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Restraint Complaint Form

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Hopkinton Public Schools Restraint Complaint Form 

This form includes the elements of what the complaint must contain. It is not required that this form be used to file a complaint. 


This complaint is filed by (check one): ☐ Parent of the child 

☐ Student 

☐ Legal Guardian 

☐ Other, please explain:. 

Name of complainant: 


Preferred Phone Number:

If this complaint is filed on behalf of a specific child, please indicate the information below: Child’s name: 

Child’s address: 

School the student attends:


Name of school that the child was attending when the alleged violation occurred: 

Name of School Principal: 

Address of School: 



Zip Code: 

Statement of Alleged Violation of the Use of Restraints 

This Complaint includes a violation of the Hopkinton Public School Districts Restraint Policy aligned to 603 CMR 46. 

☐ Yes ☐ No ☐ Don’t Know 

Please describe: 

a) The date the violation began (Cannot be more than one year prior to the date this complaint is filed): b) The violation (statement that an employee has violated a requirement regarding the use of restraint): 

c) Identify the portion of the statute, policy, or procedure alleged to have been violated, if known (attach additional pages if necessary):

Please describe any other background information and facts on which the complaint is based. 

Complete the below information and submit to:

Print Name:




Date :


Print Name:




Date :



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