Texas Department of Human Services
|[pic] |Day Activity and Health Services |Form 3683 |
| |Daily Attendance Record |October 2004 |
|Name of Facility |Vendor No. |Page of |
| | | |
| |
|CLIENT NAME |MONDAY |TUESDAY |WEDNESDAY |THURSDAY |FRIDAY |TOTAL |
| | | | | | |UNITS |
| | | | | | |OF |
| | | | | | |SERVICE |
| |Date |Date |Date |Date |Date | |
| | | | | | | |
| |
|I hereby certify that this is a correct daily attendance record for HHSC clients. | | | |
| |Signature–Facility Representative | |Date |
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