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RESTRAINT FORM 		DEPARTMENT OF DEVELOPMENTAL SERVICES          

RESTRAINT FORM 	COMMONWEALTH OF MASSACHUSETTS, DEPARTMENT OF MENTAL RETARDATION

SECTION I – ALL RESTRAINTS (* = Required Field)

*(1) Individual: First Name:                                                Last Name:                                                                     

*(2) Reporting Provider:                                               *(3) Area Office/ Facility:      

*(4) Provider Location:                                                          

*(5) Order Date:                                   *(6) Type of Restraint Order:  Initial   Renewal    Hold

*(7) Time of: 
(7A) Initial Restraint:                            (7B) Restraint Renewal:                             (7C) Restraint Removal:      

*(8) Name of Staff                                                                                             (9) Position of Staff
     Identifying Emergency:                                                                                 Identifying Emergency:                                                                                    
 
*(10) Describe Emergency Situation: 
     
*(11) Categorize Emergency Situation (check all that apply):

 Substantial Risk of Serious Physical Assault              Occurrence of Serious Physical Assault 
 Substantial Risk of Serious Self-Injurious Behavior   Individual Placed Self at Imminent Risk
							   Of Significant Physical Harm
 Occurrence of Serious Self-Injurious Behavior

*(12) Describe the Individual’s Behavior or Other Antecedents Before the Emergency Situation: 
     
*(13) Describe Less Restrictive Methods Used Prior to Restraint: 
     
*(14) Did the Restraint Result in Physical Injury?  YES  NO 
*(15) Was an Incident Report Filed?  YES  NO

RESTRAINT FORM 		DEPARTMENT OF DEVELOPMENTAL SERVICES           Page 2 of 6

Individual:  First Name:                                                                 Last Name:      
SECTION II – PHYSICAL RESTRAINTS – Complete only for Physical Restraints
*(P1) Describe How the Restraint Intervention was Implemented:      
*(P2) Check the Position of Person Restrained During Restraint (check all that apply):
   Standing  	      Standing and against wall/mat    	 Sitting       Lying Supine (on Back)
   Lying on Side  Lying Prone (on Stomach)  	 Escort       Other, (describe):      
*(P3) Was Mechanical or Chemical Restraint Also Used?   No   Yes 
         If Yes: Type:             Time:      
*(P4) Has Plan to Respond to This Emergency Behavior Been Developed in ISP?   No  Yes
         If Yes, was it followed?   Yes  No (If not followed, explain why not):       
*(P5) Describe Person’s Behavior and Condition During Restraint and Safety Checks:      
*(P6) Reason for Permanent Removal of Restraint:      
*(P7) Describe Behavior and Give Indicators of Individual’s Condition After Restraint:      
*(P8) Print Names of Involved Parties:      
     	
(P8A) Authorizing Initial Restraint/Renewal: 

1.      	
2.      	
3.      	
4.      	
 (P8B) Applying Restraint: 

     	
 (P8C) Specially Trained Monitor: 	

     	
						
 (P8D) Authorizing Removal: 			         

4.

3.

2.

1.

RESTRAINT FORM 		DEPARTMENT OF DEVELOPMENTAL SERVICES           Page 3 of 6

Individual:  First Name:                                                                  Last Name:      

SECTION II – MECHANICAL RESTRAINT -  Complete only for Mechanical Restraints
*(M1) Was Physical or Chemical Restraint Also Used?   YES  NO 
         If Yes: Type:            Time:       
*(M2) Type of Mechanical Restraint Used (Mitts only in the community absent a waiver from the DDS Office for Human Rights):      
     	
*(M3) Print Names of Involved Parties: 
(M3A) Authorizing Initial Restraint/Renewal: 	

1.      	
2.      	
3.      	
4.      	
 (M3B) Applying Restraint:  			      

     	

(M3C) Specially Trained Monitor: 			
     	

(M3D) Authorizing Removal:				

*(M4) Has Plan to Respond to Behavior Been Developed in ISP?  YES  NO 
         If Yes, Was the Plan Followed?  YES  NO    If No, Explain why the Plan was not followed:      
(NOTE: If a plan to respond to behavior has been developed, the Human Rights Committee must have a copy of the plan).
*(M5) Reason For Permanent Removal Of The Restraint:      
*(M6) Describe Individual’s Condition During Restraint and Safety Checks:
TIME	INDIVIDUAL’S CONDITION	STAFF’S NAME	TIME	INDIVIDUAL”S CONDITION	STAFF’S NAME	
     	     	     	     	     	     	
