JKGA-E Restraint Documentation
JKGA - E 

RESTRAINT DOCUMENTATION 

Student: ________________________________________________ Date:_________________

Time began:______________________________ Time Ended: __________________________

Antecedent Behavior:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________

Behavior Resulting in the Restraint:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________

Type of Restraint:
____________________________________________________________________________
____________________________________________________________________________

Other types of interventions that may have been used:
____________________________________________________________________________
____________________________________________________________________________

Staff Involved in the Incident:
____________________________________________________________________________
____________________________________________________________________________

Staff Involved in the Restraint:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________

Parent Notified (as soon as possible on the day of the restraint):
__________________________________________________________________________

Program Administrator Notified within 24 hours:
____________________________________________________________________________


Adopted: November 12, 2002


M.S.A.D. #4