Physical Restraint Assessment Form
Complete this form to document and assess a physical restraint incident or decision. Please answer each question based on the observed event.
Date and time of incident
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Location of incident
*
Please Select
Classroom
Hallway
Cafeteria
Playground
Other
Role of assessor
*
Teacher
Support Staff
Administrator
Other
Reason for restraint
*
Risk of harm to self
Risk of harm to others
Severe property damage
Other
Type of restraint used
*
Standing hold
Seated hold
Team intervention
Other
Duration of restraint (minutes)
*
De-escalation strategies attempted prior to restraint
*
Verbal redirection
Time out/space
Sensory support
Other
Effectiveness of restraint in resolving the situation
*
Not effective
1
2
3
4
Highly effective
5
1 is Not effective, 5 is Highly effective
Were any injuries observed?
*
No
Yes (describe below)
Additional notes or follow-up actions (if applicable)
Submit Assessment
Should be Empty: