Written Summary of Restraint Use Sample Form


Local Education Agencies (LEAs) may use the Written Summary of Restraint Use Sample Form to inform parents/guardians about the use of restraint and to assist in the collection of data to be reported through the Public Education Information Management System (PEIMS). This form has been developed pursuant to Texas Education Code (TEC) §37.0021, Use of Confinement, Restraint, Seclusion, and Time-Out and Texas Administrative Code (TAC) §89.1053, Procedures for Use of Restraint and Time-Out, specifically TAC §89.1053(e)(3), (4), (5), (A-I). 

This form is aligned with the PEIMS Restraint Event Extension Record found in the Texas Student Data System (TSDS) web-enabled data standards. The form may be downloaded in either English or Spanish using the links below. 

LEAs are encouraged to request technical assistance about this form, restraint and time out issues, or other behavior supports through their regional, Education Service Centers (ESCs.).  

The Texas Behavior Support Initiative (TBSI) is training that satisfies the statutory requirements outlined in TEC §37.0021 and TAC §89.1053. TBSI equips school personnel with the knowledge required to successfully implement positive behavior interventions and supports for all students, including students with disabilities. TBSI training meets legislative requirements related to procedures for the use of restraint and time-out; however, it also provides a wide-ranging framework for sharing behavior strategies and prevention-based, school-wide, classroom, and individual interventions. 

The goal of TBSI is to provide educators with the tools necessary to effectively de-escalate conflicts with students and to minimize the need for the use of time-out or restraint. Specific training exists within the online TBSI modules on how to properly document the use of restraint using the Summary of Restraint Use Sample Form. Interested individuals may enroll in the virtual training through the TBSI Course webpage. Additional information may also be found by visiting the Tiered Interventions Using Evidence Based Research (TIER) website. 

English Version 

English Written Summary of Restraint Form (PDF 75.8KB)

Spanish Version 

Spanish Written Summary of Restraint Form (PDF 21.8KB)