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Exhibit 503.9E3




The following individuals must attend the debriefing meeting: employees who administered physical restraint or seclusion; an administrator or employee not involved in the occurrence; the administrator or employee who approved continuation of the physical restraint or seclusion; other relevant personnel designated by the school; if indicated by student’s behavior in occurrence, an expert in behavioral/mental health or other discipline.  The following individuals must be invited to attend the debriefing meeting:  the parent or guardian of the student, the student with guardian’s consent.


Student name:

Date of occurrence:

Date of debriefing meeting:

Time of debriefing meeting:

Location of debriefing meeting:


Names of individuals attending the debriefing meeting (must include the employees involved and at least one employee who was not involved):

Job title of employee and/or relation to student:

















Documentation reviewed during meeting (must include at least the occurrence report; and BIP, IHP, IEP and/or safety plan if applicable):







Identification of patterns of behavior and proportionate response, if any, in the student and employees involved:







Possible alternative responses, if any, to the incident/less restrictive means, if any:







Additional resources, if any, that could facilitate those alternative responses in the future:







Plans for additional follow up actions, if any:








This form has been reviewed and completed by the undersigned employee.  A written copy of this form has been sent to the student’s guardian within three school days of the debriefing meeting



____________________________________  ______________________________

Employee                                                          Date of delivered to Parent/Guardian


Method of Transmittal