[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:
Date of debriefing meeting:
Time of debriefing meeting:
Location of debriefing meeting:
Names of individuals attending the debriefing meeting(must include the employees involved and at least one employee who was not involved):
Job title of employee and/or relation to student:
Documentation reviewed during meeting (must include at least the occurrence report; and BIP, IHP, IEP and/or safety plan if applicable):
Identification of patterns of behavior and proportionate response, if any, in the student and employees involved:
Possible alternative responses, if any, to the incident/less restrictive means, if any:
Additional resources, if any, that could facilitate those alternative responses in the future:
Plans for additional follow up actions, if any:
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.
__________________________________________________________________
Employee
Date of delivered to Parent/Guardian______________________________
Method of Transmittal
