PHYSICAL RESTRAINT AND/OR SECLUSION INCIDENT REPORTING FORM
Parents will be provided verbal or written notification by the school staff following the use of physical restraint and/or seclusion by the end of the day on which the incident occurred.
Staff person completing this document _________________________ Date_____________
Check one:
♦ Physical Restraint means "the restriction of a student’s movement by one or more persons holding the student or applying physical pressure upon the student." Physical restraint "does not include touching or holding a student without the use of force for the purpose of directing the student or assisting the student in completing a task or activity." OAR 581-021-0062 (1) (a)
♦ Seclusion means "the involuntary confinement of a student alone in a room from which the student is prevented from leaving. Seclusion does not include "time-out." "Time-out" means removing a student for a short time to provide the student with an opportunity to regain self-control, in a setting from which the student is not physically prevented from leaving." OAR 581-021-0062 (1) (b) ?
Student’s Name ___________________________________ School/Program______________________________
Date of Incident ___________________________________
Grade/Age _________________________________
Location of incident_____________________________________________________________________________
Type of Incident: ____ Unsafe/harmful to self
____ Unsafe/harmful to others
____ Unsafe/harmful to property
Location of Restraint and/or Seclusion______________________________________________________________
Time Incident Began____________________________
Time Incident Ended _______________________________
Total Duration of Restraint/Seclusion _______________________________________________________________
A. Provide a narrative description of the incident:
Antecedent (What occurred prior to the behavior):
Behavior:
B. List interventions attempted prior to the restraint and/or seclusion:
C. Restraint and/or Seclusion (Check all that apply):
_____ Child Protective Hold _____ Team Control Position _____ Transport Technique
Did injury occur? _____ Yes _____ No
If yes, please describe: __________________________________________________________________________________________________________________________________________________________________________________________
Was a Jefferson County Accident Report Completed? _____ Yes _____ No
Was medical attention obtained? ______ Yes _____ No
If yes, please describe:
__________________________________________________________________________________________________________________________________________________________________________________________
D. Outcomes:
_____ Student returned to class _____ In-school suspension
_____ Student assigned to alternate setting _____ Out of school suspension
_____ Police involvement/citation issued
_____ Other: (specify)_______________________________________________
E. Signature of Staff involved in incident:
Name: ________________________________ Title: ______________________________________
Name: ________________________________ Title: ______________________________________
Name: ________________________________ Title: ___________________________________
F: Parent notification:
Name of parent contacted: ______________________________ Phone:____________________
Date and time of contact:___________________________________________________________
Documented attempt to contact parent if unable to contact verbally (describe): __________________________________________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________
Name of staff member making contact (include name and title):
Name ________________________________________________ Title: _______________________ G. Name of administrator: ______________________________Date: _____________
Please send copies of the completed documentation to:
Special Education Director, Education Service District
(if student has an IEP or 504 Plan)