C] futureAction6Description if applicable

Parent/Guardian Notification:

Verbal

The date and/or description of how staff attempted to verbally inform parent/guardian of restraint use.

Derived from:

[S_MA_LOG_RestraintNotify_C] NotifyDate, [S_MA_LOG_RestraintNotify_C]NotifyMethodType=1, 2, 3 where [S_MA_LOG_RestraintNotify_C] ContactType=2 (Parent/Guardian)

[S_MA_LOG_RestraintNotify_C]NotifyMethodType=7,0

[S_MA_LOG_RestraintNotify_C]NotifyMethodDesc

Parent/Guardian Notification:

Written

Written report sent within 3 school working days of administration of restraint injury to parent/guardian on (Date) by (teacher/administrator/other) to the following address:

Derived from:

[S_MA_LOG_RestraintNotify_C] ContactType=2

[S_MA_LOG_RestraintNotify_C]NotifyMethodType=4,5

[S_MA_LOG_RestraintNotify_C] NotifyDate

[S_MA_LOG_RestraintNotify_C]notifieName

[S_MA_LOG_RestraintNotify_C]NotifyMethodType=3,4

[S_MA_LOG_RestraintNotify_C]NotifyWrittenAddress

Parent/Guardian Notification:

Native Language

Indicates the written notification was sent in the parent’s native language if language is provided.

Derived from:

[S_MA_LOG_RestraintNotify_C] ContactType=2

[S_MA_LOG_RestraintNotify_C]NotifyMethodType=3,4

[S_MA_LOG_RestraintNotify_C]NotifyLanguage

Alpha-numeric

Parent/guardian discussion:

Parent/guardian was offered the opportunity to discuss with school officials the administration of restraint and consequences that may be imposed on the student. Results of discussion (Attach separate page if necessary)

Derived from:

[S_MA_LOG_RestraintNotify_C] ContactType=2

[S_MA_LOG_RestraintNotify_C]NotifyMethodType=3,4

[S_MA_LOG_RestraintNotify_C]discussionResults

Alpha-numeric

Copy of Log for ESE review

X if selected “Yes” on report submission page.