Seclusion and Restraint Incident Report Question Title * 1. Building Level of Incident: Question Title * 2. Student Name (Last, First) Question Title * 3. Racial/Ethnic status of the student: Question Title * 4. Date and Time of Incident: Enter Date and Time: Date Time AM/PM - AM PM Question Title * 5. Duration of any seclusion or restraint; or the beginning and ending times of the seclusion and/or restraint: Question Title * 6. Description of any relevant events leading up to the incident: Question Title * 7. Description of any interventions used prior to the implementation of seclusion or restraint: Question Title * 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: Question Title * 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; Question Title * 10. Description of any injuries (to students, staff, or others) or property damage: Question Title * 11. Description of the planned approach to dealing with the student's behavior in the future: Question Title * 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: Question Title * 13. Supervisor support to the staff member and determination when each staff member shall return to his or her duties. Staff Member Name: Notes Concerning Support: Date To Return Duties: Question Title * 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: Question Title * 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. Question Title * 16. Date and time on which the parent or guardian was notified: Enter Date and Time Date Time AM/PM - AM PM Question Title * 17. Name of Administrator/ Designee notifying parent and or guardian: Question Title * 18. List if the student has a disability (IDEA or Section 504), and the type of disability: Question Title * 19. Name of Administrator/ Designee completing this report: Done