5144.2 Form

Sample Designated Time-Out Setting

Data Collection Form

Name of Student:_________________________________________________________________________________

Date of designated time-out room use: _________________________________________________________________

Time of designated time-out room use: _________________________________________________________________

Duration of designated time-out room use: ______________________________________________________________

Name of professional staff supervising student while in designated time-out room: _________________________________

Describe:

a)  Antecedent events leading up to use of designated time-out room

b)  Behavior that resulted in use of designated time-out room

c)  Behavior observed in the designated time-out room

If used, describe the physical assistance required:

On this occasion, was the student able to self-regulate and/or control behavior in order to return to the classroom or were further interventions required? Specify.

NOTE:  This data must be placed in the student's confidential record.