1. 3319P
    2. PHYSICAL RESTRAINT AND ISOLATION INCIDENT REPORT
      1. Prevention/De-escalation Strategies Used:
      2. Administrator Documentation





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    PHYSICAL RESTRAINT AND ISOLATION INCIDENT REPORT

    THIS SECTION TO BE COMPLETED BY THE TEACHER
     
    School:   Student:   Student ID#:  

    Birth Date:   Grade:  

    Date:     Start time:     End time:  
    q Student with IEP q Student with 504 q Physical Restraint q Isolation  

    Staff involved and job title(s):

       

     

    Physical Injuries to Student or Staff: q No q Yes (Description and if medical was provided)

     

    Antecedents (What led to the use of restraint or isolation):

     

     

    Location: q Classroom q Hallway q Cafeteria q Outside Grounds q Bus q Other

    Activity:
     PE   Academic   Before school activity
     Recess   Center Activity   After school activity
     Lunch   Recreational/Free Choice   Other:  

    Incident Description (including the type of restraint and duration):

         

     



    Prevention/De-escalation Strategies Used:
     Redirect   Calm down break in classroom
     Space/Time   Calm down break in buddy room or office
     Give choices   Student problem-solving
     Physical proximity   Adult assisted problem-solving
     Restate/review expectations   Other:  

    Recommendations for changing the nature or amount of resources available to the student and staff member to avoid similar incidents:

     

     

     
    THIS SECTION TO BE COMPLETED BY THE ADMINISTRATOR
     



    Administrator Documentation

    q Student/Teacher conference   q Processing form   q Returned to class/activity

    q Parent called   q Sent home   q Police called   q Positive behavior instruction

    q Referred to administrator (Verbally notify parents within 24 hours and provide written notification post-marked within five (5) days; Special Services or 504 Team copy within two (2) days (if applicable).
    q Administrator review with teacher  Date:    Time:  
    q Administrator review with parent  Date:    Time:  
    q Written report sent to parent  Date:    Time:  
    q Written report sent to Special Services  Date:    Time:    

    Staff signature:     Title:     Date:  

    Principal signature:     Date:  

    Copy to:   Building Administration; Associate/Assistant Superintendent; 504 Team (if applicable); Special Services (if applicable)

    12/13; 10/15; 12/15

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