* 1. Building Level of Incident:

* 2. Student Name (Last, First)

* 3. Racial/Ethnic status of the student:

* 4. Date and Time of Incident:

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

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

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

* 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:

* 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;

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

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

* 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:

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

* 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:

* 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.

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

Enter Date and Time
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:

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

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

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

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