Seclusion and Restraint Incident Reporting and Debrief Form

Documents each seclusion or restraint event, required notifications, and post-incident debriefing for school compliance and state reporting.

Submission Notice

• What are you reporting?
• Date of incident
• Approximate time of incident
• Reporter name
• Reporter role
• Student identifier
  Use the local student ID or other internal identifier. Avoid entering unnecessary PII.

Incident Details

• Location of incident
• What was happening immediately before the incident?
  Briefly describe the antecedent events or trigger using objective language.
• Behavior observed
  Describe the specific behaviors that led to the intervention.
• De-escalation attempts used before seclusion or restraint
• Immediate safety risk present?

Seclusion Details

• Was seclusion used?
• Seclusion start time
• Seclusion end time
• Seclusion room or area
• How was the student monitored during seclusion?

Restraint Details

• Was restraint used?
• Type of restraint
• Restraint start time
• Restraint end time
• Describe the restraint used

Injury, Medical Response, and Notifications

• Did any injury occur?
• Describe the injury
• Was medical attention provided?
• Medical response details
• Was the parent or guardian notified?
• Time of notification
• Notification method
• Was an administrator notified?

Debrief and Follow-up

• Was a debrief completed?
• Debrief date
• Debrief participants
• Preventive actions or supports to reduce recurrence
• Is additional follow-up required?
• Follow-up details