Restraint Authorization Form
Please fill out the form, this allows us to track and program for safety. Just need to submit once and we will get a copy. Please remember to contact Nellie Aponte after each restrictive procedure.
Email address *
Select school the incident took place *
My Name (First and Las) (EXAMPLE: John Smith) *
How many Restraints were utilized? 1 form is necessary for each restraint over 15 minutes. *
Student Name (First and Last name) (This person is the learner on whom you performed the restraint) *
Date Restraint Used (EXAMPLE: 12/11/19) *
Restraint Report Designee notified: (Nellie Aponte) *
Time Restraint Report Designee notified (Notify Nellie Aponte: ( Ext 128 (Time Example: 3:15PM) *
Time Restraint Began (EXAMPLE: 1:15PM) *
Time Restraint Ended (EXAMPLE: 1:35PM) *
Time Student Visited Nurse (Required immediately following restraint) (Example: 1:25PM) *
Detailed Description of Event Requiring Restraint (i.e., Antecedents, Behaviors, what happened after) Please be as descriptive as possible. *
Did the Restraint last more than 15 minutes? *
Was Medical Attention Needed? *
Has you ever restrained this student before? *
Area and extent of injuries (N/A if no injuries) *
For every 15 minutes of restraint, identify the status of the student (eg 1 -Stable, no physical distress or 1-physical distress/Restraint Terminated) *
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