INCIDENT REPORT aligned with CHAPTER 33
(PHYSICAL RESTRAINT or SECLUSION OF A STUDENT)

Name of School/Program _______________________________________
Name of Person Completing the Report ____________________________
Date of Report ________________________
This is a report of a ____ physical restraint
		          ____ seclusion

Student Involved 

Student’s name __________________________   Age____ Gender_______ Grade___ 

Student has (check all that apply):    IEP ___   504 ___   behavior plan ___   IHP ___   other plan (identify plan) ____________      no individualized plan ___ 

Description of the Incident

Date of incident ______________ 	
Beginning time of incident ____________ Ending time of incident _____________ 
Total time of incident _______________ 

Location of the incident (be specific) ________________________________________	 ______________________________________________________________________ 

Description of the incident, including the resolution and process of return of student to program (if appropriate) ______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

Description of prior events and circumstances _________________________________ ______________________________________________________________________
______________________________________________________________________
______________________________________________________________________ 

Least restrictive interventions attempted prior to the use of physical restraint or seclusion (if none used, explain why) ______________________________________________________________________
______________________________________________________________________
______________________________________________________________________ 

Student behavior that justified the use of physical restraint or seclusion ______________________________________________________________________
______________________________________________________________________
______________________________________________________________________ 
Description of Restraint or Seclusion; Staff Involved

Detailed description of the physical restraint/seclusion used ______________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

Staff person(s) involved, their role in the use of physical restraint or seclusion, and their certification, if any, in an approved training program 
________________________________________________________________________________________________________________________________________________________________________________________________

Bodily Injury of Student or Staff 

Did the student sustain serious bodily injury?		Yes ___ No ___  
Describe injury(ies) sustained ___________________________________________________
___________________________________________________________________________ 

Date & time school nurse or emergency response personnel notified, and treatment administered _______________________________________________________________________________

Did student or death? 			Yes ___ No ___  
If yes, date and time of notification to the DOE ___________________________

Did a staff member sustain bodily injury?		Yes ___ No ___  
If yes, name of person(s) sustaining injury _______________________________
Describe injury(ies) sustained _______________________________________________________
_______________________________________________________________________________ 

Date & time school nurse or emergency response personnel notified, and treatment administered _______________________________________________________________________________

Notification; Debriefing; 

Date, time, and method of parent notification _____________________________

Date and time of staff debriefing _______________________________________

Date and time of student debriefing _____________________________________

This incident is the _____ incident (number of incidents) this school year.
If this is the 3rd incident, then the student’s IEP, 504 team, or a team (for general education students) shall meet within 10 school days of the 3rd incident to discuss the incident.  

Date and time of required team meeting __________________________