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[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.

Date of delivered to Parent/Guardian
Method of Transmittal