Link to PDF version of form here
Student: _________________________ School: __________________________
Date: ___________________________ Time: ____________________________
Location: ________________________________________________________
Staff directly involved in restraint (include names and titles; attach supplemental statements, if any):
________________________________________________________________
________________________________________________________________
Witnesses (include names and titles):
________________________________________________________________
________________________________________________________________
Description of events immediately before the behavior occurred:
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Efforts/alternatives made prior to the use of restraint:
____ Teaching interaction
____ Offered self-control strategy
____ Verbal de-escalation
____ Other(s) (please describe): __________________________________
_____________________________________________________________
Type of restraint used:_____________________________
Time restraint began: ________________________________
Time restraint ended: ________________________________
Chronological description of incident (include behavior, statements made, actions taken):
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Resolution:
___ Student calm/reintegrated into classroom/educational programming
___ Student calm/additional time provided for de-escalation outside of instructional setting
___ Additional support requested (medical/mental health/parent/police)
___ Other(s) (please describe): __________________________________
Injuries or property loss/damage:
________________________________________________________________
________________________________________________________________
________________________________________________________________
Persons notified of incident (include name, title, date and time notified):
________________________________________________________________
________________________________________________________________
________________________________________________________________
______________________________________
Name and title of person writing report
______________________________________
Signature
__________________________________________
| Checklist | Date | Comments |
| If an injury to staff or student has occurred, submit student accident report and/or staff incident report. | ||
| Building principal or designee verbally notify parent by end of the school day that the restraint was used. | ||
| Conduct internal review of incident of restraint. | ||
| Review documentation to ensure use of alternative strategies and recommend adjustments to procedures, if appropriate. If any restraint was used a written report of the incident was filled out no later than one school day after the incident. | ||
| If restraint was between one and five minutes, written notice given to parents on the day of the restraint | ||
| If restraint was five minutes or more or any seclusion, verbal or written notice given to parent on the day of restraint or seclusion, and written report emailed, mailed or faxed to parent within five calendar days of the use of restraint. | ||
| If requested by parents or the school, convene a meeting (that may be an IEP, BIP or 504 meeting) to review the incident. |
One copy each to the Parent/Guardian, Principal, District Office and Student’s confidential record.
Issued: July 2010
Reviewed: September 2020
Revised: June 2024
Revised: August 2026
Lake County School District R-1, Leadville, Colorado