Person Activity LogPerson Activity 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 * Activity Person First & Last Name * Describe the activity here * Time Spent * 1 Hour2 Hour3 Hour4 Hour5 Hour Completed? * Yes No Comments Was it planned? * Yes No Comments Was it unplanned? * Yes No Comments Did the person refuse the activity? * Yes No Comments 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 activity log. Staff Signature * signature keyboard Clear Submit If you are human, leave this field blank.
