Restraint/Seclusion Debriefing Form
Date of Debriefing
Time of Debriefing
Individuals in Attendance (Check all that apply)
General Education Teacher
Give a brief description of the circumstances leading up to this point:
Give a summary of incident:
What was the intervention used?
What was the outcome?
From the information gained at the meeting what needs to be changed?
Has a support plan/contract been initiated?
Is this is a repeated instance of restraint or seclusion, if so, an FBA shall be conducted. Has an FBA been initiated?
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This form was created inside of Circleville City Schools.