Seclusion and Restraint -Options Charter School
Person completing form
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School
Student Name (First, Last)
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Date of Incident
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DD
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YYYY
Time of Incident
Time
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Duration of Restraint and/or Seclusion
Time
:
Description of relevant events leading up to the incident
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Interventions used prior to implementation of restraint and seclusion
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Student's behavior during restraint and/or seclusion including a description of injury which resulted in the restraint and/or seclusion
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Description of any injuries to students, staff, or others
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Description of property damage
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School personnel involved in the implementation, monitoring, and supervision of restraint or seclusion and whether they had training related to restraint or seclusion
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Date and time parent or guardian was notified
MM
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DD
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YYYY
Date seclusion/restraint document was mailed home
MM
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DD
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YYYY
Signature of staff member completing document
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