Restraint Incident Report From

Restraint Incident Report
Location
Student Name
Select one of the options below
Time of Incident
Location of Incident
Date of Incident

MonthDayYear
Date
Duration of Incident (in minutes)
Duration of hold time (in minutes)
Staff Completing Report
Incident Information
Staff 1 Name
Staff 1 Role
- 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

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)
Description of restraint/escort:

0/900
Medical Evaluation
Checked by Nurse
Treatment Required
Parent Contact
Name of Parent/Guardian Notified
Date Notified

MonthDayYear
Date
Time Notified
Form of Notification

Follow-Up Activities
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

MonthDayYear
Date
Hour MinutesAM/PM Option
Should be Empty: