Form 223-1

Incident Report on the Use of Restraint/Seclusion

Fort McMurray School Division believes in providing an opportunity to learn in a safe and positive environment where each individual is respected and valued.  This form is to be completed when staff feel that a student is acting in an unsafe manner that is threatening to the safety of the student, the safety of others or is likely to damage property and restraint / physical intervention is necessary to restore and maintain safety.  Restraint cannot be chemical or mechanical.  Restraint that is physical in nature or involves isolation must be previously approved by the school principal to be utilized.

Does the student have a current behaviour plan?    Yes No

If the student has a current behaviour plan, does the safety portion mention the use of restraint or seclusion?    Yes No

Describe the incident.  Include what led up to the incident, student behaviour and staff response.  Please provide specifics.

Describe the specific safety issue that necessitated the use of restraint/seclusion,

Which of the following interventions were applied? (check all that apply)
Reminder of consequences (positive and/or negative)
Choices given
Time allowed for compliance
Other attempted de-escalation techniques including restraint or seclusion (please specify below):

Describe the restraint or seclusion used:

Describe the student’s behaviour during the use of restraint or seclusion:

What was the time of the incident and the duration of the restraint or seclusion?

Describe any specific injuries sustained by either student, bystanders or the staff member:

       A.M.   P.M.

Name of Staff who provided notification:

Name of Staff involved in this incident (please print):


Thank you for taking the time to complete this report. Please provide this report to your immediate supervisor before the end of the day.