File:† JKA-E

Student Restraint Incident Report Form

 

Student: _________________________†††††† School: ___________________________

Date: ___________________________†††††† Time: ____________________________

Location: __________________________________________________________

 

Staff directly involved in restraint (include names and titles; attach supplemental statements, if any):

________________________________________________________________________________________________________________________________

 

Witnesses (include names and titles):

________________________________________________________________________________________________________________________________

 

Description of events immediately before the behavior occurred:

________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________

 

Efforts/alternatives made prior to the use of restraint:

 

_____† Teaching interaction

_____† Offered self-control strategy

_____ Verbal de-escalation

_____ Other(s) (please describe):________________________________________________________________________________________________________________________

 

Type of restraint used:†

________________________________________________________________________________________________________________________________

 

Time restraint began:† ________________________________

 

Time restraint ended:† ________________________________

 

Chronological description of incident (include behavior, statements made, actions taken):

________________________________________________________________

________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________

________________________________________________________________

 

Resolution:

 

_____† Student calm/reintegrated into classroom/educational programming

_____† Student calm/additional time provided for de-escalation outside of instructional setting

_____ Additional support requested (medical/mental health/parent/police)

_____ Other(s) (please describe):_______________________________________

 

Injuries or property loss/damage:

________________________________________________________________

________________________________________________________________

________________________________________________________________

 

Persons notified of incident (include name, title, date and time notified):

________________________________________________________________

________________________________________________________________

________________________________________________________________

 

 

 

______________________________________

Name and title of person writing report

 

______________________________________

Signature

 

Checklist

Date

Comments

If an injury to staff or student has occurred, submit student accident report and/or staff incident report.

 

 

Building principal or designee verbally notify parent by end of the school day that the restraint was used.

 

 

Conduct internal review of incident of restraint.

 

 

Review documentation to ensure use of alternative strategies and recommend adjustments to procedures, if appropriate.

 

 

Report e-mailed, mailed or faxed to parent within 5 calendar days of the use of restraint.

 

 

If requested by parents or the school, convene a meeting (that may be an IEP, BIP or 504 meeting) to review the incident.

 

 

 

Copies:† parent, studentís confidential file [required]

 

Adoption date: September 22, 2014