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JKAA-FRM1

Restraint Complaint Form

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. 

Date: 

This complaint is filed by (check one): ☐ Parent of the child  ☐ Student  ☐ Legal Guardian  ☐ Other, please explain:.  Name of complainant:  Address:  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: 

City: 

State: 

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:
Signature:		Date :
Print Name:
Signature:		Date :