Rights Restriction Form Form

Person Name *

Program Name

Restriction of a person's rights is allowed only if determined necessary to ensure the health, safety, and well-being of the person. Any restriction of those rights must be documented in the person's coordinated service and support plan or coordinated service and support plan addendum and in the individual abuse prevention plan. The restriction must be implemented in the least restrictive alternative manner necessary to protect the person and provide support to reduce or eliminate the need for the restriction in the most integrated setting and inclusive manner.

1. Identify the protection-related rights to be restricted (check the applicable right):

A person's protection-related right to:

associate with other persons of the persons choice

personal privacy

engage in chosen activities

For a person residing in a residential site licensed according to chapter 245A, or where the license holder is the owner, lessor, or tenant of the residential service site, the right to:

have daily, private access to and use of a non-coin-operated telephone for local calls and long-distance calls made collect or paid for by the person

receive and send, without interference, uncensored, unopened mail or electronic correspondence or communication

have use of and free access to common areas in the residence

privacy for visits with the persons spouse, next of kin, legal counsel, religious advisor, or others, in accordance with section 363A.09 of the Human Rights Act, including privacy in the persons bedroom

2. Identify how the restriction of rights is justified based on an assessment of the person's vulnerability related to exercising the right without restriction (meaning why the restriction is needed and how this was determined):

3. Identify how the right will be restricted (in the least restrictive manner necessary to protect the person and provide support to reduce or eliminate the need for the restriction in the most integrated setting and inclusive manner):

4. Identify the objective measures set as conditions for ending the restriction (meaning how and when everyone will know the person’s rights must be restored):

5. dentify the schedule for reviewing the need for the restriction based on the conditions for ending the restriction (it must occur semiannually from the date of initial approval, at a minimum, or more frequently if requested by the person, the person's legal representative, if any, and case manager):

Date to be reviewed

Restriction was lessened or lifted

Yes

No

If no, justify why and whether changes to the person’s service outcomes or supports are needed to restore the person’s rights (attach dated documentation).

Attach Resume

Approval of rights restriction: I participated in the discussion of why this restriction of my rights is needed to ensure my health, safety, and well-being. My approval of this restriction of my rights is limited to the restriction as identified in this document. I understand that I may withdraw my approval at any time. If I withdraw my approval I understand that my rights must be immediately and fully restored.

Person/Legal Representative

Date

Withdrawal of approval of rights restriction: I withdraw my approval for my rights to be restricted. All restrictions must end and my rights must be fully restored immediately.

Person/Legal Representative

Date