Building Level of Incident:

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* 1. Building Level of Incident:

Student Name (Last, First)

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* 2. Student Name (Last, First)

Racial/Ethnic status of the student:

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* 3. Racial/Ethnic status of the student:

Date and Time of Incident:

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* 4. Date and Time of Incident:

Enter Date and Time:
Duration of any seclusion or restraint; or the beginning and ending times of the seclusion and/or restraint:

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* 5. Duration of any seclusion or restraint; or the beginning and ending times of the seclusion and/or restraint:

Description of any relevant events leading up to the incident:

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* 6. Description of any relevant events leading up to the incident:

Description of any interventions used prior to the implementation of seclusion or restraint:

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* 7. Description of any interventions used prior to the implementation of seclusion or restraint:

Description of the incident and/or student behavior that resulted in implementation of seclusion or restraint including a description of the danger of injury which resulted in the seclusion or restraint:

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* 8. Description of the incident and/or student behavior that resulted in implementation of seclusion or restraint including a description of the danger of injury which resulted in the seclusion or restraint:

A log of the student's behavior during seclusion or restraint, including a description of the restraint technique(s) used and any other interaction between the student and staff;

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* 9. A log of the student's behavior during seclusion or restraint, including a description of the restraint technique(s) used and any other interaction between the student and staff;

Description of any injuries (to students, staff, or others) or property damage:

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* 10. Description of any injuries (to students, staff, or others) or property damage:

Description of the planned approach to dealing with the student's behavior in the future:

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* 11. Description of the planned approach to dealing with the student's behavior in the future:

List of the school personnel who participated in the implementation, monitoring, and supervision of seclusion or restraint and whether they had training related to seclusion or restraint:

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* 12. List of the school personnel who participated in the implementation, monitoring, and supervision of seclusion or restraint and whether they had training related to seclusion or restraint:

Supervisor support to the staff member and determination when each staff member shall return to his or her duties.

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* 13. Supervisor support to the staff member and determination when each staff member shall return to his or her duties.

If needed: Add more staff member(s) from previous question. Please keep in same format.

Staff Member Name:
Notes Concerning Support:
Date To Return Duties:

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* 14. If needed: Add more staff member(s) from previous question. Please keep in same format.

Staff Member Name:
Notes Concerning Support:
Date To Return Duties:

Name of (Clinic) Staff Member not involved with the incident who examined the student to ascertain if any injury has been sustained during the seclusion or restraint.

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* 15. Name of (Clinic) Staff Member not involved with the incident who examined the student to ascertain if any injury has been sustained during the seclusion or restraint.

Date and time on which the parent or guardian was notified:

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* 16. Date and time on which the parent or guardian was notified:

Enter Date and Time
Name of Administrator/ Designee notifying parent and or guardian:

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* 17. Name of Administrator/ Designee notifying parent and or guardian:

List if the student has a disability (IDEA or Section 504), and the type of disability:

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* 18. List if the student has a disability (IDEA or Section 504), and the type of disability:

Name of Administrator/ Designee completing this report:

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* 19. Name of Administrator/ Designee completing this report:

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