P C

YCS PHYSICAL CONTROL/SEPARATION REPORT

Program/School: ______Consumer:______CMHC #______

Date of Incident:______Time of Incident:______Shift __ AM __ PM __ Overnight

Person Writing Report:______Date:______

Witness(es):______Date:______

SECTION A - Type of Incident (Check all that apply)

Aggression toward
___Staff ___Resident / Disagreement with Staff / Run/Walk-Away Attempt / Theft / Terroristic Threat
Alleged Emotional Abuse
___Staff ___Guardian / Emotional Distress / Run/Walk-Away / Property Damage / Fire Starting
Alleged Physical Abuse
___Staff ___Guardian / Injury- Accidental / Medical Hospitalization / Contraband / Felony
Alleged Sexual Abuse
___Staff ___Guardian / Sexual Contact Between Residents / Client became out of control / Resident Fighting / Homicide Attempt
Assault Against
___Staff ___Resident / Inappropriate Physical Exposure / Psych. Hospitalization / Drug Possession/Sale / Homicide
Refusing A Directive / Self Abuse / Suicidal Talk / Drug/Alcohol Use / Death
Disagreement between Peers / Suicide Attempt / Suicide / Other: ______

Location Where Incident Took Place (Check all that apply)

OFF GROUNDS / RESIDENCE
In Vehicle / Out With Volunteer / Bathroom / Hallway / Outdoors
On Activity / Outdoors / Bedroom / Kitchen / Public Space
At Home / Other / Dining Room / Lounge / Other

SECTION B - Type of Intervention (Check all that apply)

□ Physical ControlTime started:______Time ended:______

□ EscortTime started:______Time ended:______

□ Separation/Quiet TimeTime started:______Time ended:______

Check techniques used during Physical Control, Escort or Separation:

CPI: □ Children’s Control Position □Team Control Position □Transport Technique

HWC: □ Primary Restraint Tech. □ Modified Primary Restraint Tech. □2-Person Escort Tech. □Supine

Check preventive CPI techniques used: □ Supportive Staff Response □Directive Approach □Therapeutic Rapport

(Empathic/Active Listening) (Setting Limits/PNP Consequence)

In order to release the child from the restraint, the child was: □Calm □ Breathing level returned to normal

□Body tension decreased □Verbally compliant

The child was made aware of the behavioral criteria he or she needed to meet in order to be released from the restraint? □ NO □ YES

Is thisthe child's' first Physical Control since admission□ NO □ YES (If YES, parent/guardian mustbe notified within 10 hours of the Control)

Was an injury reported by the child during or after the physical control or separation from group? □ NO □ YES

(For CHIMP, see nurse’s section to

Number of times this child has been physically controlled over the past 12 hours:______determine if injury was confirmed)

SECTION C - Notification (Check all that apply and fill in name of person contacted, time and date)

TITLE / NAME / TIME / DATE
Supervisor
Administrator
Clinician/Behaviorist
Nurse The Nurse must check the child with-in one hour of the Physical Control.
Psychiatrist/APN-OnCall
Psychiatrist/APN-Regular
Parent/Guardian
DYFS or DDD Worker
Other

SECTION D - Narrative Section (Please attach additional sheets if necessary)

TYPE OF INCIDENT: Describe in detail any areas checked off in SECTION A on the reverse side:

______

(Print Name)(Title)(Date) (Signature)

POSSIBLE CAUSE/PRECIPITATING FACTORS/RATIONALE FOR PHYSICAL CONTROL:

______

(Print Name)(Title)(Date) (Signature)

NURSING SUMMARY: (To be completed by Nurse)

A Nurse checked the child within one hour after the Physical Control ended? □ NO □ YES Date: ______Time:______(child was checked)

Did an injury occur to the child? □ NO □ YES

Parent/Guardian Notified (If immediate notification is required: □ NO □ YES If yes, via: □ letter □phone Date: ______Time: ______

______

(Print Name)(Title)(Date) (Signature)

INTERVENTIONS: Please Check All That Apply:

Nonverbal communication / Restate Directions / Address Alternatives
Provide Verbal Support / Provide Verbal Direction / Stress Reduction Techniques
Redirect client from the situation / Tell-show-do / Positive reinforcement
Remind client of benefits of program compliance / Redirect within the Behavior Management System / CPI (Support-Direct-Isolate)
Referred To/Brought to Nurse / Referred To/Brought to Social Worker / Quiet Time
Other Interventions as based on the client’s treatment plan: ______/ Other Interventions as based on the client’s treatment plan: ______/ Other:

SECTION E - REVIEW/FINAL DISPOSITION OF INCIDENT:(Comments/Recommendations/Follow-Up/Acknowledgement of Physical Control)

SUPERVISOR:(on the shift at the time of the physical control):

______

(Print Name)(Title)(Date) (Signature)

CLINICIAN or BEHAVIORIST:

______

(Print Name)(Title)(Date) (Signature)

ADMINISTRATOR:

______

(Print Name)(Title)(Date) (Signature)

Documents completed in conjunction with this report: □ Clinical Note □Physical Control Order Form□Nursing Assessment

□ Unusual Incident Report (if client is injured) □Staff Debriefing □ 15 minute check (as necessary) □ Client Debriefing

Revised 6.6.11 P:\Research\PIA\CRM\6.6 p.1