Restraint & Seclusion - 24 Hour Report

Restraint & Seclusion - 24 Hour Report

School or Program*

Enter the name of the School or Program for which the incident occurred

District*

Choose your district from the drop down list

Select

District Not Found

If your district was not in the drop-down list above, enter the name of your district here

Contact Name*

Enter the name of the individual ODE can contact in regards to this incident. This is the "Contact".

Contact Email Address*

Contact person email address

Contact Phone Number*

Enter phone number to reach contact person (555-555-5555)

Date of Incident*

Choose the date the incident occurred

Time of Incident*

What time did the incident occur?

Example 12:45 PM

Staff Member Name*

Enter the first and last name of the staff member that was seriously injured, or died due to the incident

Staff Classification*

Please select the classification associated with the staff member listed above

Select

Send me a copy of my responses