Sample Restraint Incident Report Restraint Information: Resident’s/Student’s Name: Date of Incident: Time of Incident: Location of Incident: Type of Restraint Used: Mechanical Chemical/Medical Seclusion Physical Physical: Standing Seated Floor: Face Up Face Down How many staff were involved: Purpose of Restraint: (Check all that apply) Self Defense Defense of Client/Youth from Defense of from self harm harm by another Protect property Maintain a safe environment Defense of other staff from harm by another Part of a behavioral plan or IEP Removal of client/student for reasons of safety/control and the client/student resisted Injuries/Physical Complaints: Photos Taken: Reviewed by Health Staff: Yes No Yes No Yes No Notification: Name and Title of person notified: Date of Notification: Time Notified: Individuals Involved (list): Role of each person involved (describe):
Sample Restraint Incident Report Restraint Information: Resident’s/Student’s Name: Date of Incident: Time of Incident: Location of Incident: Type of Restraint Used: Mechanical Chemical/Medical Seclusion Physical Physical: Standing Seated Floor: Face Up Face Down How many staff were involved: Purpose of Restraint: (Check all that apply) Self Defense Defense of other staff from harm by another Removal of client/student for reasons of safety/control and the client/student resisted Defense of Client/Youth from self harm Protect property Part of a behavioral plan or IEP Defense of from harm by another Maintain a safe environment Injuries/Physical Complaints: Yes No Photos Taken: Yes No Reviewed by Health Staff: Yes No Notification: Name and Title of person notified: Date of Notification: Time Notified: Individuals Involved (list): Role of each person involved (describe):
Sample_Restraint_Incident_Report.docx