United Way Respite Service Documentation Form Page 2
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1
2Consumer’s Legal Name:
Date of Birth: _ _ / _ _ / _ _
(include nicknames used in summary)
Direct Service Provider (DSP) Verification:
Did the DSP have access to Care Plan?:
Yes
No*
*If no, explain:
Is the DSP responsible for dispensing/observing medications/procedures? (check one)
Yes**
No
** if yes, complete a medication log
Were there any injury, illness, or safety issues during the service that required an incident/seizure report?:
Yes
No
(complete & submit incident report within 24 hours)
Are there any additional notes, concerns or issues to communicate?: Yes (document below) No
________________________________________________________________________________________________
________________________________________________________________________________________________
DSP Full Legal Name (Print):
DSP ID #
DSP Full Legal Name (Signature):
Date
Signature of Person
Responsible for Consumer
Date
st
th
Completed service notes must be turned in on the 1
& 16
each month to the Arc at:
Office Use Only
nd
Street SE, Suite 200 Cedar Rapids, IA 52401
680 2
Phone: 319-365-0487 Fax: 319-365-9938
_______
_____
Office QA by:
Date:
_________
Other QA by:
Date:
The Arc of East Central Iowa: UW Respite Service Documentation Back Page (Revised 3/1/13)
See Discussion Log:
Consumer
DSP
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