Quarterly Rights & Safety Review
Please complete this form to review important rights, responsibilities, and safety information with the consumer.
Consumer Name
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Staff Name
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Date Reviewed
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Month
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Day
Year
Date
1. Your Right to Be Safe (Sexual Abuse Awareness)
Your body belongs to you. No one is allowed to touch your private parts unless it is for health or hygiene and you agree, or a doctor is helping you. Private parts are the parts covered by a swimsuit. No one should ask you to keep secrets about touching, ask for private pictures, or show you private pictures. If someone makes you feel scared, uncomfortable, confused, or pressured, tell a trusted adult right away.
Staff: Confirm you reviewed the following with the consumer:
Explained body safety and private parts
Explained no secrets about touching
Reviewed who to tell (staff, guardian, manager, 911)
Ask the consumer: What should you do if someone touches you in a way you don’t like? Write their answer below.
2. Your Rights (Bill of Rights)
You have rights. Rights are things people must respect. You have the right to be treated with respect, be safe, have privacy, make choices, say no, have your own opinions, practice your religion, talk to who you want (unless unsafe), and make a complaint without getting in trouble.
Staff: Confirm you reviewed the following with the consumer:
Reviewed rights with consumer
Ask the consumer: What does respect mean to you?
3. Your Responsibilities
Responsibilities are things we must do to help everyone stay safe and happy. This includes treating others with respect, following rules, using kind words, keeping hands to yourself, telling the truth, and asking for help when needed.
Staff: Confirm you reviewed the following with the consumer:
Reviewed responsibilities
Ask the consumer: Why is it important to follow rules?
4. HIPAA – Privacy of Your Information
Your personal information is private. This includes your health information, address, phone number, medications, and diagnosis. Staff cannot share your private information unless it is to help care for you. We keep your paperwork safe.
Staff: Confirm you reviewed the following with the consumer:
Reviewed privacy rights
Ask the consumer: Who can we share your information with?
5. Right to Choose
You have the right to make choices. You can choose what clothes to wear, what food to eat (within rules), what activities to do, and who to spend time with. Sometimes choices have safety rules.
Staff: Confirm you reviewed the following with the consumer:
Reviewed right to choose
Ask the consumer: Tell me one choice you can make every day.
6. Reporting Problems or Complaints
You will not get in trouble for reporting a problem. It is okay to speak up. We are here to help you.
7. Reporting Neglect and Exploitation
Neglect means someone is not taking care of you the way they should. This could mean not helping you with food, medicine, hygiene, or safety. Exploitation means someone is using you for money, gifts, or personal benefit without your permission. This could include taking your money, asking you to sign papers you do not understand, or pressuring you to give them things.
If you think someone is neglecting you or exploiting you, tell staff, your guardian, your manager, or call 911 if you are in danger. You will not get in trouble for reporting.
Staff: Confirm you reviewed the following with the consumer:
Reviewed neglect definition
Reviewed exploitation definition
Reviewed who to report to
Ask the consumer: What should you do if someone is not taking care of you or is using your money without permission?
If you had a problem with staff, what would you do?
Final Staff Confirmation
Consumer understands the information
Consumer needed extra explanation
Consumer declined to participate
Staff Signature
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Consumer Signature (if able)
Submit Review
Submit Review
Should be Empty: