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Restrictive Procedure Report Form (General Education Only)
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Student Name:
Your answer
Student DOB:
Your answer
Building:
Your answer
Date of Incident:
MM
/
DD
/
YYYY
Time of Incident:
Time
:
AM
PM
Person Completing this Form:
Your answer
Involved Staff:
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:
Your answer
Type of Restrictive Procedure:
Hold
Seclusion
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:
Yes
No
Clear selection
Was the student denied the restroom:
Yes
No
Clear selection
Positive or least restrictive interventions tried before use of restrictive procedure:
Redirection, correction, verbal / non-verbal feedback
Brief supervised removal to another location - discuss or engage in activities to address behavior
Safe place to relax / regroup - voluntary
Other:
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
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