INCIDENT REPORT aligned with CHAPTER 33
An “incident” consists of all actions from the time a student begins to create a risk of harm to the time the student ceases to pose a risk of harm and returns their regular programming. Ch33 Sec2(9)

Name of School/Program ______________________________________ Date of Report _________
Name of Person Completing the Report ________________________________________________
Total Restraints During Incident ______	   	Total Seclusions During Incident ______
Student Involved 

Student’s name __________________________   Age____ Gender_______ Grade___ 

Student has (check all that apply):    IEP ___   504 ___   behavior plan ___   IHP ___   
other plan (identify plan) ____________      no individualized plan ___ 

Description of the Incident

Date of incident ______________		Total time of incident _______________ 
Beginning time of incident ____________ 	Ending 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 attempted prior to the use of physical restraint or seclusion (if none used, explain why) ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Student behavior that was an imminent danger of serious physical injury ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Description of Restraint or Seclusion; Staff Involved

Detailed description, including the start and end time, of each use of restraint and/or seclusion) ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Staff person(s) involved, their role in the use of physical restraint or seclusion, and their certification, if any, in an approved training program 
________________________________________________________________________________________________________________________________________________________________________________________________

Bodily Injury of Student or Staff 

Did the student sustain serious bodily injury?		Yes ___ No ___  
Describe injury(ies) sustained ___________________________________________________
___________________________________________________________________________ 

Date & time school nurse or emergency response personnel notified, and treatment administered _______________________________________________________________________________

Did a staff member sustain serious bodily injury?		Yes ___ No ___  
If yes, name of person(s) sustaining injury _______________________________
Describe injury(ies) sustained _______________________________________________________
_______________________________________________________________________________ 

Date & time school nurse or emergency response personnel notified, and treatment administered _______________________________________________________________________________

Notification; Debriefing; 

Date, time, and method of parent notification _____________________________

Date and time of staff debriefing _______________________________________

Date and time of student debriefing _____________________________________

This incident is the _____ incident (number of incidents) this school year.
If this is the 3rd incident, then the student’s IEP, 504 team, or a team (for general education students) shall meet within 10 school days of every 3rd incident to discuss the incident.  

Date and time of required team meeting __________________________