Restraint Incident Report
Location
*
Please Select
Bergen Primary
Bergen Elementary
Bergen Middle
Bergen High
Bronx Primary
Bronx Elementary
Hudson Elementary
Hudson Middle
Passaic Primary
Passaic Elementary
Passaic Middle
Passaic High
Passaic Clifton Primary
Passaic Clifton Elementary
Passaic Clifton Middle
Passaic Clifton High
Paterson Silk City Primary
Paterson Primary
Paterson Elementary
Paterson Middle
Paterson High
Student Name
Select one of the options below
General Education Student
Special Education Student
Time of Incident
Location of Incident
Date of Incident
-
Month
-
Day
Year
Date
Duration of Incident (in minutes)
Duration of hold time (in minutes)
Staff Completing Report
Incident Information
Staff 1 Name
Staff 1 Role
Add More Staff
Staff 2 Name
Staff 2 Role
Staff 3 Name
Staff 3 Role
Staff 4 Name
Staff 4 Role
Staff 5 Name
Staff 5 Role
Staff 6 Name
Staff 6 Role
Staff 7 Name
Staff 7 Role
Staff 8 Name
Staff 8 Role
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Antecedent (What happened prior to behavior?)
0/900
Behavior that presented imminent danger of serious physical harm to self/others (includedescription of physical damage):
0/900
Prevention, redirection, and/or de-escalation techniques utilized prior to restraint:
0/900
Types of Restrained Used (Check all that apply)
PRT
Modified PRT
Description of restraint/escort:
0/900
Medical Evaluation
Checked by Nurse
Yes
No
Treatment Required
Yes
No
Parent Contact
Name of Parent/Guardian Notified
Date Notified
-
Month
-
Day
Year
Date
Time Notified
Form of Notification
Phone
In Person
Email (if unable to reach by phone)
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Follow-Up Activities
Team staffing to review district procedures, data and IEP (mandatory)
Notification of case manager if classified (mandatory)
Revision of IEP
Administration of FBA
Revision of BIP
Follow-up Counseling
Disciplinary Action
Other
If Disciplinary Action Selected Above, please specify
0/900
If Other Selected Above, please specify
0/900
Email
example@example.com
Signature
Sign Date and Time
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
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