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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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Start time of use of physical restraint or seclusion: |
End time of use of physical restraint or seclusion: |
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Employee names and titles who observed, were involved with or implemented physical restraint and/or seclusion during occurrence (including administrators who approved extended time if applicable): |
Employee’s date of last training on use of physical restraint and seclusion: |
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Describe student actions before, during and after occurrence: |
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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 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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Approval from administrator to continue physical restraint or seclusion past 15 minutes: |
Approval obtained from administrator to continue physical restraint or seclusion more than 30 minutes past last approval time: |
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Administrator approving: |
Administrator approving: |
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Time approved: |
Time approved: |
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Reasons for length of incident: |
Reasons for length of incident: |
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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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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:
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Parent/Guardian contacted: |
Time and manner of attempted notification: |
Was notification successful? |
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Employee attempting notification:
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Parent/Guardian contacted: |
Time and manner of attempted notification: |
Was notification successful? |
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Employee attempting notification:
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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 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.
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Employee Date of form delivered to Parent/Guardian
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Method of Transmittal
