RECOVERY ROOM - SECLUSION

Student Name: __________________________________________________

Date:_______________________

# of incidents this week ______Day:________________________

TIME IN
Seclusion

TIME OUT
Seclusion

TOTAL TIME in Seclusion

(minutes)

OWED TIME
(minutes)

Verbal Aggression

Physical Aggression

Defiance of Authority

Inappropriate language to staff

Inappropriate language to peer
Sexual Vulgarity
Harassment/Bullying
Threat to do bodily harm
Other:_____________________
______________________________
______________________________
______________________________

Physical aggression to staff

Physical aggression to self
Physical aggression to peer
Misuse of Property
Property Damage/Vandalism
Weapon brought in
Weapon made by student
Other:___________________
_____________________________
___________________________

Refused COOL DOWN

Refused TAKE 5 Break
Refused pocket/bag check
Dress code violation
Preventing peers from learning
Other:_____________________
______________________________
______________________________
______________________________
______________________________

Reason for Entry: Specific Behavior

Method of Entry
Voluntary

Adult Escort

Staff-directed& student walked independently

CPI 2-person transport

Staff:___________________________________
Staff:___________________________________

Staff-directed & student REFUSED prompt:

2-minute Timer student walked independently
2-minute Timer student REFUSED

CPI Restraint Child Restraint

Staff:___________________________________

Staff-directed: NO TIMER Dangerous Behavior

CPI Restraint Team Control
Staff:___________________________________
Staff:___________________________________

NOTES ON CPI TRANSPORT/RESTRAINT

Teacher Initials ___________

Staff Initials____________

Staff Initials____________

RECOVERY ROOM - SECLUSION

Setting
(Where did the behavior occur?)
Classroom
Pocket/Bag check
Instructional activity
Social Skills activity
Independent work at desk
Choice Time
Lunch
Hallway
Restroom
Cafeteria
Transportation
Gym
Other:
_____________________________

Predictors
(What triggered the behavior?)
Lack of attention
Adult direction/requests
Difficult task
Undesired task
Transitions
Change in routine
Negative social interaction
Consequence for negative behavior
Sensory needs
Personal/Home stress
Medication change
Substitute Staff:
_______________________________
Substitute Teacher:
_______________________________
Other: _________________________

Possible Function of Behavior

(What was the behavior achieving?)
Obtain peer attention
Obtain adult attention
Obtain items/activities
Avoid peer(s)
Avoid adult
Avoid task or activity
Avoid a place
Disrupt the learning environment
Obsessive behavior
Medical diagnoses
Other: ______________________
________________________________
________________________________
________________________________

Action Taken
STUDENT
Life Space Crisis Intervention (therapeutic talk)
Owed Time ___________
Owed S.T.A.M.P.S. money ___________
Crossroads Detour
Restart Crossroads Level
Behavior Contract
Conference with student
Suspension :Number of days: __________________
Starting Date: ___________________

Conference scheduled
Date: ___________________
Time: ___________________

CONTACT NOTES:

Teacher Initials ___________

Date: ___________________
Time: ___________________

Behavior Support Contacted:_____________________

Date: ___________________
Time: ___________________

Staff Debriefing scheduled:

PARENT/GUARDIAN
Parent/Guardian contacted : __________________
Date: ___________________
Time: ___________________

BAISD EI STAFF
Supervisor contacted : __________________________

Date: ___________________
Time: ___________________

Behavior Plan Reviewed? Yes

No

Behavior Plan Revised?

Yes
No
If no, why not?________________________________
____________________________________________
____________________________________________
____________________________________________

Staff Initials____________

Staff Initials____________

RECOVERY ROOM - SECLUSION

Student Name:_______________________________________________________________________

Date:_______________________ Day:________________________

Staff completing observation log:__________________________________________________

Seclusion Observation LogBehaviors and language of the student in seclusion must be recorded as each specific
behavior is displayed, and language must be quoted with detailed accuracy.

TIME

SPECIFIC BEHAVIORS

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Teacher Initials ___________

Staff Initials____________

Staff Initials____________