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502.14-E3 - Documentation of Debriefing Meeting Regarding Physical Restraint and/or Seclusion of Students

 

 

 

Click here to download the documentation of debriefing meeting form


Student Name:
Building:
Date of Original Occurrence:
Date of Debriefing Meeting:
Time of Meeting:
Location of Meeting:

Names of all attendees including titles and/or relation to student:
(*Denotes a role required for attendance)
Parent:
Student:
*Administrator:
*Administrator not involved in occurrence:
*Names of those who administered seclusion/restraint:
Behavior/Mental Health Expert:
Others in Attendance (Name and Title):

Documentation reviewed during the meeting: (Check all that apply)
____Seclusion/Restriant Report
____Individualized Education Plan (IEP)
____Behavioral Intervention Plan (BIP)
____Individualized Health Plan (IHP)
____Safety Plan
____Other (Please specify)

Identification of patterns or behavior and proportionate response, if any, in the student and employees involved:

Possible alternative responses, if any, to the incident; or less restrictive means, if any:

Additional resources, if any, that could facilitate alternative responses in the future:

Plans for additional follow up actions, if any:

Names and Title of Employee Completing Form:
Date:
Date Delivered to Parent/Guardian:
Method of Transmittal:


Adopted: 2/21
Related Policy (Code#): 502.14; 502.14-R, 502.14-E1-E2