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Run: Seclusion and Restraint Incident Reporting and Debrief Form

Log each seclusion or restraint incident, required notifications, and the post-incident debrief in one school compliance form. Use it to create a clear recor...

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Submission Notice

What are you reporting? (required)

Date of incident (required)

Approximate time of incident (required)

Reporter name (required)

Reporter role (required)

Student identifier (required)

Use the local student ID or other internal identifier. Avoid entering unnecessary PII.

Incident Details

Location of incident (required)

What was happening immediately before the incident? (required)

Briefly describe the antecedent events or trigger using objective language.

Behavior observed (required)

Describe the specific behaviors that led to the intervention.

De-escalation attempts used before seclusion or restraint (required)

Immediate safety risk present? (required)

Seclusion Details

Was seclusion used? (required)

Seclusion start time

Seclusion end time

Seclusion room or area

How was the student monitored during seclusion?

Restraint Details

Was restraint used? (required)

Type of restraint

Restraint start time

Restraint end time

Describe the restraint used

Injury, Medical Response, and Notifications

Did any injury occur? (required)

Describe the injury

Was medical attention provided? (required)

Medical response details

Was the parent or guardian notified? (required)

Time of notification

Notification method

Was an administrator notified? (required)

Debrief and Follow-up

Was a debrief completed? (required)

Debrief date

Debrief participants

Preventive actions or supports to reduce recurrence

Is additional follow-up required? (required)

Follow-up details

Get your results

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Email (required)

Your name (optional)

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