DADS or HHSC Form

							Texas Department of Aging                                                                                                              Form 4120
and Disability Services                                                                                                             February 2012
                                      Home and Community-based Services/Texas Home Living Services
                                                 Day Habilitation Service Delivery Log
Individual Name (First, Last)                                   Place of Service(s)                               Local Case No./CARE ID



           Monday                          Tuesday                   Wednesday                      Thursday                     Friday
mm/dd/yy                        mm/dd/yy                      mm/dd/yy                     mm/dd/yy               mm/dd/yy
Time In                         Time In                       Time In                      Time In                Time In
Time Out                        Time Out                      Time Out                     Time Out               Time Out
Time In                         Time In                       Time In                      Time In                Time In
Time Out                        Time Out                      Time Out                     Time Out               Time Out
Time In                         Time In                       Time In                      Time In                Time In
Time Out                        Time Out                      Time Out                     Time Out               Time Out

Mark (initial or check) all areas in which you provided assistance to the person:
Self-Help Skills                                            Monday           Tuesday             Wednesday     Thursday              Friday
Personal Hygiene
Eating
Meal Preparation
Cleaning
Adaptive Skills
Ambulation and Mobility
Reinforce Therapies
Socialization Skills
Communication
Socialization Skills Development
Community Activities
Group Activity
Transportation
Employment Skills Training
Accessing Employment Skills
Employment Skill Development
IP Skill Development
Other
Other

Comments (Special Events/Occurrences)
   Date      Staff Initials                                                           Comments




            Employee Signature                   Initials       Staff ID                 Employee Signature           Initials            Staff ID