     	     	     	     	     	     	
     	     	     	     	     	     	
     	     	     	     	     	     	
     	     	     	     	     	     	
     	     	     	     	     	     	

(M7) Relief Periods :

START TIME	STOP TIME	INDIVIDUAL’S CONDITION	STAFF’S NAME	
     	     	     	     	
     	     	     	     	
     	     	     	     	

RESTRAINT FORM 		DEPARTMENT OF DEVELOPMENTAL SERVICES          Page 4 of 6

Individual:  First Name:                                                                  Last Name:      

SECTION II – CHEMICAL RESTRAINT -  Complete only for Chemical Restraints
*(C1) Was Physical or Mechanical Restraint Also Used?   YES  NO
         If Yes: Type:           Time:       
*(C2) Involved Parties:

MD Ordering Medication	     	
Person Administering Medication	     	
Person Obtaining Telephone Order	     	

*(C3) Individual’s Current Medication Orders per ISP:      
*(C4) Special Instructions (Including Significant Medical Problems):      
*(C5) Has Plan to Respond to Behavior Been Developed in ISP?   YES  NO 
         If Yes, Was the Plan Followed?   YES  NO    If No, Explain why the Plan was not followed:      
___________________________________________________________________________________________________
(NOTE: If a plan to respond to behavior has been developed, the Human Rights Committee must have a copy of the plan).

*(C6) Name of Medication Used:      

*(C7) Dosage:                                                                                              *(C8) Route:                                                 

*(C9) Time of Administration:        

*(C10) Describe Individual’s Condition During at Time Intervals Ordered by M.D.:      

TIME	INDIVIDUAL’S CONDITION	STAFF’S NAME	TIME	INDIVIDUAL”S CONDITION	STAFF’S NAME	
     	     	     	     	     	     	
     	     	     	     	     	     	
     	     	     	     	     	     	
     	     	     	     	     	     	
     	     	     	     	     	     	
     	     	     	     	     	     	

RESTRAINT FORM 		DEPARTMENT OF DEVELOPMENTAL SERVICES          Page 5 of  6

Individual:  First Name:                                                                  Last Name:      

SECTION III – ALL RESTRAINTS
INTERVIEW OF THE INDIVIDUAL:
*Person Interviewing the Individual:      

*Did the Individual Wish to Comment?   YES  NO
If Yes, Comment:      
If No, or Individual Incapable of Comment, Staff’s Interpretation of Individual’s Response to Restraint:      

SECTION IV – ALL RESTRAINTS – Finalizing Initial Report

*Signature of Person Completing Initial Form:      

*Date:      

SECTION V – ALL RESTRAINTS – REVIEWS

*Restraint Manager (HOP) Review and Comment 

(A)	To the best of your knowledge, were all procedures and protocols followed for this Restraint Action?  YES  NO
(B)	If NO, areas where this Restraint Action needs improvement (select one or more)
   	 Authorization of restraint			   Renewal Order 
 Monitoring of restraint			   Restraint training of staff
 Physical examination of person restrained	   Other, please describe in Comment Section
(C) Comments or Explanation:      

*(D) Date Of Review:      

*(E) Signature:      

RESTRAINT FORM 		DEPARTMENT OF DEVELOPMENTAL SERVICES        Page 6 of  6

Individual:  First Name:                                                                  Last Name:      

SECTION V – ALL RESTRAINTS – REVIEWS – continued

Service Coordinator/Area Office – QMRP/Facility Review and Comment

*(A) Complete?  YES  NO
*(B) If No, give reason:   Inadequate Action Steps
                                         Incorrect Categorization
                                         Additional Information Needed
                                         Other: (please explain):      

(C) Once Status is “Complete”, please review below:       

(D) Date Received By DDS :                                               *(E) Date of Area/Facility Review:       

*(F) Signature of Area/Facility Reviewer:      

Human Rights Committee Review and Comments:
      
*Date of HRC Review:                                       *Signature of HRC:      

Commissioner’s Review and Comments:
     

*Date of Commissioner’s Review:      

*Signature of Human Rights Specialist
Performing Commissioner’s Review:      

SECTION VI – CLOSING THE RECORD
*Date Closed:                                          *Closed By: