Restraint and Seclusion - Incident Report Form
This form provides a means of documenting events, circumstances and interventions associated with incidents involving the restraint and/or seclusion (R&S) of a student.  Since this information may be referenced by the district for future use/reporting , it is very important that all information be clear, thorough and descriptive.  Consider involving others to assist in capturing key information, even while events are occurring.  
Email *
Incident Report
Student Name *
Student ID *
Parent/Guardian Name *
Parent/Guardian Street Address *
Parent/Guardian Zip *
Student Race *
Sex *
Is the student on an IEP? *
Is the student on a 504 Plan? *
Attending School *
Date of Incident *
MM
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DD
/
YYYY
Location of Incident *
Time of Incident *
Time
:
Person Completing Form *
Triggering events, circumstances, precipitating factors and interventions prior to student's acute physical behavior.  Describe the sequence of events prior to the acute physical behavior of the student, including the environment, the actions of the student and others, and your efforts to deescalate the situation. *
Student's acute physical behavior requiring a higher level of intervention.  Describe the behavior of the student that was a danger to himself or others, including the actions of others. *
Less restrictive interventions in response to the student's acute physical behavior (ie., prior to the use of R&S).  Describe the interventions and the student's response to those interventions immediately following the acute physical behavior and prior to the use of R&S. *
Restraint and/or seclusion event-Description (describe the details of the R&S, including the actions and response by the student). *
Restraint and/or seclusion event-Restraint Techniques *
Restraint and/or Seclusion-Time Period: Start Time *
Time
:
Restraint and/or Seclusion-Time Period: End Time *
Time
:
Restraint and/or Seclusion-List names of all present with their titles.(ie., student, witness, staff, person performing restraint, other) *
Student Injury-Was there an injury to the student due to the restraint or seclusion?   *
Student Injury- If yes, describe the injury (AND complete a Student Accident ). *
Staff Injury-Was there an injury to the staff due to the restraint or seclusion?   *
Staff Injury- If yes, describe the injury (AND complete an employee Accident/Exposure Incident Report). *
Notifications-Was the student's parent/guardian notified of the restraint or seclusion immediately following the incident?   *
Notifications-Please list the name(s) of parent/guardian that was notified, along with how notified.  Provide description of conversation. *
Attendees of Debriefing Meeting (include position title and if trained in Restraint and Seclusion) *
Summary of the incident:
**Note this will be included in the letter sent to parents**
 *
Include interventions used and if any additional assessments should be done.
Functional Behavior Assessment (FBA)-Is this a repeated instance of restraint and seclusion for this student? *
Functional Behavior Assessment (FBA)-Does an FBA need to be initiated? *
Functional Behavior Assessment (FBA)-If an FBA needs to be initiated, enter who is responsible? *
Functional Behavior Assessment (FBA)-If an FBA needs to be initiated, enter the target completion date for the FBA.
MM
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DD
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YYYY
Positive Behavior Support Plan (PBSP) or Behavior Intervention Plan (BIP)-Does the student have a PBSP or BIP? *
Positive Behavior Support Plan (PBSP) or Behavior Intervention Plan (BIP)-If yes, are you reviewing the PBSP or BIP because of this incident? *
Positive Behavior Support Plan (PBSP) or Behavior Intervention Plan (BIP)-Describe any updates to the PBSP or BIP, or provisions for a short term plan. *
A copy of your responses will be emailed to .
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