Every Human Disability Services Pty Ltd
Unauthorised Restrictive Practice Form
General Participant Information
Participant Name
General Employee Information
Full Name
Date of start of the week
*
Date at the end of the week
*
Time the restrictive practice was used?
*
Territory Information
Where and When did the practice take place?
What was used?
*
Type of Restrictive Practice used
*
Chemical
Environmental
Mechanical
Physical
How was the restrictive practice carried out?
What actions were taken in response to the restrictive practice?
Protocol Requirements
1. Has the Worker read the participants Behaviour Support Plan?
*
Yes
No
2. Has the worker had appropriate training to apply the restrictive practice
*
Yes
No
3. Was the restraint included in the participants plan?
*
Yes
No
4. What type of restrictive practice was used?
*
Chemical
Mechanical
Physical
5. Were all alternative measures practiced ?
*
Yes
No
N/A
6. Was implied consent able to be obtained?
*
Yes
No
N/A
7. Is the practice expected to be continued?
*
Yes
No
8. Were there any noted side-effects?
*
Yes
No
9. Which side-effects were noted?
Emotional distress
Dizziness
Muscle convulsions
Vomiting
Sleepiness
Outcome and Additional Notes
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