Get Form 4122

Filling out Form 4122 can streamline the process of documenting host and companion service delivery. This guide provides clear, step-by-step instructions for completing the form online, ensuring that users can accurately input necessary information.

Follow the steps to complete the Form 4122 effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the individual’s name in the 'Individual Name' field. This should include their first and last name.
3. Fill in the 'Location' where the services are being provided, ensuring the address is complete and accurate.
4. Input the local case number or case ID in the designated field to keep records organized.
5. Specify the 'Week Of' that the log corresponds to, using the appropriate date format.
6. At the end of each day, mark or initial all items that you completed with the individual for each corresponding day of the week, from Sunday to Saturday.
7. If any incidents, concerns, or special events occurred during the week, document these in the comments section at the bottom of the form.
8. Complete the 'Activities of Daily Living' section by checking off applicable tasks such as bathing, dressing, and eating.
9. Proceed to the 'Habilitation' section and document any skills developed, using checkmarks for activities like community integration or leisure activities.
10. In the 'Assisting With' section, mark any tasks you assisted with, including medication administration and transportation.
11. For individuals not in the home during the week, select the appropriate option in the 'Not in Home' section.
12. Ensure to fill out your initials, printed name, signature, and staff ID in the specified fields to validate the form.
13. Finally, review all entries for accuracy, then save changes, download, print, or share the completed form as needed.

Complete your Form 4122 online for efficient documentation of service delivery.