Form 1745 - Service Delivery Log With Written Narrative/written Summary - 2014 Page 2
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2Texas Department of Aging
Consumer Directed Services
Form 1745
and Disability Services
Service Delivery Log with Written Narrative/Written Summary
Page 2 of 2, 08/2014-E
Program
Participant Name
Pay Period
Employer Name
Service Type
Service Provider Name
PAS
SHL
Respite
Community Support
Residential Habilitation
Other
Place of
Service Date
Written Narrative
Service
Signature — Service Provider
Date
Signature — Employer or DR
Date
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Parent category: Legal