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Daily Log
Instructions
Align with the consumers outcome
Be thorough, accurate and objective
Tell the story completely
Complete a form for each shift worked
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* Indicates required question
Email
*
Your email
Consumer Name
*
Your answer
Service Plan Year
*
Your answer
ISP Outcome
*
Your answer
Service Strategies (check all that apply)
*
Assistance with Activities of Daily Living (such as getting dressed, eating, personal hygiene, etc.)
Assistance with Increasing Community Participation (such as daily errands, attending events, restaurant, purchasing items, travel training, etc.)
Assistance with Increasing Independence (such as helping the individual learn to do laundry, cook, clean, dress, grocery shop, pay for items, etc.)
Assistance with On-The-Job Support (such as safety awareness, using the restroom, attending to task, lunch/breaks, etc.)
Assistance with Learning Activities (such as basic tutoring – math, reading, writing; support in attending a class; etc.)
Required
Date
*
MM
/
DD
/
YYYY
Start Time (EVV Start Time)
*
Your answer
End Time (EVV End Time)
*
Your answer
Activity Performed
*
Your answer
Tell us about the day, and how the activities will help the individual reach the above outcome (Who, What, Where, When, Why):
*
Your answer
Completed by: (Your Name)
*
Your answer
A copy of your responses will be emailed to the address you provided.
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