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Written Summary of Restraint Use Sample Form


The Written Summary of Restraint Use Sample Form has been developed pursuant to Texas Education Code §37.0021. Use of Confinement, Restraint, Seclusion, and Time-Out and Texas Administrative Code §89.1053. Procedures for Use of Restraint and Time-Out, specifically §89.1053(e)(3),(4),(5)(A-I).

This form is aligned with the PEIMS Record 435 (Special Education Child Restraint – Student) reporting requirement. Districts may use this form to inform parents about the use of restraint and also to assist in the collection of data to be reported through PEIMS.

Districts will be required to submit 435 data with the June 2004 PEIMS submission. The form can be downloaded in MS Word or Adobe Acrobat PDF format:

Written Summary of Restraint Use Sample Form
Districts may use this form or create their own form based on the required items reflected in §89.1053(e)(3),(4),(5)(A-I).

English: Adobe Acrobat PDF
Spanish: Adobe Acrobat PDF

Technical Assistance
Districts are encouraged to request technical assistance about this form, restraint and time-out issues from the Texas Behavior Support Initiative contacts at regional education service centers.

Additional Resources on the Web:

Division of IDEA Coordination

1701 North Congress Avenue | Austin, Texas 78701-1494

Telephone: 512.463.9414 | Fax: 512.463.9560


Page last modified on 4/14/2011 09:29:39 AM.