CLICK HERE TO DOWNLOAD THE DOCUMENTATION OF DEBRIEFING MEETING REGARDING USE OF PHYSICAL RESTRAINT
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/Restraint 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
Reviewed: 10/23
Related Policy: 502.14; 502.14-R, 502.14-E1-E2