PHYSICAL RESTRAINT REPORTING FORM

North Carolina Department of Health and Human Services

Division of Social Services

Attention:This form must be completed and submitted to the Division of Social Services, Regulatory and Licensing Services, via email to and to your agency consultant, within 72 hours of the incident. This form should be password protected before being emailed. For any questions or comments regarding this form please contact Cindy Norton at the email address above or at 828-669-3388 x222.

Agency: Address:

Site (indicate the name of the group home/cottage/foster home): Address:

Child’s Name: Date of Admission:

Age: ; Height: ; Weight:

Name of Child’s Legal Custodian: ; Date & Time of Notification:

The Child’s Behavior(s) that Necessitated the Use of Physical Restraint:

Date and Time Physical Restraint Used:

Type of Hold Used: Duration of Hold:

Staff Member(s) Administering the Hold:

Staff Member(s) Witnessing the Hold:

Foster Parent Administering the Hold:

Foster ParentWitnessing the Hold:

Child’s Medical Condition Prior to Restraint: Poor ; Fair ; Good ; Excellent

List Child’s Medications, if any:

Less Restrictive Alternatives That Were Attempted Prior to Utilizing Physical Restraint:

Plan Established from Life Space Interview:

Debriefing with Staff:

Was the Child monitored concurrent with the administration of a physical restraint hold and for a minimum of 15 minutes subsequent to the termination of the hold?

If no, explain:

Were the following monitoring techniques implemented?

  1. Monitoring of the child’s breathing: Explain
  1. Assessed if the child was verbally responsive and motorically in control: Explain
  1. Assessed if the child remained conscious without any complaints of pain: Explain

Child’s Medical Condition After Restraint: Poor ; Fair ; Good ; Excellent

Did the Child’s Condition Necessitate Medical Attention?

If yes, explain.

This is the physical restraint for this child since admission.

(This may be filled in by supervisor.)

Does this child receive behavioral mental health treatment services?

Who provides behavioral mental health treatment services?

What date did behavioral mental health treatment start?

Is this child assessed as Level I?

Is this child assessed as Level II?

Is this child assessed as Level III?

When was child assessed?

Date Report Sent to Legal Custodian:

Date Report Sent to Licensing Authority:

Staff Member Making Report:

Reviewed By: Title: Date:

(SUPERVISORY STAFF)

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RLS 11

Revised 8/21/2009