PHYSICAL RESTRAINT, ISOLATED TIME-OUT, AND/OR TIME-OUT (RTO) COMPLAINT FORM

Oct 10, 2026

Uploaded by Ophelia

This form collects signed complaints alleging that a school district or other entity violated Illinois regulations related to physical restraint and isolated time-out or time-out (RTO). It explains eligibility for review, including that the alleged violation must have occurred within one year prior to when the complainant received notification. The form requires complaint and student details, contact information, incident timing, the complainant’s relationship to the student, preferred communication, confidentiality request, and a description of alleged violations, proposed resolution, and steps taken to resolve the issues.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages3

Reading Time8 min

AccessFree to download

COMPLAINT INFORMATION

RTO INCIDENT DETAILS

COMPLAINANT DETAILS

STUDENT INFORMATION

Student Enrollment and Current School

ALLEGED VIOLATIONS AND SIGNATURE

Description, Resolution, and Steps Taken

100 North First Street Springfield, Illinois 62777-0001 PHYSICAL RESTRAINT, ISOLATED TIME-OUT, AND/OR TIME-OUT (RTO) COMPLAINT FORM Per 23 Ill. Adm. Code 1.285 , any parent or guardian, individual, organization, or advocate may file a signed written complaint with the state superintendent alleging that a school district or other entity serving the student has violated this section. The complaint shall only be considered for review if it alleges a violation occurring not more than one year prior to the date in which the parent, guardian, individual, organization or advocate received notification of the violation. Use of this form, including all information requested, is required in order to process the complaint. Additional pages may be included as needed. Please send the completed form and any additional pages as attachments to [RestraintTimeOut@isbe.net](RestraintTimeOut@isbe.net. For)[. For](RestraintTimeOut@isbe.net. For) assistance in completing this form, please call 217-782-5270. COMPLAINT INFORMATION | DATE OF RTO INCIDENT | | | | | | | | | | | COMPLAINANT NAME | | | | | | EMAIL ADDRESS | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | ADDRESS (Include Street, City, State, and ZIP Code) | | | | | | | | | | | | BEST DAYTIME PHONE NUMBER | | | | | CELL PHONE NUMBER | | RELATIONSHIP TO STUDENT | | | | | | | | | | | | ANY ADDITIONAL INFORMATION PERTAINING TO RELATIONSHIP | | | | | | | | | Parent/Guardian
Advocate | | | | Individual
Self | | | | Organization | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | PRIMARY LANGUAGE | | | | | | | | Other: | | | | BEST MODE OF COMMUNICATION | | | | | | | | | English | | Spanish | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | COMPLAINANT REQUESTS THAT THEIR IDENTITY REMAINS CONFIDENTIAL: | | | | | | | | | | | | | | YES | | NO | | STUDENT INFORMATION | NAME | DATE OF BIRTH | ADDRESS (Include Street, City, State, and ZIP Code) | | | | | | --- | --- | --- | --- | --- | --- | --- | | SCHOOL WHERE RTO INCIDENT(S) OCCURRED | | SCHOOL ADDRESS (Include Street, City, State, and ZIP Code) | | | | | | SCHOOL PHONE NUMBER (Include Area Code) | | OTHER CONTACT INFORMATION | | | | | | IS THE STUDENT CURRENTLY ENROLLED IN THE SCHOOL IDENTIFIED ABOVE?: | | | | YES | | NO | | IF NO, NAME OF CURRENT SCHOOL | | CURRENT SCHOOL ADDRESS (Include Street, City, State, and ZIP Code) | | | | | Continued next page. COMPLAINT INFORMATION The facts on which the complaint is based. Additional pages may be included as needed. A DESCRIPTION OF THE ALLEGED RTO VIOLATIONS: WHAT IS THE PROPOSED RESOLUTION OF THE ALLEGED RTO VIOLATIONS: STEPS TAKEN TO RESOLVE THE ISSUE(S): OTHER INFORMATION (including any facts related to the concern or any additional student names/contact information related to the concern): Digital or Original Signature Date of individual completing this form ISBE 11-01B (4/26) Print Reset Form PAGE 3 of 3

FAQs

Who may file an RTO complaint, and what must it allege?

A parent or guardian, individual, organization, or advocate may file a signed written complaint alleging that a school district or other entity serving the student violated the specified regulation section.

What time limit applies for the alleged violation to be considered for review?

The complaint is considered only if it alleges a violation occurring not more than one year prior to the date the complainant received notification of the violation.

What information is required in the complaint and student sections?

The form requests RTO incident date, complainant identity and contact details, relationship to the student, preferred communication, confidentiality request, and student information including the school where the incident occurred and current enrollment status. It also requires a description of alleged violations, proposed resolution, and steps taken to resolve the issues, plus a signature date.

Oct 10, 2026

Uploaded by Ophelia