Reports Related to the Use of Seclusion & Restraint

Reports Related to the Use of Seclusion & Restraint

The Indiana Department under the direction of the Commission on Seclusion and Restraint in Schools (IC 20-20-40) will accept incidents reports related to the use of seclusion and restraint in schools. Please read the following instructions before filling out all sections of this form. This form should be used only when all avenues have been exhausted to have your incident/ issue resolved at your student's school. This report is not intended to replace the process for making a special education complaint. Please go to https://www.doe.in.gov/specialed/special-education-complaints for that purpose.

Name:

First NameLast Name

Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number:

Email

example@example.com

Issue: (Check all that apply)

Plan ComplianceStatute ComplianceData Reporting

School Corporation:

School Name:

Who have you contacted previously about your complaint?

PrincipalSuperintendentSchool Board MeetingSchool Employee

How did you become aware of this situation?

Report Details:

Please provide an outline of your report. Include relevant date/details of phone conversation and/or meetings that you think are important in explaining your incident report. Please do not provide personally identifiable information regarding your particular student. Attach any extra pages or documents relevant to your complaint.

How do you think this issue can be resolved?

Date:

Date

Signature

Type Name Here:

Per the Family Educational Rights and Privacy Act (FERPA), and equivalent state law, any information provided, which may identify a student, is confidential and will not be shared with any person outside the Indiana Department of Education. Likewise, the identity of any person who submits a report herein, will remain confidential.