State of Illinois Department of Human Services - Division of Developmental Disabilities/SODC

NOTICE REGARDING RESTRICTION OF RIGHTS OF AN INDIVIDUAL

Page 1 of 2IL462-2004D (R-04-21) Notice Regarding Restriction of Rights of An Individual Printed by Authority of the State of Illinois -0- Copies

Regarding (Name): Identification Number:

who is receiving services aton at A.M. P.M.

due to:Physical holding restraint

due to:

Restraint device applied due to:

Transport procedure/device used

due to:Chemical restraint administered

Medication: Dosage: Route of administration:Movement/Freedom of Access/Level of Supervision Specify:

Due to: Restriction expires at: P.M.A.M.

Restriction from Telephone

Specify:Searches of Person Room

Due to:

I certify that on I,

provided a copy of this notice to the individual

attempted to provide a copy of this notice to the individual, but he/she did not accept

I certify that on I, His/Her guardian of person or each of the following entities required to receive this notice.

Parent of person under 18 years of age Name:Address:Person designated by individual

Other person

Specify relationship: Name:Address:Representative of the Guardianship and Advocacy Commission

Name:Address:

Signature of Employee Completing Notice

Restriction Information Reason for Restriction

Certifications:

as clearly as possible, regarding the reason for his/her restriction of rights.

informed the individual served,

mailed a copy of this notice to

I certify this notice has been placed in the individual's record.

certain rights of the above named individual were restricted as follows:

I also:

Title

Date

Printed Name of Employee Completing Notice

On

Personal Possessions Specify:Other

On

Specify:Other restrictions not listed

Restriction expires at: A.M. P.M.

Due to: OnRestriction expires at: A.M. P.M.

Restriction expires at Conclusion of search.Due to:

Less restrictive procedures that were tried but were ineffective:

State of Illinois Department of Human Services - Division of Developmental Disabilities/SODC

NOTICE REGARDING RESTRICTION OF RIGHTS OF AN INDIVIDUAL

Page 2 of 2IL462-2004D (R-04-21) Notice Regarding Restriction of Rights of An Individual Printed by Authority of the State of Illinois -0- Copies

REPORT/PROTOCOL GUIDELINES TITLE: Restriction of Rights REPORT No: IL-462-2004D DATE GUIDELINES ISSUED: 4/2021

DOCUMENTATION GUIDELINES

DHS IL462-2004D - Notice Regarding Restriction of Rights of an Individual A. General Procedures: 1. All entries must be in black ink. 2. All entries must be legible. 3. Be specific. Do not record "physical aggression", instead record "hitting and kicking" 4. Note: Within one hour after restraints have been applied, the person who ordered the restraint must inform the individual of his or her right to have any person he or she chooses notified of the restriction of rights. A progress note is to be documented in the person's record confirming verbal contact occurred. Written notification is to occur on the first workday following the use of restraint. B. Completion of the Notice Regarding Restriction of Rights of an Individual 1. Information Section - Completed by any staff a. Staff should enter the individual's name, ID#, the name of the Center, the date and time of the restriction. b. Record the reason the restriction occurred. Be specific. (i.e. not Physical Aggression, but hitting and kicking) 2. Restriction Information - Completed by any staff a. Check each restriction which occurred. Note: More than one restriction may be recorded on the same form. b. Note: "Search of Person" must always be checked when Mechanical restraints are utilized per policy. Search must be completed within 5 minutes of Mechanical Restraint application and the search restriction expires at the conclusion of the search. c. Add specific information asked for (i.e. chemical dosage, what route, etc.) 3. Certifications - Completed by the designated staff. Note: If more than one restriction occurred in response to one behavioral episode, the time of the first restriction is listed. Note: For a Property Restriction, check "Personal Possessions" and specify "radio" for example and indicate when the restriction expires.