Human Rights Committee Checklist
Please ensure you have included the following information for every consumer each time they are being
reviewed by the Human Rights Committee (HRC).
HRC Coversheet (Please ensure all sections are complete.)
Medication Section

Prescription/Psychotropic Medication: Include original start date and date for the most current dosage. List
any changes within the past 6 months.

Prescribing physician/psychiatrist: Give name of the current doctor and date last seen.
Requirements Section

Ensure each question is answered and up-to-date.
Program Referral Form (Please ensure all sections are complete.)
IBSSP Documents

Please include all IBSSP’s that address the issue(s) being reviewed and/or that relate to the current IP.

If the IBSSP has expired, or the consumer has met the criteria, but the IBSSP is still in use, give the reason
and please explain.

IBSSP’s for restrictive procedures or rights suspensions; briefly describe the plan the consumer needs to
follow to lift restriction or restore rights. (If the IBSSP does not address restoration include explanation.)
Informed Consent Forms

Attach current copies of Informed Consent(s) for each medication and/or restrictive procedure(s) being
reviewed. (Informed Consent is not required for a Rights Suspension, but please include a copy of the
notification sent to consumer/guardian).
HRC Recommendations/Questions

Review recommendation sheet from prior HRC review and address any questions and/or recommendations.
Provide answers under #6 on the Program Review Referral Form.
The report is due to Case Management Records Room no later than the 4 th Friday of the month prior to the
meeting.
Occasionally the HRC Committee will request additional clarification and ask you to attend the meeting. If that
happens, call 303-926-6426 by the 4th Friday of the Month prior to the meeting to schedule yourself on the agenda.
Please DO NOT show up at the meeting without prior scheduling.
HRC Recommendation Sheets will be provided to applicable recipients approximately one week after the HRC
Meeting Date.
Revised 3/2012
Human Rights Committee Cover Sheet
Person/Provider Completing Form:
HRC Review Date:
Client’s Name:
Last HRC Review Date:
Client’s Address:
Guardian:
Service Provider: Day:
Residential:
SLS:
Reason(s) for review (check all that apply)
Psychotropic Medications
Restrictive Procedure
Suspension of Rights
Behavior ISSP (Restrictive Program):
If yes, is Plan:
Yes
New
No
Revised
Emergency Control Procedure
Safety Control Procedure
On-going
LIST ALL CURRENT PRESCRIPTION AND PSYCHOTROPIC MEDICATION(S) BEING REVIEWED
START DATE
(mo/day/yr)
DOSE CHANGE
SINCE LAST
REVIEW
MED/DOSAGE
DIAGNOSIS
Psychiatrist:
Date of last Psychiatric Review:
Primary Care Physician:
Date last seen by Primary:
PURPOSE
TARGETED
SYMPTOMS
HAVE THE FOLLOWING REQUIREMENTS BEEN COMPLETED? (Actual Documentation not required.)
Documented in IP/IP Addendum?
Yes
No
Date:
Comprehensive Life Review?
Yes
No
Date:
ISSP developed and implemented?
Yes
No
Date:
Functional Analysis?
Yes
No
Date:
Date of last IDT Review:
PERSON RESPONSIBLE FOR IMPLEMENTING PLAN:
Day:
Residential:
SLS:
PERSON RESPONSIBLE FOR MONITORING PLAN:
Day:
Residential:
SLS:
Revised 3/2012
HUMAN RIGHTS COMMITTEE
PROGRAM REVIEW REFERRAL
CLIENT’S NAME:
AGE:
DATE OF REVIEW:
HAS THIS PERSON BEEN REVIEWED BY THE HRC BEFORE?
Yes
No
DATE OF LAST REVIEW:
PERSON COMPLETING REFERRAL FORM & TITLE:
ORGANIZATION:
1. Give a description of the issue(s) being reviewed.
2. Attach an IBSSP(s) with objective(s) that are to be achieved by the Plan, as well as the
methods being used to achieve the objective(s). Be sure to include a baseline for
behaviors being addressed and the criteria for success of the Plan.
3. Please provide the HRC with a clearly labeled table with target behavior, as described in
IBSSP, data for the past SIX months. Be certain to include the 30-day baseline for each
behavior being tracked.
Target
Behaviors
List
Behavior
List
Behavior
List
Behavior
List
Behavior
Revised 3/2012
Baseline
Data
(Month/Year)
1st Month/yr
2nd Month/yr
3rd Month/yr
4th Month/yr
5th Month/yr
6th Month/yr
4. Please include a clearly labeled table with data for replacement behaviors, as described
in IBSSP, displayed for the past 6 months. Please include the baseline for each
replacement behavior being tracked.
5. In your opinion, what are the reasons for the changes you have seen in the past 6
months—positive or negative?
6. Please respond to any questions or requests for clarification from previous HRC
recommendation sheet. If HRC posed recommendations were they implemented? If not
please describe reasonable attempts or reasons for not implementing. If implemented,
have you seen any changes?
7. Please provide a thumbnail sketch of a typical day in the life of this person.
8. Give a relevant history (short synopsis) of any life event(s) that the HRC may need to be
aware of that have occurred since the last review.
Revised 3/2012