Pike Seclusion and Restraint Documentation Log

Pike Seclusion and Restraint Documentation Log
Student Information:
Student's Name *

First Name Middle Name Last Name
STN #
School *
Date of and Time Incident *

- Month - Day Year
at
: Hour Minutes AM/PM Option Date Picker Icon
Student Educational Services *
Was the Student's IEP and/or BIP and/or 504 implemented? *

YES NO
Type (select all that apply) *

Time Out Seclusion Restraint
Duration of Time Out *

: Hour Minutes
Duration of Seclusion *

: Hour Minutes
Duration of Restraint *

: Hour Minutes
De-escalation Strategies Used Prior to Restraint/Exclusion *

Acknowledgement Proximity Cool Down Area Assist with Task Setting Limits Empathy Praise Reassurance Speak Privately Movement Break Reinforcement Soft Tone of Voice Allow Space Provide Choices
Description of Events leading up to the incident: *
Location of Incident *

Gen Ed Class Special Ed Class Cafeteria Hallway Playground Gym
The Behavior(s) that caused the need for seclusion/restraint posed: *
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Describe the event/behavior that resulted in the need for seclusion or restraint. *
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Summary of the student's behavior DURING the seclusion or restraint. *
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
List staff members who assisted with the implementation, monitoring and supervision of seclusion or restraint. *
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
After examination, did the school nurse/designee identify an injury to the student, staff, or other students as a result of the seclusion or restraint? *

YES NO
Description of injuries *
****A personal injury form must be completed for any injured person.
Did the student cause any property damage related to this incident? *

YES NO
Description of any damage to property *
Explain what happened after the incident concluded. What type of debriefing occurred with the student and/or staff members? *
Were parents verbally notified by...? *

Phone Face to Face
Date WRITTEN notice will be sent to parent? *

- Month - Day Year
Date Date Picker Icon
The Behavior Consultant will automatically be notified. Please enter any other email addresses for staff members that need to be notified:
YOUR Name *

First Name Last Name
YOUR Email address *
Should be Empty:

Pike Seclusion and Restraint Documentation Log

The Behavior Consultant will automatically be notified. Please enter any other email addresses for staff members that need to be notified: