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SAN ANTONIOINDEPENDENTSCHOOL DISTRICT

DOCUMENTATION AND NOTIFICATION

FOR THE USE OF STUDENT RESTRAINT

This form is for documenting emergency student restraint incidents and parent notification. A copy of the completed form is kept in the Eligibility Folder of a student with disabilities and in the Permanent Cumulative Record Folder of a general education program student. A copy is given to the parents of special and general education program students. The campus administrator must be informed every time restraint is used to manage a student’s behavior, so that the student’s parent can be notified within one school day of the incident. *Beginning on September 1, 2003, a PEIMS data entry (435 Record) is required for every restraint incident involving a student with disabilities.

TO BE COMPLETED BY CAMPUS ADMINISTRATOR:
Campus of
Enrollment: / Student
ID #: / SSN: / Grade:
Student’s Name:
Last Name First Middle
Teacher/Instructor #: / Administrator #:
Check one: General Education Special Education List disabilities:
*For student with disabilities, checkRestraint Reason Code:
01 - Imminent Serious Physical Harm to Themselves
02 - Imminent Serious Physical Harm to Others
03 - Imminent Serious Physical Harm to Themselves and Others
04 - Imminent Serious Property Destruction
05 - Imminent Serious Physical Harm to Themselves and Imminent Serious Property Destruction
06 - Imminent Serious Physical Harm to Others and Imminent Serious Property Destruction
07 - Imminent Serious Physical Harm to Themselves and Others and Imminent Serious Property Destruction
Date: / Time restraint initiated:
Campus of Restraint: / Teacher #: / Administrator #:
TO BE COMPLETED BY:
Name(s) of staff witness(es) to restraint incident:
Time the student seen by the school nurse or clinic staff? / State result:
DESCRIBE THE RESTRAINT INCIDENT:
1. Describe the nature of the restraint and the specific procedures used:
2. Describe the activity in which the student was engaged immediately before the use of restraint:
3. Describe the student’s behavior(s) that prompted the restraint. This may include behaviors, signals/cues or demeanor:
4. Describe the efforts to de-escalate the situation and the alternatives used prior to restraint:
5. Length of restraint:
6. Location of restraint:
PARENT NOTIFICATION:
Parent phone notification (date and time):
Phone call result:
Person placing parent notification call:
Print Name / Signature
Date written notification sent to parent: (parent must be notified in writing within one school day of the incident.)
Name of person completing this report:
Print Name / Position/Title
Copies to: Eligibility Folder/Discipline Folder Parent Administrator

San Antonio Independent School District does not discriminate on the basis of race, religion, color, national origin, sex, or disability in providing education services, activities, and programs, including vocational programs, in accordance with Title VI of the Civil Rights Act of 1964, as amended; Title IX of the Educational Amendments of 1972; Section 504 of the Rehabilitation Act of 1973, as amended.

November 2003FORM F29-A