Service Delivery Record - Advent One Home Care Agency
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1Texas Department of Aging and
Form 3054
Disability Services
August 2009
Primary Home Care
Month and Year of Service
Service Delivery Record
Employee Name
No.
Employee Mailing Address
If more than one employee serves the client, list employee name(s):
Client Name
Client No.
County
TASK(S) ASSIGNED (for family care and primary home care only):
Meal Preparation
Ambulation
Bathing
Laundry
Other (specify):
Dressing
Toileting
Escort
Exercising
Transfer
Shopping
Assist with Self-
Feeding
Cleaning
administered Medications
Routine Hair/Skin Care
Grooming
Note: Claiming services not actually
provided constitutes fraud.
Scheduled or Authorized Hours
Day
In
Out
Total
Day
In
Out
Total
Day
In
Out
Total
Sunday
Wednesday
Saturday
Monday
Thursday
Total Authorized
Tuesday
Friday
Hours Per Week:
Record of Time
Time (Hours:Minutes)
Time (Hours:Minutes)
Time (Hours:Minutes)
Day of
Day of
Day of
Total Daily
Total Daily
Total Daily
Month
Month
Month
Time in
Time Out
Time
Time in
Time Out
Time
Time in
Time Out
Time
1
12
23
2
13
24
3
14
25
4
15
26
5
16
27
6
17
28
7
18
29
8
19
30
9
20
31
10
21
Monthly Total of Hours:
11
22
This is to certify that I worked the hours recorded and
completed the work tasks assigned.
Signature–Employee
This is to certify that to the best of my knowledge the
employee has worked the hours recorded and completed
the tasks assigned.
Signature–Timekeeper
Date*
*The date indicated here must not be before the last day the provider worked.
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