Restraint Documentation Form

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BURKE CO. PUBLIC SCHOOLS/RESTRAINT DOCUMENTATION FORM
Circle One:
Planned Intervention
Emergency Intervention
(Requires Team meeting after incident)
Student’s Name: _______________________ School: _________________________________________
Homeroom: ___________________________ If EC Student-Identification: __________________________
Person Completing Report ____________________________________
Date: ___/___/___
Time: ___:___
Location: (circle one)
AM/PM
Class
Playground
Hallway
Bus
Cafeteria
Bathroom
Outside
Gym
Auditorium
Other: __________________________
Conditions Immediately Preceding Incident
(circle one or more and describe)
Request by staff __________________________
Request by student ______________________________
Provoked by another student ________________
Disruptive Environment __________________________
Change in routine _________________________
Other _________________________________________
Describe behaviors exhibited by the student and interventions attempted before restraint/seclusion was used:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Describe behavior that warranted the use of physical restraint/seclusion:____________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Describe the restraint/seclusion that was used: __________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Individuals involved with restraint/seclusion: _____________________________________
__________________________________________________________________________________________________
Injury Noted to student/staff as a result of incident, restraint, or seclusion:__________________________________
__________________________________________________________________________________________________
What led to the end of the restraint/seclusion?__________________________________________________________
__________________________________________________________________________________________________
What was behavior of student following the restraint/seclusion?___________________________________________
__________________________________________________________________________________________________
Name of school staff member that met with student following restraint _____________________________________
Date/time of meeting______________________________________________
What was discussed? ______________________________________________________________________________
________________________________________________________________________________________________
Plan to prevent future restraint/seclusion: ______________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Principal Notification (Name/Date/Time) ______________________________________________________________
Verbal Parent Notification (Name/Date/Time) __________________________________________________________
(Must be before the end of the school day)
Written Parent Notification (Name/Date/Time) _________________________________________________________
(Must be sent by the end of the following school day)
If Emergency Use of Restraint, Complete the Following:
Date/Time of Scheduled Meeting: ________________________________________________________________
Behavior Support Personnel Involved: __________________________________________________________________
Updated 9/09

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