Restraint & Seclusion Questionnaire

What is your child's school?

What is your child's district?

Please place a check next to any of the following statements that apply to your child.

My child has an Individualized Education Program (IEP).

My child has a Section 504 plan.

My child has a Behavior Support Plan (BSP).

My child has a BSP that includes restraint and/or seclusion.

None of the above applies to my child.

What is your child's disability?

How often is your child restrained or secluded?

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Briefly describe the type of restraint and/or seclusion that your child has experienced. Do you feel it has been appropriate or inappropriate?

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On average, how long is your child restrained or secluded?

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Are you receiving a phone call or written notification on the day of the restraint or seclusion?

Yes
No

Are you receiving debriefing documentation for each incident?

Yes
No

If we have questions, can we contact you via e-mail or phone?

Yes
No

Your E-Mail Address

Your Phone Number (Required)