STUDENT PERSONNEL
Series 500
Policy Title: Use of Physical Restraint and/or Seclusion Documentation Form
Code No: 539.E1
Page 1 of 3
USE OF PHYSICAL RESTRAINT AND/OR SECLUSION DOCUMENTATION FORM
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Student Name: |
Date of occurrence: |
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Start time of occurrence: |
End time of occurrence: |
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Duration of restraint: |
Duration of seclusion: |
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Check all that apply: |
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Employee Name: |
Employee Title: |
Observed Restraint |
Involved Restraint |
Imple- mented Restraint |
Observed Seclusion |
Involved Seclusion |
Imple- mented Seclusion |
Date of last Chapter 103 training: |
Date of last CPI training: |
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Administrator Signature:
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15 min time: initials: |
30 min time: initials: |
30 min time: initials:
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30 min time: initials: |
30 min time: initials: |
30 min time: initials: |
30 min time: initials: |
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If Administrator approval was not obtained at 15 minutes or every 30 minutes thereafter, or a student was not provided with breaks for bodily needs in incidents lasting longer than 15 minutes, explain why: |
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Describe the incident; must include the antecedent (what happened before the behavior) and the behavior (what the student did). |
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Describe any less restrictive means attempted as an alternative to physical restraint and seclusion or why those means would not be effective or feasible, or have failed: |
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Parent/Guardian notification: Parents/Guardians will be notified as soon as practicable once the occurrence is under control, but no more than one hour after, or the end of the school day, whichever occurs first. Space below for documenting multiple attempts to notify guardians is listed in case the guardian cannot be reached in the first attempt. |
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Employee attempting notification: |
Parent/Guardian contacted: |
Time and manner of attempted notification:
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Was notification successful? |
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Employee attempting notification: |
Parent/Guardian contacted: |
Time and manner of attempted notification: |
Was notification successful? |
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If Parent/Guardian notification requirements were not complied with, explain why: |
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Describe employee actions before, during and after occurrence, including the reason for any of the following, if applicable: use of non-approved restraint, use of non-designated seclusion rooms, any restraint or seclusion that lasted longer than necessary: |
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Describe injuries sustained or property damaged by students or employees: |
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Describe future approaches to address student behavior including any consequences or disciplinary actions that may be imposed on the student: |
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This form has been reviewed and completed by the undersigned employee. A written copy of this form has been sent to the student’s parent or guardian within three school days of the occurrence. Unless the parent or guardian agrees to receive the report by email, fax, or hand delivery, the report must be sent by mail and postmarked by the third day following the occurrence. Enclosed with a copy of this form is an invitation for the parents or guardians to participate in the debriefing meeting scheduled in accordance with the law.
________________________________________________ Employee
________________________________________________Date of form delivered to Parent/Guardian
________________________________________________Method of Transmittal
