Restrictive Procedure Report Form (General Education Only)
Email address *
Student Name:
Your answer
Student DOB:
Your answer
Building:
Your answer
Date of Incident:
MM
/
DD
/
YYYY
Time of Incident:
Time
:
Person Completing this Form:
Your answer
Involved Staff:64645
Your answer
Description of incident and emergency that lead to use of restrictive procedure, include any information regarding risk of injury to self and/or others: 64614
Your answer
Type of Restrictive Procedure:
Description of hold or seclusion; techniques used, start/end times of restrictive procedure, child's behavior and physical status during restrictive procedure, clothing or items removed, meals delayed, etc.:
Your answer
Was the student denied water:
Was the student denied the restroom:
Positive or least restrictive interventions tried before use of restrictive procedure:
Description of why a less restrictive intervention failed or was determined by staff to be inappropriate or impractical:
Your answer
Parent Notification; include date, time, parent name, by whom, parent comments:
Your answer
Was law enforcement contacted? Include "yes / no", by whom, and outcome of call:
Your answer
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of Duluth Public Schools. Report Abuse - Terms of Service - Additional Terms