_______________ 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.