✨ Physical Restraint Forms
NEW ZEALAND GAZETTE, No. 89 — 1 SEPTEMBER 2017
Date of birth ___ Gender M ☐ F ☐
Ethnicity __
Time restraint started ____
Time restraint ended __
Name/s of staff member/s administering restraint ___
Trained in safe physical restraint? Yes ☐ No ☐
Other staff/adults who witnessed _____
Place where restraint occurred
- Classroom ☐
- Corridor ☐
- Assembly hall ☐
- Outdoor area ☐
- Toilet block ☐
- Administration area ☐
- Other (identify) __
Behaviour directed at ___
- Staff member – name _____
- Student – name _____
- Self ☐
- Property – describe the serious and imminent risk to the safety of self or others ____
Reason restraint was considered necessary
Serious and imminent risk to safety – describe ___
Actual injury – describe and attach injury form __
Signatures
Principal or Principal’s delegate __
Staff member involved ___
Other staff (witnesses) __
Place a copy of this form on the student’s file.
Note: The information in this form may be the subject of requests made under the Privacy Act 1993 and the Official Information Act 1982.
Appendix 2: Information for the Ministry of Education and the employer – in accordance with Rule 8(1) of the Education (Physical Restraint) Rules 2017
If a teacher or staff member physically restrains a student the incident must be reported to the Ministry of Education and the employer (board of trustees, sponsor of a partnership school kura hourua, or manager of a private school). Complete the form below and email it to physical.restraint@education.govt.nz. Provide a copy of the form to the employer.
Why is the Ministry collecting this information?
The Ministry will use the information to provide appropriate support to schools and students when there are incidents of physical restraint on students.
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NZ Gazette 2017, No 89
✨ LLM interpretation of page content
🎓
Guidelines for Registered Schools in New Zealand on the Use of Physical Restraint
(continued from previous page)
🎓 Education, Culture & SciencePhysical Restraint, Guidelines, Registered Schools, Student Safety, Staff Wellbeing, Teachers, Authorised Staff, Legal Framework, Seclusion Ban, Board Responsibilities, Communication, Review, Good Practice, Risk Assessment, De-escalation Techniques, Physical Contact, Preventative Techniques, De-escalation Techniques, Student Support, Escalation Management, Restraint Techniques, Police Intervention, Reporting, Incident Documentation, Individual Behaviour Plan
🎓 Physical Restraint Incident Report Form
🎓 Education, Culture & SciencePhysical Restraint, Incident Report, Student Safety, Staff Training, Witnesses, Injury Documentation, Privacy Act, Official Information Act
🎓 Information for the Ministry of Education on Physical Restraint Incidents
🎓 Education, Culture & SciencePhysical Restraint, Incident Reporting, Ministry of Education, Employer Notification, Support Services, Data Collection