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Get Attendant Carehousekeeping Service Monitoringsupervision

Used to evaluate Attendant Care/Housekeeping service provided by an Independent Provider or Qualified Vendor employee. A Qualified Vendor may choose to use this form or one by their own agency. INDIVIDUAL S NAME (Last, First, M.I.) I.D. NO. SUPPORT COORDINATOR S NAME SERVICE START DATE MONITORING VISIT DATE SERVICE 1. OUTCOME (Objective) Attendant Care (ANC) 5 days Attendant Care Family (AFC) 30 days (ANC/AFC/HSK in-home) Housekeeping 60 days (if required) 90 days Check the appro.

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