Person Initiating Emergency Safety Physical Intervention (ESPI) Is Responsible to Fill

Central Dauphin
School District / Safe Crisis Intervention
Report

· Person initiating Emergency Safety Physical Intervention (ESPI) is responsible to fill out Page 1 and 2 of report.

· All adults involved or witnessing the crisis event must complete page 2 of this form.

· This form must be completed and faxed to your Supervisor and Administrator by the end of the work day in which the incident took place.

· These forms must be attached to the incident report of any Special Education student.

Student: DOB: Age:______Date:

PA Secure ID:______Grade:______

Building: Case Manager (if applicable):

Regular Education Special Education Disability Category______

Staff involved:______Leader Assist Witness Monitor

Safe Crisis Management was necessary because the student displayed:

A danger to self

A danger to others

Date of Incident: Location of Incident:

Start Time of Incident: End Time of Incident:

Was an Emergency Safety Physical Intervention (ESPI) used? Check the approved Safe Crisis Management Emergency Safety Physical Intervention (ESPI) that was used during the Crisis Cycle:

Extended-arm Assist Upper Torso Assist

Multiple-person Extended- arm Assist Multiple-person Upper Torso Assist Crossed Arm Assist Upper Torso Assist to the Floor

Multiple-person Bicep Assist Kneeling/seated Upper Torso Assist Multiple-person Kneeling/seated Bicep Assist Multiple-person Kneeling/seated Upper Torso Assist

Cradle Assist

Cradle Assist to Floor

Kneeling/seated Cradle Assist

Duration of Emergency Safety Physical Intervention(ESPI) in minutes:______

Did any of the following systems appear to experience distress during the intervention?

Respiratory system Musculoskeletal system Circulatory system

Neurological system Gastrointestinal system

If any systems were checked, please describe:______

Central Dauphin
School District / Safe Crisis Intervention
Report

Were there any injuries to the individual reported or assessed? Yes (fill out questions below) No

Name of staff who performed injury assessment: ______

If injured, please describe: ______

If injured, what follow-up occurred:______

Were there any injuries to the staff reported or assessed? Yes (fill out questions below) No

Name of person who performed injury assessment:______

If injured, please describe:______

If injured, what follow-up occurred?:______

Describe the setting events that occurred prior to this incident: ______

______

Describe in detail the antecedent event (trigger/stimulus) that occurred immediately before the individual’s behavior

of concern. ______

______

Describe in detail the incident that occurred including non-physical interventions that were attempted to de-escalate

the situation, and indicate the individual’s response to each (Chronological narrative of the event):______

______
______

Describe in detail the reason for the use of physical intervention. Include all techniques that were utilized, staff’s position,

and reasons for any transitions that occurred:______

______
______

Indicate the reasons that the intervention was ended (what indicated that the individual was no longer a danger to self/or others): ______

______

What was the outcome of the incident? (Check all that apply)

Assessment by nurse Increased supervision Need for assessment Therapeutic follow up

Medical treatment Monitored time alone Psych. hospitalization

Increased supervision Need for assessment Law enforcement involved

Disciplinary Outcome______Other______

Signature of Reporter:______Date:____/____/______

Signature of Supervisor:______Date:____/____/______

Signature Incident Review:______Date:____/____/______

/ Central Dauphin
School District / Safe Crisis Intervention
Report

Action Plan:

1. Notify Parent: Date:

2. Schedule IEP meeting to review Crisis Plan: Date:

Signature of Staff Date

Note: Each person who is involved with or observes the incident must complete a separate form.

Please attach all intervention forms and a copy of the Crisis Plan. Send to your Supervisor by the end of the work day.

Number of Attachments

Review Team Use Only:

Date Received by Safe Crisis Management Review Committee

cc: Director of Special Education

Building Principal

Revised 2/9/2012