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.