Form 4122, Host Home/Companion Care Service Delivery Log - Texas
Individual Name (First, Last)
Home and Community-based Services
Host Home/Companion Care Service Delivery Log
Location
Local Case No.
Form 4122 May 2022-E
Week Of
At the end of the day, initial all items that you completed with the individual. If there were any incidents, concerns or special events, document on the bottom of the form.
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
[mm/dd/yyyy] 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 Participate in Leisure Activities IP Skill Development Assisting With Ambulation and Mobility Administration of Medication Reinforcing Specialized Therapies Transportation Supervising Safety and Security Monitoring Health Monitoring Personal Hygiene Not in Home Temporary Discharge Active on Leave Host Home/Companion Care Initials
Date
Initials
Comments
Host Home/Companion Care Printed Name
Host Home/Companion Care Staff Signature
................
................
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