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Attendant Manual Clock In/Out Form

Attendant Manual Clock In/Out Form

Attendant & Consumer Information

Attendant Name(Required)
Consumer Name(Required)

Shift Details

MM slash DD slash YYYY
Clock-In Time(Required)
:
Clock-Out Time(Required)
:

ADLs & IADLs

Bathing(Required)
(Bathing/Showering, Sponge/Bed Bath, Shampoo, Shave, Oral/Denture Care)
Bladder/Incontinence(Required)
(Toilet/Commode, Bedpan/Urinal, Brief/Pad, Incontinent, Catheter, Peri Care)
Ambulating(Required)
(Transfers, Cane/Crutches, Walker/Wheelchair, Distance, Frequency)
Range of Motion(Required)
(Assistance with Movement, Application of Prosthesis/Braces, TEDS/Ace Wraps)

Skin(Required)
(Lotion, Dressing Change, Turning & Repositioning, Nail Care, Foot Soak, Glasses, Hearing Aid)
Meals(Required)
(Meal Preparation, Feeding, Supplement Given, Restrict/Push Fluids, Weight)
Household(Required)
(Kitchen/Dishes, Bathrooms, Vacuum, Garbage, Laundry, Make Bed/Linens)
IADL(Required)
(Transportation, Appointments, Shopping/Errands, Social Interaction, Companionship)
Please note above any other duties performed: Hygiene Assistance, Incontinence Care, Medication Reminders, or Other. If other, please list the activity.

Signatures & Date

By signing below, I do hereby attest that this information is true, accurate, and complete to the best of my knowledge. I understand that any falsification may subject me to administrative, civil, or criminal liability.
The attendant will sign here (with finger via mobile device, or with mouse via computer).
The consumer will sign here (with finger via mobile device, or with mouse via computer).
MM slash DD slash YYYY
MM slash DD slash YYYY
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1432 Wilkins Rd. | Erie, PA 16505
  • Phone TTY: (814) 874-0064
  • Toll Free: (866) 407-0064
  • Fax: (814) 874-3497
Office hours: 8:30 AM to 4:30 PM Monday through Friday
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