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, and actions taken): ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ Resolution: …
Read Full Policy- Last Reviewed/Revised:
- Last Adopted: August 12, 2010