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STATE OF CONNECTICUT DEPARTMENT OF DEVELOPMENTAL SERVICES DDS RESTRAINT LOG - I.D.PR.009 ATTACHMENT D

Individual’s Name: ______DDS #: ______Date From: ____/____/____ To: ____/____/____

Restraint Types Behaviors Injury Incident Final Caused by Date Date Out Time IN Time OUT 1 2 3 4 1 2 3 4 Restraint

Am Pm Am Pm Yes No

Am Pm Am Pm Yes No

Am Pm Am Pm Yes No

Am Pm Am Pm Yes No

Am Pm Am Pm Yes No

Am Pm Am Pm Yes No

Am Pm Am Pm Yes No

Am Pm Am Pm Yes No

Am Pm Am Pm Yes No

Am Pm Am Pm Yes No

Am Pm Am Pm Yes No

Am Pm Am Pm Yes No

Am Pm Am Pm Yes No

Am Pm Am Pm Yes No

Am Pm Am Pm Yes No

Am Pm Am Pm Yes No

Am Pm Am Pm Yes No

Am Pm Am Pm Yes No

Am Pm Am Pm Yes No

Am Pm Am Pm Yes No

Am Pm Am Pm Yes No

Am Pm Am Pm Yes No

Am Pm Am Pm Yes No

I.D.PR.009 Attachment D DDS Restraint Log Rev. December 2014 Page 1 of 2 STATE OF CONNECTICUT DEPARTMENT OF DEVELOPMENTAL SERVICES DDS RESTRAINT LOG - I.D.PR.009 ATTACHMENT D

Reportable Restraint Types for Incident Report DDS Form 255 - Section 2c RESTRAINT

Code Description CHE CHEMICAL FPT FOUR POINT SCF SAFETY CUFFS FLS FLOOR CONTROL SUPINE HBA HELD BY ARMS LAC LIFTED AND CARRIED PHI PHYSICAL ISOLATION

Restraint Behavior Codes for Incident Report DDS Form 255 - Section 2c RESTRAINT

Code Description AGC AGGRESSOR TO CLIENT AGS AGGRESSOR TO STAFF DIS DISRUPTIVE BEHAVIOR FOB FALL OUT BED PREVENT FOC FALL OUT CHAIR/OTHER PREVENT PIC PICA PD PROPERTY DESTRUCTION REM REMOVE SUTURES, TUBES, ETC. RUN RUNNING AWAY SEL SELF-ENDANGERING SIB SELF INJURIOUS BEHAVIOR

I.D.PR.009 Attachment D DDS Restraint Log Rev. December 2014 Page 2 of 2

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