503.6E1 - Physical Restraint or Physical Confinement Documentation

Student Name:  _______________________      Date of Occurrence: _______________________

 

Building of Attendance: ___________________________________

Beginning of Occurrence: __________________ 

End of Occurrence: _______________________           

                                                                                           

IEP?  (check one)     Yes____             No___         

 

 

Name of staff members involved:

 

Describe the actions of the student and employees involved before the occurrence:

 

Describe the actions of the student and the employees involved during the occurrence:

 

Describe the actions of the student and the employees involved after the occurrence:

 

Describe student and staff debriefing:

 

Describe alternatives to physical restraint or physical confinement attempted before the occurrence: 

 

Describe future approaches to the student’s behavior, including any consequences or disciplinary actions:

 

Describe any injuries to the student, employees or others, and any property damage:  

 

Describe future approaches to the student’s behavior:

 

If the occurrence involved a period of physical confinement that exceeds 15 minutes, the name of the administrator or designee who authorized any additional period of physical confinement.

 

Date and time of the debriefing meeting if needed (held within 5 days of letter):

 

Student’s Parent or Guardian Contacted by:

 

Date: 

Time:     

Method:

 

If the parent or guardian is not contacted on the same day of occurrence, describe attempts to notify the parent or guardian that day:                                                                      __________________________

                                                                                                                                                           

 

Date that a copy of this documentation was provided to the parent or guardian (must be within 3 school days of the occurrence):

Documentation provided (check one):

Sent home with student:  ___

By mail (postmarked within 3 school days of occurrence): ___

By electronic mail: _____

By facsimile transmission upon written request of parent/guardian: ____