Seclusion/Restraint Incident Reporting Form

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

Date of Report*

Answer Required

School*

Answer Required

Student's Name*

Answer Required

Grade*

Answer Required

Student's Primary Exceptionality*

Answer Required

Date of Incident*

Answer Required

Starting Time of Incident*

Answer Required

Ending Time of Incident*

Answer Required

Location*

Answer Required

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

Answer Required

Incident Type (Check all that apply)*

Answer Required

Seclusion

Restraint

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

Answer Required

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

Answer Required

Seclusion/Restraint Details

Method Used*

Answer Required

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

Injury to Student?*

Answer Required

Yes

If an injury to the student occurred, please describe.

Answer Required

Injury to Staff?*

Answer Required

Yes

If an injury to the student occurred, please describe.

Answer Required

Parent/Guardian Notification

Answer Required

Notified by:*

Answer Required

Post-Restraint Health Assessment

Post-Restraint Health Assessment Form*

Answer Required

Choose a file or drag it here.

Please fix the highlighted areas below before submitting.

Seclusion/Restraint Incident Reporting Form