Seclusion/Restraint Report Form
(To be completed directly after use of seclusion or physical restraint)
Note: Seclusion is defined as involuntary confinement of a student alone in a room or area where the student is prevented from leaving.
Student Name:
Grade:
School:
Date:
Person Completing Form:
Title:
Time of Incident:
Location of Seclusion/Restraint:
If seclusion used, list total minutes of seclusion:
If restraint used, list total minutes of restraint:
Time Administration Notified of Restraint:
Names & titles of staff involved with or present during seclusion/restraint:
Name:
Title:
If restraint was used, please answer the following questions:
Was training completed by personnel involved in administering restraint?
Children’s Control
Place a check by the type(s) of restraint used:
Was there any injury or damage?
 Yes
 Yes

 No
(If no, training will be completed within 30 days, typically.)
Team Control

Transport

 No
If injury/damage, list details:
Describe the behavior that led to seclusion/restraint, activity & other contributing factors. Document with a clear description of the safety concerns posed to self and/or
others.
Interventions used in attempt to de-escalate the student prior to using seclusion/restraint:
Student behavior during seclusion/restraint (minimum report every 5 minutes)
Time:
Student behavior(s):
Behaviors displayed demonstrating the student’s ability to return to educational environment from seclusion/restraint:
List any follow-up actions that are needed after the seclusion/restraint (check one or more)

Reconvene IEP meeting

Schedule Re-eval to conduct/update FBA

Parent/Guardian Conference/Contact

Review/Revise BIP

Schedule a Problem Solving meeting

Other-specify
Parent contacted by administrator (attempt must occur on the day of the incident)
Documentation sent home to parent (must occur by the end of the day after the
incident for seclusion & by end of the school day for restraint):
By whom:
By whom:
Date:
Method:
Time:
Date:
Method:
Time: