At the end of your shift, initial all items that you completed with the individual.
Incidents: if there were any incidents, concerns or special events, document on bottom of form.
Night initials: for individuals who receive SL service, no night initials are necessary.
Check one: RSS or SL.
| Question | Answer |
|---|---|
| Form Name | Form 4119 |
| Form Length | 1 page |
| Fillable? | Yes |
| Fillable fields | 189 |
| Avg. time to fill out | 32 min |
| