4321.12 F2 Use of Physical Restraints/Time Out

Student Name:

Student ID #:

Date of Birth:

_____ IEP _____ 504 Plan

_____ BIP

Grade:

School:

Incident Description

Date Incident Occurred:

Time Restraint/Time Out Began:

A.M./P.M.

Time Restraint/Time Out Ended:

A.M./P.M.

Identify Staff Administering Restraint:

Other Staff Present:

Restraint Used:

□ Physical Restraint

□ Time Out

Description of Restraint Used:

Location of Incident:

□ Classroom

□ Hall

□ Cafeteria

□ Playground

□ School Bus

□ Other:

Antecedent to the Student’s Behavior, if known:

Specific description of the emergency situation (i.e., the serious, probably, and imminent threat of bodily injury) that necessitated use of restraint:

Description of efforts made to de-escalate and alternatives that were attempted prior to the use of restraint:

Description of how student was monitored during restraint, including names of staff responsible for monitoring student’s physical safety:

Description of any injury to student and/or staff (to be completed and initialed by nurse on duty):

Initialed: ___________

Description of how restraint ended, and any efforts made to safely cease the use of restraint:

Parent notification (Parent must be verbally notified same day as incident.)

Name of Parent contacted:

___________________________

Phone Numbers:

Date of contact:

Time of contact: ________ A.M./P.M.

How were parent(s) notified?

□ Spoke with parent

□ Left voicemail

Name/position of staff member who verbally notified parents: