FAR NORTHERN REGIONAL CENTER
POST-EMERGENCY RESTRAINT REPORT (PERR)
Restraints will not be utilized as an intervention to a behavior. In some emergency situations restraints may only
be used when a behavior occurs that poses clear and present danger of serious physical harm to the consumer
and others. Manual/physical restraint does not include briefly holding a person without undue force in order to
calm or comfort, or physical contact intended to gently assist a person in performing tasks or to guide or assist a
person from one area to another.
In the event a restraint procedure was used to stop a consumer from harming themselves or when a consumer
has other, continuous and dangerous behavior, a verbal Special Incident Report (SIR) is to be made within 24
hours of incident. A written SIR and this POST-EMERGENCY RESTRAINT REPORT (PERR) must be
completed by the Direct Care Staff and Administrator involved in the incident and returned to the service
coordinator within 48 hours.
Name: ___________________
D.O.B.: __________ UCI#:____________________________
Date of Restraint: ____________
Time of Incident Start: ______ End: ____________
To be completed by Support Staff at the time of Incident:
What behavior occurred that posed a clear and present danger of serious physical harm to the consumer
and/or others resulting in an emergency restraint? (Check all that apply)
Injury to Self
Injury to Others
Imminent Danger to Self
Other (Explain) ____________________________
Imminent Danger to Others
Review Attached SIR
OR
Describe in detail the facts and circumstances leading to the use of the restraint
(attach additional paper if necessary):
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Emergency Protocol used during the emergency:
Professional Crisis Management (PCMA)
Technique: __________________________
Professional Assault Crisis Training (ProAct) Technique: __________________________
Crisis Prevention Institute (CPI)
Technique: __________________________
Other_____________________
Technique: __________________________
Describe the type of techniques used during the incident:
__________________________________________________________________________________________
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If an immobilization technique was used, was a mat utilized prior to implementing the procedure?
Yes
No (if no, explain)
__________________________________________________________________________________________
__________________________________________________________________________________________
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*NOTE: If an immobilization technique was used, a Team meeting will be required. Participants must
include Service Coordinator and Administrator.
What is the date of the meeting? ______________________________
Please mark where the consumer was touched during the procedure
What de-escalation actions and/or techniques were used by staff member prior to the emergency
restraint?
__________________________________________________________________________________________
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Is there a behavior plan in place for this consumer?
Yes Date of Behavior Plan: _____/______/_____
No
Were the following post-crisis strategies performed, and what were the results?
Consumer was checked for any injuries?
Minor: (explain) _______________________________________________________________________
Major:(explain)________________________________________________________________________
___________________________________________________________________________________
Was Medical Care Obtained?
Yes
No
Inspection of immediate environment
Potentially dangerous items were removed or cleaned up
Yes
Items that could be viewed as weapons were removed
Yes
No
No
Consumer returned to appropriate activities (explain)
____________________________________________________________________________________
____________________________________________________________________________________
Explain any, and all, post-crisis de-briefing techniques used related to the restraints:
This should occur within 24 hours between staff and supervisor.
Specific to the Consumer:
Identify Antecedents: _________________________________________________________________
List alternatives to avoid escalation in future:
____________________________________________________________________________________
___________________________________________________________________________________Specific to the Staff Member:
Identify Antecedent: __________________________________________________________________
List alternatives to avoid escalation in future:
____________________________________________________________________________________
____________________________________________________________________________________
This report was completed by:
Signature: ________________________ Position or Title: ________________________________________
Print Name ______________________Date of Completion of Training: ___________ Expiration: _______
Date: _______________
……………………………………………………………………………………………………....
To be completed by Administrator:
How many individuals were involved in the crisis intervention? _________________________
Was all staff involved trained in the crisis intervention protocol?
Yes
No
If no, what is the anticipated date of the training for staff member(s) involved? ________________
Is there a behavior plan in place for this consumer?
Yes Date of Behavior Plan: _____/______/_____ Developed by: ____________________________
No Referral made to: ________________________
Will the behavior plan be changed as a result of the emergency restraint used in this incident?
Yes
No
If yes - What are the planned changes?
____________________________________________________________________________________
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If no – Why:_________________________________________________________________________
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Did staff member follow the protocol prior to incident?
Yes
No (If no, please explain)
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Did staff member follow the protocol after the incident?
Yes
No (If no, please explain)
____________________________________________________________________________________
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Was a copy of the Special Incident Report and this PERR report was provided to your agency behavior
analyst or consultant.
Yes
No
If yes, what were the recommendations?
__________________________________________________________________________________________
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Signature: _____________________________ Position or Title: _______________
Print Name: __________________________
Date: __________________________