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Student name: |
Date of occurrence: |
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Date of debriefing meeting: |
Time of debriefing meeting: |
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Location of debriefing meeting: |
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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: |
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Documentation reviewed during meeting (must include at least the occurrence report; and BIP, IHP, IEP and/or safety plan if applicable): |
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Identification of patterns of behavior and proportionate response, if any, in the student and employees involved: |
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Possible alternative responses, if any, to the incident/less restrictive means, if any: |
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Additional resources, if any, that could facilitate those alternative responses in the future: |
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Plans for additional follow up actions, if any: |
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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.
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Employee Date of delivered to Parent/Guardian
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Method of Transmittal
