Pike Seclusion and Restraint Documentation Log

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

First NameLast Name
STN #
School*
Date of and Time Incident*

MonthDayYearHourMinutesAM/PM Option
If less than one minute, how many seconds?
Student Educational Services*
Was the Student's IEP and/or BIP and/or 504 implemented?*

YESNO
Type (select all that apply)*

Time OutSeclusionRestraint
Duration of Time Out*

:HourMinutes
Duration of Seclusion*

:HourMinutes
Duration of Restraint*

:HourMinutes
Was a police/resource officer involved?*

YESNO
De-escalation Strategies Used Prior to Restraint/Exclusion*

AcknowledgementProximityCool Down AreaAssist with TaskSetting LimitsEmpathyPraiseReassuranceSpeak PrivatelyMovement BreakReinforcementSoft Tone of VoiceAllow SpaceProvide ChoicesOther
Description of Events leading up to the incident:*
Location of Incident*

Gen Ed ClassSpecial Ed ClassCafeteriaHallwayPlaygroundGymOther
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?*

YESNO
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?*

YESNO
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...?*

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

MonthDayYear
Date
The Behavior Consultant will automatically be notified. Please enter any other email addresses for staff members that need to be notified:
Email
example@example.com
YOUR Name*

First NameLast 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: