502.13 E1 - Physical Restraint or Physical Confinement Documentation

Student Name:                                                            Date of Occurrence: ___________________

Building of Attendance: __________________        Time of Occurrence:  _________________

IEP?  (check one)      Yes ______       No ______     Duration of Occurrence: _______________

 

Name of staff members involved:                                                                                                     

                                                                                                                                                           

                                                                                                                                                           

                                                                                                                                                           

 

Describe the actions of the student and employees involved before the occurrence:                                  

                                                                                                                                                           

                                                                                                                                                           

                                                                                                                                                           

                                                                                                                                                           

                                                                                                                                                           

                                                                                                                                                           

 

Describe the actions of the student and the employees involved during the occurrence:                                                                                                                                                                                        

                                                                                                                                                           

                                                                                                                                                           

                                                                                                                                                           

                                                                                                                                                           

                                                                                                                                                           

 

Describe the actions of the student and the employees involved after the occurrence:                               

                                                                                                                                                           

                                                                                                                                                           

                                                                                                                                                           

                                                                                                                                                           

                                                                                                                                                           

                                                                                                                                                           

 

Describe student and staff debriefing:                                                                                                                                                                                                                                                                

                                                                                                                                                           

                                                                                                                                                           

                                                                                                                                                           

                                                                                                                                                           

 

 

Describe alternatives to physical restraint or physical confinement and detention attempted before the occurrence:                                                                                                                                                                                                                                                                                                

                                                                                                                                                           

                                                                                                                                                           

                                                                                                                                                           

                                                                                                                                                           

 

Describe any injuries to the student, employees or others, and any property damage:                               

                                                                                                                                                           

                                                                                                                                                           

                                                                                                                                                           

                                                                                                                                                           

                                                                                                                                                           

 

Describe future approaches to the student’s behavior (including possible IEP meetings to address behavior concerns):                                                                                                                                    

                                                                                                                                                           

                                                                                                                                                           

                                                                                                                                                           

                                                                                                                                                           

                                                                                                                                                           

 

If the occurrence involved a period of physical confinement and detention that exceeded the shorter of 60 minutes or the school’s typical class period, the name of the administrator or designee who authorized any additional period of physical confinement and detention:                                                                 

 

 

Student’s Parent or Guardian Contacted by:                                                                                           

Date:                                         Time:                            Method:                                                         

 

If the parent or guardian is not contacted on the same day of occurrence, describe attempts to notify the parent or guardian that day:                                                                                                                    

                                                                                                                                                           

 

Date that a copy of this documentation was provided to the parent or guardian (must be within 3 school days of the occurrence):                                        

Documentation provided (check one):

By mail (postmarked within 3 school days of occurrence): _____

By electronic mail upon written request of parent/guardian: _____

By facsimile transmission upon written request of parent/guardian: ____