Skip to content
Navigation
Content starts here

Policies » Section J: Students » JKAA-R: Incident Report – Intentional Physical Contact and/or Physical Restraint/Seclusion

Policy Date: 02/20/2024

Download Policy Now

HSD FILE: JKAA-R
HOOKSETT SCHOOL DISTRICT
INCIDENT REPORT – INTENTIONAL PHYSICAL CONTACT

Student: ______________________________      Date of Incident: ________________

School/Program: ________________________     Grade: ___________________

Student has: _____ IEP      _____ 504 Plan      _____ Behavior Plan

Time: _________________     Location: ________________________________

Person Completing Report: _________________________    Title: ________________

Individuals Involved:

___________________________________________     Title: ___________________

___________________________________________     Title: ___________________

___________________________________________     Title: ___________________

 

1. Description of the student’s behavior before, during, and after the incident.

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

 

2. Description of the actions of the school staff before, during, and after the incident:

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

 

3. Description of any injuries to the student, staff, or others. Description of any medical care
administered to the student or others.

____________________________________________________________________

____________________________________________________________________

 

Signature of Person Completing Report: _____________________________________

Report Date: ___________________________

 

 

HSD File: JKAA-R
HOOKSETT SCHOOL DISTRICT
INCIDENT REPORT – PHYSICAL RESTRAINT/SECLUSION

Student: ______________________________     Date of Incident: __________________

School/Program: ________________________     Grade: _____________________

Student has: _____ IEP     _____ 504 Plan      _____ Behavior Plan

Incident Involves: _____ Restraint(s)     _____ Seclusion(s)      _____ Both Restraint(s) and Seclusion(s)

Beginning Time of Each Restraint/Seclusion: _______________________________

Ending Time of Each Restraint/Seclusion: _________________________________

Location: ______________________________________________________

Person Completing Report: _____________________     Title: ________________

Staff Involved in Restraint/Seclusion (including Co-Regulator):

____________________________________________     Title: _______________

____________________________________________     Title: _______________

____________________________________________     Title: _______________

 

Others Involved/Observers:

____________________________________________      Title: _______________

____________________________________________      Title: _______________

 

1. Description of the activity the student was engaged in immediately preceding the
restraint/seclusion:

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

2. Description of the student’s behavior(s) that prompted the restraint/seclusion, including the
justification for initiating the use of the restraint/seclusion:

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

3. Description of each restraint/seclusion used, including the restraint hold(s) used and the reason
the hold was necessary:

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

4. Description of the student’s behavior before, during, and after the restraint/seclusion:

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

5. Description of the actions of the school staff before, during, and after the restraint/seclusion:

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

6. Description of the interventions utilized prior to the restraint/seclusion and the student’s
response(s):

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

7. Description of any injuries to the student, staff, or others. Description of any medical care
administered to the student or others. Attach any injury reports that were necessitated by the
restraint/seclusion.

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

8. Description of any property damage associated with the incident:

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

9. Description of the actions taken to address the emotional needs of the student during and
following the incident. For incidents involving a seclusion, description should include actions
taken by the co-regulator to monitor the child and develop a plan to help the child manage their
state of regulation and their return to a less restrictive setting.

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

10. Description of any future actions to be taken with respect to the student’s behaviors:

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

11. Anticipated Date of Final Report to Parents: ______________________________

 

Signature of Person Completing Report: __________________________________

Report Date: _______________________________

 

Legal References:
RSA 126-U:1 to RSA 627:1, 4, 6 Ed 1200 – 1203 Ed 510

Adopted: June 9, 2015
Revised: February 20, 2024