1. Survey Restraints, Seclusion, and Aversives

(Revised May 19, 2009)

Welcome to the Council of Parent Attorneys and Advocates (COPAA's) reporting form about abusive interventions in school. This is a survey about the use of restraints, seclusion, and aversive interventions upon children with disabilities in school programs. We very much appreciate your taking the time to complete this form.

Information that you report through COPAA will be shared with the Government Accountability Office (GAO), the investigative arm of Congress and the relevant House and Senate Education Committees.
We may also use the information to update our report on restraints, seclusion, and other abusive measures in school. Our current report is at
http://www.copaa.org/news/unsafe.html The report will be updated on a regular basis.

In COPAA's own documents that we write, we avoid using your name unless we get your permission first. (So we might say "a Texas family....")But we cannot make any guarantees of confidentiality about Congress or the GAO and what they may do; we obviously do not control them. So, please do not share any information here that you do not want made public. Share only what you are comfortable sharing.

If you are an attorney or advocate who has represented several children, it is okay to select one child and just fill out the form for that child. Or if you prefer to answer for many children, you can.

INSTRUCTIONS: Only the questions with an asterisk (*) are mandatory; the other questions are all optional. THERE IS A GRAY NEXT BUTTON AT THE BOTTOM OF THE PAGE. WHEN YOU FINISH EACH PAGE, CLICK THE GRAY NEXT BUTTON AND IT WILL TAKE YOU TO THE NEXT PAGE.

If you have any questions, please contact govrelations@copaa.org


* 1. What is your name?

Please note that stories without first and last name will not be used. While COPAA will not use your name in our materials without your permission, we do require you to give us your full name.

* 2. What is your email address?

* 3. May COPAA share your email address?

* 4. Please describe (summarize) what happened to the child. Please note any harm or injury that the child suffered.

* 5. Has your case already been reported to the Government Accountability Office (GAO)?

* 6. If this involved a due process hearing, court case, or criminal case, do you have the citation or the court or state involved?

* 7. If case involved a due process hearing or civil case in court, did the parents prevail?

* 8. What is the State where the child was abused? PLEASE USE YOUR TWO-LETTER POSTAL ABBREVIATION (e.g. AK, NY, TX).

* 9. How old was the child?

* 10. Where did the abuse occur? (Check all that apply).

* 11. Did the school implement a research-based, positive behavioral intervention program for the child?

* 12. Do you wish to identify the child's disability? (Check all that apply).


* 13. What city or school district where the child attended school? (This question is optional, but we would appreciate it if you wish to provide it.)

* 14. OPTIONAL: What is your address, including city, state, and zip code? (If you are not comfortable giving your street address, you can also just give city, state, and zip code).