Physical Restraint Documentation Form

 

(to be submitted to the principal within 24 hours of the occurrence of the incident.Multiple incidents cannot be merged into a single report).

 

Student Name:†††††††††† ________________________________††††††† Grade:________________

Date of Birth:††††††††† ________________________________††††††† School:________________

Date of Report:†††††††† ________________________________††††††† Gender_____††††††††††† Ethnicity_____

Mark all that apply:_____IEP††††††† _____504††††††† _____BIP

If this is the second incident of restraint with the student within 10 school days, an IEP/504 meeting is required: _____yes†††††††† _____no††††††††††††††††††††††††††††
Date of previous occurrence(s):__________________________________________________________________

Person Completing Form: _____________________________________________________________

Position:___________________________________________________________________________

 

Physical Restraint was used: (Check all boxes that apply)

􀂉 after less intrusive interventions had failed. List interventions attempted:

 

 

􀂉 after less intrusive interventions were deemed inappropriate or inadequate. This

†††††† decision is substantiated by the following explanation:

 

 

􀂉 in an emergency situation:

 

 

􀂉 an emergency situation existed that necessitated the use of physical restraint due to immediate ††††

†††††† threat of harm to: 􀀀 self 􀀀 others

 

 

􀂉 physical restraint was used only for the time period that was necessary to contain

†††††† the behavior of the student so that the student no longer posed an immediate threat

†††††† of causing physical injury to self or others

 

􀂉 physical restraint was implemented in accordance with all school division and/or

†††††† program policies and procedures regarding the use of physical restraint

 

􀂉 the force used in the application of physical restraint did not exceed the force that

†††††† was reasonable and necessary under the circumstance precipitating the use of

†††††† physical restraint

 

Date of Incident:_____________Location of Incident: ____________________________________

 

Time physical restraint began:____________ ††††††† Duration of restraint:_______________________

 

Time physical restraint ended:____________

 

Name(s) of person(s) involved: ___________________________________________________________________________________

 

 

Detailed Description of Incident (including student behavior prompting the restraint, antecedent events/circumstances, and resolution and process of return of student to educational setting if appropriate):

______________________________________________________________________________________________________________
______________________________________________________________________________________________________________

______________________________________________________________________________________________________________
______________________________________________________________________________________________________________

 

Detailed Description of Physical Restraint Method Used: ______________________________________________________________
______________________________________________________________________________________________________________

______________________________________________________________________________________________________________
______________________________________________________________________________________________________________

 

School/Program Administrator notified.††††† Date:__________Time: _____________

 

Parent/Guardian notified. ††††††††††††††††††††††††††† Date:__________Time: _____________

 

(Building administrator must be notified by the end of the school day. Parent must be notified the same day [or as soon as practicable if occurrence is at the end of the school day] as the incident. Written incident report must be given to the principal within two school days of the incident. Copy of incident report should be sent to the parent within 7 calendar days of the incident.)

 

Date and Document All Follow-up Actions (including whether any bodily injury was sustained by anyone and follow up action, i.e. nurse treatment): ________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________

________________________________________________________________________________________________________________
________________________________________________________________________________________________________________

 

Staff Debriefing:

 

Date__________††††††† Time__________†††††† ††††††††††† __________________________________________

††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† Administratorís Signature

 

Copy:††† Student File, Parent/Guardian, Principal, and Director of Human Resources/Pupil/Personnel,

Director of Special Education