Mechanical Restraints Monitoring Chart

Tennessee Department of Children’s Services Transportation Report

/ / Region/Office: Time: a.m. p.m. Date: Transportation Officer/Employee: Rider: Files or Other Date of Placement/ Arrival Property/Meds Child/Youth’s Name Documents In Custody of: (Signature) Birth Destination Time Transported Transported

del d/n u Y N del d/n u del d/n u del d/n u del d/n u del d/n u

Document any other places/locations that stops were made other than the destination above: Location/Place: Purpose Arrival Time Departure Time

am pm am pm

If “YES” checked, provide explanation below: YES NO If “NO” checked, provide explanation below: YES NO ESCAPE Vehicle checked ESCAPE PROPERLY REPORTED Vehicle searched INJURY/ILLNESS *Child/youth searched (see below) INJURY/ILLNESS PROPERLY REPORTED Review of child/youth’s records MECHANICAL RESTRAINT USED Instructed child/youth to wear seat belt or properly EQUIPMENT MALFUNCTION placed child in child restraint seat as required by law EQUIPMENT REPAIRED

*When a child/youth is searched, complete items below:

 Reason for Search and problems encountered:  Location of where the search was performed (Search should occur in a location that is as private as possible):  Prohibited items confiscated? Yes No (if yes, list items and how they were stored or disposed of below):  Employees and other persons involved in the search: COMMENTS/EXPLANATION:

Justification for use of Restraints: Total Time in restraints: Parents notified: Date: Time: Supervisor granting approval: TC or DESIGNEE Approved: Extended Use of Restraints: Incident Report Completed By:

Check the “Forms” Webpage for the current version and disregard previous versions. This form may not be altered without prior approval. Distribution: Original: Transportation Supervisor Copy: Family Service Worker RDA 2982 CS-0350, Rev 12/14 Page 1 Mechanical Restraints Monitoring Chart

Extended Use Monitoring (Every 15 minutes):

Time Discomfort Food/Water/Bathroom Break Employee’s Signature

Check the “Forms” Webpage for the current version and disregard previous versions. This form may not be altered without prior approval. Distribution: Original: Transportation Supervisor Copy: Family Service Worker RDA 2982 CS-0350, Rev 12/14 Page 2