Use of Physical Restraint and/or Seclusion Documentation Form
Student Name: ____________________________________ Date of Occurrence: ______________
Start Time of Occurrence: ___________ End Time of Occurrence: ___________
Start Time of Use of Physical Restraint or Seclusion: _____________
End Time of Use of Physical Restraint or Seclusion: _____________
Employee Names and Titles who observed, were involved with or implemented physical restraint and/or seclusion during occurrence (including administrators who approved extended time if applicable):
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Employees Date of last training on use of physical restraint and seclusion:
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Describe student actions before, during and after occurrence:
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Describe employee actions before, during and after occurrence including the reason for any of the following, if applicable: use of nonapproved restraint, use of nondesignated seclusion rooms, any restraining or seclusion that lasted longer than necessary:
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Describe any less restrictive means attempted as an alternative to physical restraint and seclusion or why those means would not be effective or feasible or have failed:
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Approval from administrator to continue physical restraint or seclusion past 15 minutes: _________
Administrator approving: ______________________________ Time approved: ___________
Reasons for length of incidents: ____________________________________________________
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Approval obtained from administrator to continue physical restraint or seclusion more than 30 minutes past last approval time: _________
Administrator approving: ______________________________ Time approved: __________
Reasons for length of incidents: ____________________________________________________
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If administrator approval was not obtained at 15 minutes or every 30 minutes thereafter or a student was not provided with breaks for bodily needs in incidents lasting longer than 15 minutes explain why:
Reasons for length of incidents: ____________________________________________________
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Parent/Guardian notification: Parents/Guardians will be notified as soon as practicable once the occurrence is under control but no more than one hour after or the end of the school day, whichever occurs first. Space below for documenting multiple attempts to notify guardians is listed in case the guardian cannot be reached in the first attempt.
Employee attempting: _________________________ Parent/Guardian contacted: _______________
Time and manner of attempted notification: ___________________ Notification successful: _______
Employee attempting: _________________________ Parent/Guardian contacted: _______________
Time and manner of attempted notification: ___________________ Notification successful: _______
Employee attempting: _________________________ Parent/Guardian contacted: _______________
Time and manner of attempted notification: ___________________ Notification successful: _______
If parent/guardian notification requirements were not complied with, explain why:
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Describe injuries sustained or property damaged by students or employees: ___________________________________________________________________________
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Describe future approaches to address student behavior including any consequences or disciplinary actions that may be imposed on the student:
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This form has been reviewed and completed by the undersigned employee. A written copy of this form has been sent to the student’s parent or guardian within three school days of the occurrence. Unless the parent or guardian agrees to receive the report by email, fax, or hand delivery, the report must be sent by mail and postmarked by the third day following the occurrence. Enclosed with a copy of this form is an invitation for the parents or guardians to participate in the debriefing meeting scheduled in accordance with the law.
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Employee Signature Date of form delivered
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Method of Transmittal
Approved: 7/14/25 Reviewed: Revised