503.06-E(1) - Use of Physical Restraint and/or Seclusion Documentation Form

Student name:

Date of occurrence:

Start time of occurrence:

End time of occurrence:

Start time of use of physical restraint or seclusion:

End time of use of physical restraint or  seclusion:

Employee names and titles who observed, were involved with or  implemented physical restraint and/or seclusion during occurrence (including administrators who approved extended time if  applicable):

Employee’s date of last training  on use of physical restraint and  seclusion:

Describe student actions before, during and after occurrence:

Describe employee actions before, during and after occurrence, including the reason for any of the  following, if applicable: use of non-approved restraint, use of non-designated seclusion rooms, any  restraint or seclusion that lasted longer than necessary:

Describe any less restrictive means attempted as an alternative to physical restraint and seclusion or  why those means would not be effective or feasible, or have failed:

Approval from administrator to continue physical  restraint or seclusion past 15 minutes:

Approval obtained from administrator to continue  physical restraint or seclusion more than 30  minutes past last approval time:

Administrator approving:

Administrator approving:

Time approved:

Time approved:

Reasons for length of incident:

Reasons for length of incident:

If Administrator approval was not obtained at 15 minutes or every 30 minutes thereafter, or a student  was not provided with breaks for bodily needs in incidents lasting longer than 15 minutes, explain why:

Parent/Guardian notification: Parents/Guardians will be notified as soon as practicable once the  occurrence is under control, but no more than one hour after, or the end of the school day, whichever  occurs first. Space below for documenting multiple attempts to notify guardians is listed in case the  guardian cannot be reached in the first attempt.

Employee attempting  notification:

Parent/Guardian 

contacted:

Time and manner of  attempted notification:

Was notification 

successful?

Employee attempting  notification:

Parent/Guardian 

contacted:

Time and manner of  attempted notification:

Was notification

successful?

Employee attempting  notification:

Parent/Guardian 

contacted:

Time and manner of  attempted notification:

Was notification 

successful?

If Parent/Guardian notification requirements were not complied with, explain why:

Describe injuries sustained or property damaged by students or employees:

Describe future approaches to address student behavior including any consequences or disciplinary  actions that may be imposed on the student: