Written Summary of Restraint Use Sample Form

Districts may use the Written Summary of Restraint Use Sample Form to inform parents about the use of restraint and also to assist in the collection of data to be reported through PEIMS. This 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.  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 Written Summary of Restraint Form (PDF 75.8KB)

Spanish Written Summary of Restraint Form (PDF 21.8KB) 

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.