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Get WA DSHS 15-051 2015-2024

Copies will be requested by Case Managers at the time of reassessment. DSHS may request copies at any time. CLIENT S SIGNATURE This form is available at https //www. dshs. wa.gov/fsa/forms DSHS 15-051 REV. 06/2015 COPIES TO Individual Provider Client/Employer. HOME AND COMMUNITY SERVICES HCS DEVELOPMENTAL DISABILITIES ADMINISTRATION DDA Individual Provider Time Sheet CLIENT/EMPLOYER NAME Day of Month A Time Service Began B Ended C Total Hours Each Day D Mileage INDIVIDUAL PROVIDER S NAME CM NAME MONTH/YEAR TOTALS CHECK TASKS PEFORMED DURING MONTH AS ASSIGNED IN CLIENT S SERVICE PLAN PERSONAL CARE PROVIDERS ONLY Meal Preparation Eating Escort / Transport to Medical Tasks for adult clients only. Dressing Personal Hygiene Bed Mobility / Positioning Walking / Locomotion Application of Lotion / Ointment Toenails Trimmed Transfer Bathing Toileting Housework Passive Range of Motion Treatment Essential Shopping Wood Supply Dry Bandage Change Medication Management DDD Respite INSTRUCTIONS FOR DOCUMENTING YOUR DSHS AUTHORIZED HOURS A. Enter time service began indicate AM or PM as appropriate. C. Enter total hours worked each day. DO NOT send these time sheets to Case Managers unless requested* Keep completed time sheets in your records for six 6 years. Copies will be requested by Case Managers at the time of reassessment. DSHS may request copies at any time. CLIENT S SIGNATURE This form is available at https //www. dshs. wa*gov/fsa/forms DSHS 15-051 REV. 06/2015 COPIES TO Individual Provider Client/Employer. Dressing Personal Hygiene Bed Mobility / Positioning Walking / Locomotion Application of Lotion / Ointment Toenails Trimmed Transfer Bathing Toileting Housework Passive Range of Motion Treatment Essential Shopping Wood Supply Dry Bandage Change Medication Management DDD Respite INSTRUCTIONS FOR DOCUMENTING YOUR DSHS AUTHORIZED HOURS A. Enter time service began indicate AM or PM as appropriate. C. Enter total hours worked each day. DO NOT send these time sheets to Case Managers unless requested* Keep completed time sheets in your records for six 6 years. Enter time service began indicate AM or PM as appropriate. C. Enter total hours worked each day. DO NOT send these time sheets to Case Managers unless requested* Keep completed time sheets in your records for six 6 years. Copies will be requested by Case Managers at the time of reassessment. DSHS may request copies at any time. Dressing Personal Hygiene Bed Mobility / Positioning Walking / Locomotion Application of Lotion / Ointment Toenails Trimmed Transfer Bathing Toileting Housework Passive Range of Motion Treatment Essential Shopping Wood Supply Dry Bandage Change Medication Management DDD Respite INSTRUCTIONS FOR DOCUMENTING YOUR DSHS AUTHORIZED HOURS A. Enter time service began indicate AM or PM as appropriate. C. Enter total hours worked each day. DO NOT send these time sheets to Case Managers unless requested* Keep completed time sheets in your records for six 6 years. Copies will be requested by Case Managers at the time of reassessment. DSHS may request copies at any time. .

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