Seclusion/Restraint Incident Reporting Form

This form must be completed and submitted within 24 hours of the incident.

Date of Report*

Answer required for "Date of Report"

School*

Answer required for "School"

Student's Name*

Answer required for "Student's Name"

Grade*

Answer required for "Grade"

Student's Primary Exceptionality*

Answer required for "Student's Primary Exceptionality"

Date of Incident*

Answer required for "Date of Incident"

Starting Time of Incident*

Answer required for "Starting Time of Incident"

Ending Time of Incident*

Answer required for "Ending Time of Incident"

Location*

Answer required for "Location"

Staff involved (Include names and roles *i.e. restrained, monitored, etc)*

Answer required for "Staff involved (Include names and roles *i.e. restrained, monitored, etc)"

Incident Type (Check all that apply)*

Answer required for "Incident Type (Check all that apply)"

Seclusion

Restraint

Precipitating Events: (Describe events leading up to the incident)*

Answer required for "Precipitating Events: (Describe events leading up to the incident)"

Behavior Displayed by Student: (Describe actions necessitating intervention)*

Answer required for "Behavior Displayed by Student: (Describe actions necessitating intervention)"

Seclusion/Restraint Details

Method Used*

Answer required for "Method Used"

Primary Restraint Technique (PRT) - Standing Position

Primary Restraint Technique (PRT) - Sitted Position

Primary Restraint Technique (PRT) - Full Take Down

Modified Primary Restraint Technique (PRT) - Standing Position

Modified Primary Restraint Technique (PRT) - Sitted Position

Bite release

Hair pull release

Blocking

Escort

Duration (Mins)*

Answer required for "Duration (Mins)"

Injury to Student?*

Answer required for "Injury to Student?"

Yes

If an injury to the student occurred, please describe.

Answer required for "If an injury to the student occurred, please describe."

Injury to Staff?*

Answer required for "Injury to Staff?"

Yes

If an injury to the student occurred, please describe.

Answer required for "If an injury to the student occurred, please describe."

Parent/Guardian Notification

Please fix the highlighted areas below before submitting.

Seclusion/Restraint Incident Reporting Form