Respite Worker Daily Sheet printable pdf download

Respite Worker Daily Sheet

UNITED CEREBRAL PALSY OF THE INLAND EMPIRE

RESPITE WORKER DAILY SHEET

CHECKLIST FOR DUTIES PERFORMED - (Title 17 requirement for service)

Client/Consumer Full Name:_________________________________________________

Age: _____

Date of report: ___________________________(mm/dd/yyyy)

Long term goal from Parent/IPP:

YES NO

W/P

Notes/Comments

DAILY LIVING SKILLS

Duties Supervised: Client/Consumer

Prepared light meal/snack

Cleaned-up area(s)

Bathing/Grooming

Personal hygiene –wash hands, face, etc.

Progress toward above listed

long term goal

Recreational Activity

Assisted w/Board Games/Puzzle

Assisted w/Communications

Watched Movie/TV/Educational

Assisted w/ Computer Skills

Assisted w/Homework

W/P = With Prompts

Comments:

Parent/Legal Guardian Signature: ______________________________________________________________

Employee’s Name (please print)_______________________________________________________________

Employee’s Signature: _____________________________________________________Date______________

PLEASE NOTE: “SIBLING CARE IS NOT DOCUMENTED ON THIS FORM”.

Revised 9/23/2010

Respite Worker Daily Sheet