Person Daily Support Plan Log Please Fill out This Form: Date * Facility Program * Staff Name * Staff Name First Name First Name Last Name Last Name Staff Phone Number * Staff Email address * How was the person supported on the following ADLS:Activity Person First & Last Name Initial * Bathing/Showering * Yes No TA PA VP Independent RefusedToileting * Yes No TA PA VP Independent RefusedBrushing Teeth * Yes No TA PA VP Independent RefusedGretting Dressed * Yes No TA PA VP Independent RefusedWalking around the house * Yes No TA PA VP Independent RefusedCooking Meal * Yes No TA PA VP Independent RefusedGrocery shopping * Yes No TA PA VP Independent RefusedCompleting laundry * Yes No TA PA VP Independent RefusedCleaning personal space * Yes No TA PA VP Independent RefusedMaking bed * Yes No TA PA VP Independent RefusedDid the person refuse any of the daily support? * Yes No If yes, what was the reason? Write the reason in the space below. plus1 Add Person minus1 Remove PersonStaff Acknowledgement Date * Supervisor Name * Enter the name of the supervisor who will review the client daily support plan log. Staff Signature * signature keyboard Clear Submit If you are human, leave this field blank.
