Form Ddd-1164aforna - Attendant Care Progress Notes

DDD-1164AFORNA (2-07)

ARIZONA DEPARTMENT OF ECONOMIC SECURITY

Division of Developmental Disabilities

ATTENDANT CARE PROGRESS NOTES

INDIVIDUAL’S NAME (Last, First, M.I.)

ASSISTS ID NO.

SUPPORT COORDINATOR’S NAME

MONTH/YEAR

DAYS OF THE MONTH

1

2

3

4

5

6

7

8

9

10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

ATTENDANT

CARE HOURS

:

TOTAL HOURS

FOR MONTH:

PROGRESS/OUTCOME

BEHAVIORAL ISSUES

MEDICAL ISSUES

COMMENTS

RECOMMENDATIONS

BARRIERS

PROVIDER’S SIGNATURE

DATE

RESPONSIBLE PERSON’S SIGNATURE

DATE

Equal Opportunity Employer/Program

Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the Americans with Disabilities Act of 1990 (ADA),

Section 504 of the Rehabilitation Act of 1973, and the Age Discrimination Act of 1975, the Department prohibits discrimination in admissions, programs, services, activities,

or employment based on race, color, religion, sex, national origin, age, and disability. The Department must make a reasonable accommodation to allow a person with a

disability to take part in a program, service or activity. For example, this means if necessary, the Department must provide sign language interpreters for people who are

deaf, a wheelchair accessible location, or enlarged print materials. It also means that the Department will take any other reasonable action that allows you to take part in

and understand a program or activity, including making reasonable changes to an activity. If you believe that you will not be able to understand or take part in a program or

activity because of your disability, please let us know of your disability needs in advance if at all possible. To request this document in alternative format or for further

information about this policy, contact the Division of Developmental Disabilities ADA Coordinator at 602 542-6825; TTY/TDD Services: 7-1-1.