File: JKA-E - Student Restraint Incident Report Form

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.
Report e-mailed, mailed or faxed to parent within 5 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]

Adopted August 10, 2010

Reviewed August 21, 2023