Fillable PHYSICAL RESTRAINT AND TIME OUT FORM 100 North (Illinois State Board of Education)

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PHYSICAL RESTRAINT AND TIME OUT FORM 100 North (Illinois State Board of Education)

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ISBE 11-01 (9/20)
Instructions: Per 23 IAC 1.285(f)(1), a written record of each event involving a time out or physical restraint must be maintained in the
student’s temporary record. Public school districts, private special education schools, special education cooperatives, charter schools,
regional safe school programs, and any other educational program serving Illinois public school students must complete this form in
its entirety. Written parent notification must occur within 24 hours of the incident. Within two business days, serving entities must enter
the data into ISBE’s Student Information System (SIS).
STUDENT NAME DATE OF BIRTH
GRADE
RACE GENDER
☐
Female
☐
Male
HOME SCHOOL DISTRICT
SERVING LOCATION
☐ District School or Program ☐ Cooperative Program
☐ Non-Public Special Education Facility
Does the student have an IEP? Yes No If yes, what is the disability category
Does the student have a 504 Plan? Yes No
Check Reason for Restraint or Time Out:
☐ Imminent Danger of Serious Physical Harm to Self
☐ Imminent Danger of Serious Physical Harm to Staff
☐ Imminent Danger of Serious Physical Harm to Other Student(s)
1. A description of events leading up to the incident:
☐ Physical Restraint
☐ Isolated Time Out
☐ Time Out
☐ Physical Restraint
☐ Isolated Time Out
☐ Time Out
☐ Physical Restraint
☐ Isolated Time Out
☐ Time Out
☐ Physical Restraint
☐ Isolated Time Out
☐ Time Out
Date of Incident: Date of Incident: Date of Incident: Date of Incident:
Time Started: Time Started: Time Started: Time Started:
Time Ended: Time Ended: Time Ended: Time Ended:
Total Minutes: Total Minutes: Total Minutes: Total Minutes:
Location: Location: Location: Location:
PHYSICAL RESTRAINT
AND TIME OUT FORM
100 North First Street
Springeld,Illinois62777-0001
Document the incident(s) that occurred on a single day. Multiple forms may be used instead.
Incident #1 Incident #2 Incident #3 Incident #4
Use your "Mouse" or "Tab" key to move through the fields and check boxes. After completing last field, save document to hard drive to make future updates or click print button.
2. A description of the interventions used prior to implementation of isolated time out, time out or physical restraint (e. g.,
directives used, removed the trigger, use of proximity control, etc.)
3. A description of the incident or student behavior that resulted in isolated time out, time out, or physical restraint (this
should be the behavior that posed an imminent danger to self or others):
4. For isolated time out, a description of the rationale for why the needs of the student could not have been met by a less
restrictive intervention and why an adult could not be present in the time out room
If an episode of isolated time out or time out exceeds 30 minutes or a physical restraint exceeds 15 minutes or if repeated
episodes occur during any three hour time period, a certified staff person knowledgeable about the use of time out or trained
in the use of physical restraint must evaluate the situation.
Certified or trained staff member evaluating the situation: _________________________________________
Time of evaluation: _______________________
Did the student require:
Yes
Yes
nourishment ☐
medication ☐
use of restroom ☐
Yes
☐ No
☐ No
☐ No
need for alternate strategies
☐ assessment by mental health crisis team
☐ assistance from police
☐ transportation by ambulance
☐ other _____________________________________________________
Was the time out or restraint able to be safely continued?
☐ Yes ☐ No
ISBE11-01(9/20)
☐ 1-person hold in seated position
☐ team hold in seated position
☐ prone restraint
5. Type of physical restraint used (check all that apply for incident)
☐ 1-person hold in standing position
☐ team hold in standing position
☐ supine restraint
☐ other ___________________________________________________________________
6. Attach behavior log of student behavior during isolated time out, time out, and/or restraint and any interaction between the
student and staff.
7. Evaluation by Certified or Trained Staff Member
8. Were there any injuries to student or staff or others? ☐ Yes ☐ No
If yes, evaluated by: _________________________________________
Description of injuries:
9. Was there property damage:
☐ Yes ☐ No
If yes, describe:
10. Description of any planned approach to dealing with the student's behavior in the future, including any de-escalation
methods or procedures that may be used to avoid the use of time out or physical restraint:
☐ Continue IEP
☐ Develop a BIP
☐ Refer to Problem-solving Team
☐ Other ____________________________
11. School personnel who participated in the implementation, monitoring, and supervision of time out or restraint.
Name___________________________________________Title__________________________________
Name__________________________________________ Title __________________________________
Name___________________________________________Title__________________________________
Name___________________________________________Title__________________________________
Name___________________________________________Title__________________________________
12. Parent Notification:
Required Written Parent Notification Phone call, if occurred
Date ________________ Date ___________________
Time ________________ Time ___________________
Method _______________
Date data was submitted into state reporting system: ___________ By whom: ________________________
Copies of the form and attached behavior log to be kept in the temporary file.
ISBE11-01(9/20)
Parents who wish to file a state complaint regarding the use of time out, isolated time out, or physical restraint can submit
the complaint to restrainttimeout@isbe.net. If the complaint involves other
special education matters, parents can submit
the complaint to statecomplaints@isbe.net using the form or processes found at isbe.net/pages-Special-Education-
Complaint-Investigations.aspx. A copy of the complaint must be forwarded to the local public school district or the public
agency serving the student.
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PHYSICAL RESTRAINT AND TIME OUT FORM 100 North (Illinois State Board of Education)

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Completed 25 March 2021

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