Human Rights Committee Review Form

A submission packet for the committee that oversees behaviour support plans and restrictive interventions. It records the person served, why the case is being raised, the restrictions under review and each prescribed medication with its possible side effects. The behaviour specialist signs and dates it before presenting.

Use this template

Name of person served

Nombre

Apellido

Date of Behavior Support Plan and/or Medication Reduction Plan

Reason for Review

New plan Annual review Revision of the current plan Medication change Restrictive intervention Complaint received Other reason

If other, give details

Brief Description of Restrictions for Review

Medication 1

Possible Side Effects:

Medication 5

Possible Side Effects:

Medication 9

Possible Side Effects:

Medication 13

Possible Side Effects:

Medication 17

Possible Side Effects:

If PRN is prescribed, include the Prescriber's criteria for when the PRN is to be administered:

Behaviour clinician presenting the case:

Sign here

Behaviour clinician printed name:

Nombre

Apellido

Date Submitted:

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