[The following individuals must attend the debriefing meeting: employees who administered physical restraint or seclusion; an administrator or employee not involved in the occurrence; the administrator or employee who approved continuation of the physical restraint or seclusion; other relevant personnel designated by the school; if indicated by student’s behavior in occurrence, an expert in behavioral/mental health or other discipline. The following individuals must be invited to attend the debriefing meeting: the parent or guardian of the student, the student with guardian’s consent.]
Student name: ____________________________________ Date of occurrence: ___________________
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Date of debriefing meeting: _________________Time of debriefing meeting: ________________ |
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Location of debriefing meeting: |
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Names of individuals attending the debriefing meeting (must include the employees involved and at least one employee who was not involved). Also the title of employee and/or relation to student: _________________________________________ _______________________________ _________________________________________ _______________________________ _________________________________________ _______________________________ _________________________________________ _______________________________ Name Job Title |
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Documentation reviewed during meeting (must include at least the occurrence report; and BIP, IHP, IEP and/or safety plan if applicable):
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Identification of patterns of behavior and proportionate response, if any, in the student and employees involved:
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Possible alternative responses, if any, to the incident/less restrictive means, if any:
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Additional resources, if any, that could facilitate those alternative responses in the future:
Plans for additional follow up actions, if any:
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This form has been reviewed and completed by the undersigned employee. A written copy of this form has been sent to the student’s guardian within three school days of the debriefing meeting.
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Employee Date of delivered to Parent/Guardian
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Method of Transmittal
