Pike Seclusion and Restraint Documentation Log

Pike Seclusion and Restraint Documentation Log
Student Information:
Student's Name

First NameLast Name
STN #
School
Date of and Time Incident

MonthDayYearHourMinutesAM/PM Option
If less than one minute, how many seconds?
Student Educational Services
Was the Student's IEP and/or BIP and/or 504 implemented?
Type (select all that apply)
Duration of Time Out

:HourMinutes
Duration of Seclusion

:HourMinutes
Duration of Restraint

:HourMinutes
Was a police/resource officer involved?
De-escalation Strategies Used Prior to Restraint/Exclusion

Other
Description of Events leading up to the incident:
Location of Incident

Other
The Behavior(s) that caused the need for seclusion/restraint posed:
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Describe the event/behavior that resulted in the need for seclusion or restraint.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Summary of the student's behavior DURING the seclusion or restraint.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
List staff members who assisted with the implementation, monitoring and supervision of seclusion or restraint.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
After examination, did the school nurse/designee identify an injury to the student, staff, or other students as a result of the seclusion or restraint?
Description of injuries
****A personal injury form must be completed for any injured person.
Did the student cause any property damage related to this incident?
Description of any damage to property
Explain what happened after the incident concluded. What type of debriefing occurred with the student and/or staff members?
Were parents verbally notified by...?
Date WRITTEN notice will be sent to parent?

MonthDayYear
Date
The Behavior Consultant will automatically be notified. Please enter any other email addresses for staff members that need to be notified:
Email
example@example.com
YOUR Name

First NameLast Name
YOUR Email address
Should be Empty:

Pike Seclusion and Restraint Documentation Log

The Behavior Consultant will automatically be notified. Please enter any other email addresses for staff members that need to be notified: