<p> STATE OF CONNECTICUT DEPARTMENT OF DEVELOPMENTAL SERVICES DDS RESTRAINT LOG - I.D.PR.009 ATTACHMENT D</p><p>Individual’s Name: ______DDS #: ______Date From: ____/____/____ To: ____/____/____ </p><p>Restraint Types Behaviors Injury Incident Final Caused by Date Date Out Time IN Time OUT 1 2 3 4 1 2 3 4 Restraint</p><p>Am Pm Am Pm Yes No</p><p>Am Pm Am Pm Yes No</p><p>Am Pm Am Pm Yes No</p><p>Am Pm Am Pm Yes No</p><p>Am Pm Am Pm Yes No</p><p>Am Pm Am Pm Yes No</p><p>Am Pm Am Pm Yes No</p><p>Am Pm Am Pm Yes No</p><p>Am Pm Am Pm Yes No</p><p>Am Pm Am Pm Yes No</p><p>Am Pm Am Pm Yes No</p><p>Am Pm Am Pm Yes No</p><p>Am Pm Am Pm Yes No</p><p>Am Pm Am Pm Yes No</p><p>Am Pm Am Pm Yes No</p><p>Am Pm Am Pm Yes No</p><p>Am Pm Am Pm Yes No</p><p>Am Pm Am Pm Yes No</p><p>Am Pm Am Pm Yes No</p><p>Am Pm Am Pm Yes No</p><p>Am Pm Am Pm Yes No</p><p>Am Pm Am Pm Yes No</p><p>Am Pm Am Pm Yes No</p><p>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</p><p>Reportable Restraint Types for Incident Report DDS Form 255 - Section 2c RESTRAINT</p><p>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</p><p>Restraint Behavior Codes for Incident Report DDS Form 255 - Section 2c RESTRAINT</p><p>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</p><p>I.D.PR.009 Attachment D DDS Restraint Log Rev. December 2014 Page 2 of 2</p>