5144.1 Appendix D

_______________ Public Schools

____________________, Connecticut

Protective Measure Report

Date:_______________    Time (begin): _________   Time (end): _______________

Name of Staff Person(s) Administering Protective measures:________________

Name of Observer(s):_________________________________________________

Administrator Notified:________________________________________________

1. Description of the activity of all parties involved prior to the use of the protective measure.

2. The student’s behavior which prompted the protective measure.

3.  Describe the de-escalation efforts.

4. Justification of the protective measure and a description of the administration of the protective measure.

5. Other information and/or related information.