Physical Restraint Survey
Name of Facility: ________________________________
Contact:________________________________________
Facility Population for 12/15/03:____________________
How many times in the month of December of 2003 was force used or a youth restrained in your facility?_________________________
Do you fill out an incident report for each incident of restraint?_____________
Is a medical evaluation/assessment done after each restraint incident?________
Is it done by a medical person, i.e. nurse?_______________________
If not who does it if at all?____________________________________
Was there any injury to staff or youth during restraint for the month of December
of 2003? If so how many?____________________.
Who provides use of force training for your staff?___________________________
What program do you use?______________________________________________
How many hours of use of force training do you provide for staff per year?_________
How many hours for first year employees?________________
What type of restraint equipment do you use at your facility?
( )Handcuffs( )Shackles( )Leather Restraints( )Restraint Chair( )Helmets( )Chemical agents -what kind? ( )Pepper Spray ( )Mace( )Stun Gun