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					Texas Department of Aging                                                                                                                           Form 4119
and Disability Services                                                                                                                          February 2012
                                                            Home and Community-based Services
                Residential Support Services (RSS) and Supervised Living (SL) Service Delivery Log
Individual Name (First, Last)                                     Place of Service(s)                              Local Case No./CARE ID        Week Of


Check One:                   At the end of your shift, mark (initial or check) all items that you completed with the individual. If there were any incidents,
                             concerns or special events, please document on bottom of form. For individuals who receive SL service, no night initials or
      RSS         SL         check marks are necessary.
                                                             Sunday       Monday         Tuesday      Wednesday       Thursday        Friday       Saturday
                                               mm/dd/yy
Activities of Daily Living
Bathing
Dressing
Personal Hygiene
Eating
Meal Planning
Meal Preparation
Housekeeping
Habilitation
Develop and Improve Independent Living Skills
Community Integration
Develop Socially Valued Behaviors
Use of Natural Supports
Participation in Leisure Activities
IP Skill Development
Assisting With
Ambulation and Mobility
Administration of Medication
Reinforcing Specialized Therapies
Transportation
Supervising Safety and Security
Night Shift
Supervising Safety and Security
Monitoring Health
Monitoring Personal Hygiene
Not in Home
Temporary Discharge
Active on Leave
                                    Staff Initials
                                    Staff Initials
  Date      Staff Initials                                                               Comments




            Employee Signature                        Initials        Staff ID                Employee Signature                    Initials        Staff ID

				
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