ESI DOCUMENTATION FORM - LINK TO GAAF
ESI Documentation Form
GAAF – ESI DOCUMENTATION FORM
Emergency Safety Intervention Documentation
ESI Documentation Form - Printable Version
Date: ____________________________
Dear: ____________________________
The purpose of this letter is to inform you that on (Date)_______________________, at (Time) ________ (a.m./p.m.)
the need for the use of an Emergency Safety Intervention was required for
(Student’s Name)___________________________.
K.A.R. 91-42-1 through 92-42-7 provide that emergency safety intervention (hereafter “ESI”) is defined to include the use of seclusion or physical restraint but not the use of time-out or physical escort. Whenever an ESI is used, the parent(s)/guardian(s) must be informed of the use the day it happens. This notice requirement is deemed satisfied if the school attempts at least two methods of contact to reach the parent or guardian. By the day following the ESI use, written notification of the following shall be provided to the parent or guardian.
Type of ESI used: Seclusion _____ Restraint _____ Duration of seclusion/restraint: ________ (minutes)
Location: _________________________
Name of staff member(s) who participated in or supervised the ESI:
_____________________________________________________________________________________
_____________________________________________________________________________________
Did the student have an Individualized Education Program (“IEP”), Section 504 Plan, or a Behavior Intervention Plan at the time of the incident? ___________ If so, specify which: _______________________
_____________________________________________________________________________________
Description of events leading up to the incident:
_____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________
_____________________________________________________________________________________
Student behaviors necessitating the ESI:
_____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________
Steps taken to transition the student back into the educational setting:
___________________________________________________________________________________________ ___________________________________________________________________________________________
Parents or guardians of the above-named student are invited and strongly encouraged to schedule a meeting to discuss the ESI and how to prevent future ESI use. Please contact the following staff member at the email address and/or phone number listed below to schedule such a meeting or if you have any questions regarding this use of ESI.
(Staff Member Name) ___________________________________________
(Staff Member Email Address) ____________________________________
(Staff Member Phone Number ____________________________________
(Signature of person completing report) _______________________________________
(Date) _______________________
*Parent(s)/guardian(s) notified of this incident on _____________________ by _________________________.
Please feel free to provide feedback or comments concerning this ESI use below and email or deliver them to the staff member specified above.
__________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________
__________________________________________________________________________________________
*Original provided to Building Principal
*Copy provided to (Parents/Guardians, Administrative Office)
Form revised: 07/11/2022