State of Illinois
Department of Human Services
NOTICE REGARDING RESTRICTION OF RIGHTS OF AN INDIVIDUAL
Regarding (Name):
Identification Number:
who is receiving services at
on
at
A.M.
P.M.
certain rights of the above named individual were restricted as follows:
Restriction Information
Reason for Restriction
Emergency use of exclusionary time out
due to:
Physical holding restraint
due to:
Restraint device applied
due to:
Transport procedure/device used
due to:
Chemical restraint administered
due to:
Medication:
Movement/freedom of access
Specify:
Restriction from
Dosage:
due to:
, on
telephone
visitors
personal possessions
Restriction expires at:
A.M.
P.M.
Restriction expires at:
A.M.
P.M.
due to:
mail
other
specify:
Searches of
Route of administration:
, on
room
person
due to:
Other restrictions not listed
due to:
specify:
Certifications
I certify that on
I,
informed the individual served,
as clearly as possible, regarding the reason for his/her restriction of rights.
I also:
provided a copy of this
notice to the individual
I certify that on
attempted to provide a copy of this notice
to the individual, but he/she did not accept
I,
His/Her guardian of person or
parent of person under 18 years of age
each of the following entities required to receive this notice.
Person designated by individual
mailed a copy of this notice to
Name:
Address:
Name:
Address:
Other person
specify relationship:
Name:
Address:
Representative of the Guardianship and Advocacy Commission
Name:
Address:
I certify this notice has been placed in the individual's record.
Signature and Title of Employee Completing Notice:
IL 462-2004D (R-07-14) Notice Regarding Restriction of Rights of An Individual
Printed by Authority of the State of Illinois -0- Copies
Date:
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