Form 699Q Use of Unplanned Physical Restraint Summary

							                                                                                              Form 699Q
                                                                                            Sept. 28, 2009
                                                                                              Page 1 of 1
                       Special Education Students
              Use of Unplanned Physical Restraint Summary

                                           (To be used for unplanned physical restraints)

                             School:

                             Gender:                   Male       Female 

                       Date of Birth:   Day: _______    Month: ___________ Year: _______

                      Exceptionality:

                          Placement:



                               STAFF USING PHYSICAL RESTRAINT

                        Position(s):

                     Trained in CPI:              Yes                   No 



Date of restraint:
Reason for using restraint:




_______________________________                           ___________________________
    Principal’s Name/Signature                                 Date Report Completed



                     PLEASE SUBMIT TO THE APPROPRIATE
                 SUPERVISING PRINCIPAL OF SPECIAL EDUCATION