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POST SECLUSION OR RESTRAINT STAFF INTERVIEW FORM

POST SECLUSION OR RESTRAINT STAFF INTERVIEW FORM

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POST SECLUSION OR RESTRAINT STAFF INTERVIEW FORM
POST SECLUSION OR RESTRAINT STAFF INTERVIEW FORM

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Published by: sc109466 on Oct 01, 2013
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11/05/2014

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Form 237 Org: 05/05 Rev: 04/09 Page 1 of 2
Satilla Community Services
POST SECLUSION OR RESTRAINT STAFF INTERVIEW FORMName of Interviewers_____________________________Job Titles________________________ Name of Staff Being Interviewed____________________________ Job Titles _____________________ Time and Date of Incidents______________________________________________________________ Name of consumer who was secluded or restrained: ______________________________________ 
Section I
1. What was your involvement in the seclusion or restraint process?________________________________  ____________________________________________________________________________________  ____________________________________________________________________________________ 2. Who directed the seclusion or restraint process?_____________________________________________ Job Title:__________________________________________ 3. What was the reason for the consumer to be secluded?_____________________________________  ____________________________________________________________________________________ To the best of your knowledge was:YesNoDontKnowConsumer provided with: Mattress___________Bed Linens___________Fluids___________Hospital Gown___________Bed Pan___________Urinal___________Toilet Tissue___________Was consumer searched prior to being placed inSeclusion or restraints?___________Was consumer injured? ___________If yes, explain______________________________________________ Were you injured?___________If yes, explain______________________________________________ Was anyone else injured in seclusion or restraint process?___________If yes, explain______________________________________________ Was consumer given criteria for release?___________Were alternatives considered?___________ After the intervention was there a discussion with those involved to makeimprovements in procedures and/or to discuss feelings surroundingincident?___________If yes, what were the outcomes?___________________________________________________  ____________________________________________________________________________________ 
 ______________________________________________________________________ 

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