JKAA-E SAD #4 Incident Report Under Maine DOE Rule Chapter 33 (Physical Restraint or Seclusion of a Student)
NEPN/NSBA Code: JKAA-E 

SAD #4 INCIDENT REPORT UNDER MAINE DOE RULE CHAPTER 33 
(PHYSICAL RESTRAINT or SECLUSION OF A STUDENT) 

Name of School/Program: _________________________________________________________

Name of Person Completing the Report: ______________________________________________

Date of Report: __________________________________________________________________

Student Involved

Student name ______________________________ Age_____ Gender_____ Grade_______

Student has (check all that apply):     IEP _____ 504 plan_____ Behavior Plan _____

            IHP ______ Other Plan (identify) ______________ none of these plans _____

Description of the Incident

Date of incident ___________________ Beginning time of incident ___________

Ending time of incident _____________ Total time of incident _______________

Location of the incident (be specific) _____________________________________________ __________________________________________________________________________

Description of the incident, including the resolution and process of return of student to program (if appropriate) __________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

Description of prior events and circumstances _____________________________________ __________________________________________________________________________
__________________________________________________________________________

Less restrictive interventions tried prior to the use of physical restraint/seclusion (if none used, explain why) __________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

Student behavior that justified the use of physical restraint/ seclusion __________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

Description of Restraint or Seclusion; Staff Involved

Detailed description of the physical restraint/seclusion used __________________________
__________________________________________________________________________
__________________________________________________________________________

Staff person(s) involved, their role in the use of physical restraint/ seclusion, and their certification,
if any, in an approved training program

____________________________________                ________________________________



Bodily Injury of Student or Staff

Did student or a staff member sustain bodily injury? Yes _______ No ______

If yes, name of person(s) sustaining injury __________________________________________

Describe injury(ies) sustained ___________________________________________________

___________________________________________________________________________ 

Date and time of nurse or response personnel notification and treatment administered (if any) __________________________________________________________________________

Did student sustain serious bodily injury or death? Yes _______ No _______

If yes, date and time of notification to the DOE _____________________________________

Notification; Debriefing;

Date, time, and method of parent notification _____________________________________

Date and time of staff debriefing _______________________________________________

Date and time of student debriefing ____________________________________________

Has student been involved in 2 or more prior incidents during the current school year? Yes ___ No ___ 

If yes, date and time of required team meeting __________________________

Adopted: July 31, 2012

M.S.A.D. #4