100 East Third Street, P.O. Box 578 Piketon, Ohio 45661 Phone: 740-289-4171
475 Western Avenue Chillicothe, Ohio 45601   Phone: 740-702-3120
View Ross Pike ESD & SST 15

Unit Restraint Documentation

Ross Pike ESD Restraint Incident Report
Please use this form to report any incident that requires a restraint, escort in the PRT or seclusion. 

Staff Member completing this form:
Student Name
Date of Incident. Please use 01/01/2000 as format
Time of Incident: Please use 11:00 am example
Location of Incident:
Type of Restraint Used:




How many staff members were involved in the incident?
Purpose of Restraint: Please check all of the boxes that apply.







Injuries or Physical Complaints
Photos Taken?
Reviewed By Health Staff?
Did notifications occur?
Name and title of person notified
Date of Notification
Time of Notification
Please list all individuals involved including those who participated and those who were witnesses.
This section reflects staff/client interview results.
Staff interview and description of restraint incident (put staff name of each interview. Please use this form anytime that you have used the approved restraint procedure. If not applicable please indicate NA
Staff interview and description of restraint incident (put staff name of each interview. Please use this form anytime that you have used the approved restraint procedure. If not applicable please indicate NA
Staff interview and description of restraint incident (put staff name of each interview. Please indicate NA if this box is not applicable.
Client/student interview and description of restraint incident put student’s name, can use additional space below for all students involved and witnesses
Client/student interview and description of restraint incident put student’s name, can use additional space below for all students involved and witnesses. If not applicable please list NA.
Role of each person involved (describe): Please use the roles as described in the training manual.
Witnesses (list):
This section pertains to incident reports to report injury, marks from the restraint or harm to the room and others.
Staff Involved who required an incident report. Mark NA if not applicable.
Where there photos taken?
Was an incident report completed?
Was the employee seen by the health staff?
Clients/students involved
Were photos taken
Reviewed by Health Staff
Your Name:
Your Email:

To validate your submission, please answer the following math problem:

9 + 9 =
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