File: JKA-E-1 - Student Restraint Incident Report Form

NOTE: While Colorado school districts are not required by law to adopt an exhibit on this subject, this sample reflects documentation and notification requirements school districts must follow. This sample contains the content/language that CASB believes best meets the intent of the law. However, the district should consult with its own legal counsel to determine appropriate language that meets local circumstances and needs.

Student: _________________________ School: __________________________

Date: ___________________________ Time: ____________________________

Location: ________________________________________________________

Staff directly involved in restraint (include names and titles; attach supplemental statements, if any):

________________________________________________________________

Witnesses (include names and titles):

________________________________________________________________

Description of events immediately before the behavior occurred:

________________________________________________________________

Efforts/alternatives made prior to the use of restraint:

____ Teaching interaction

____ Offered self-control strategy

____ Verbal de-escalation

____ Other(s) (please describe): __________________________________

_____________________________________________________________

Type of restraint used:

________________________________________________________________

Time restraint began: ________________________________

Time restraint ended: ________________________________

Chronological description of incident (include behavior, statements made, actions taken):

________________________________________________________________

Resolution:

___ Student calm/reintegrated into classroom/educational programming

___ Student calm/additional time provided for de-escalation outside of instructional setting

___ Additional support requested (medical/mental health/parent/police)

___ Other(s) (please describe): __________________________________

Injuries or property loss/damage:

________________________________________________________________

Persons notified of incident (include name, title, date and time notified):

________________________________________________________________

______________________________________

Name and title of person writing report

______________________________________

Signature

Checklist	Date	Comments
If an injury to staff or student has occurred, submit student accident report and/or staff incident report.
Building principal or designee verbally notify parent by end of the school day that the restraint was used.
Conduct internal review of incident of restraint.
Review documentation to ensure use of alternative strategies and recommend adjustments to procedures, if appropriate.
If restraint was between one and five minutes, written notice given to parents on the day of the restraint
If restraint was five minutes or more, verbal notice given to parent on the day of restraint, and written report emailed, mailed or faxed to parent within five calendar days of the use of restraint.
If requested by parents or the school, convene a meeting (that may be an IEP, BIP or 504 meeting) to review the incident.

Copies: parent, student's confidential file [required]

(Issue date)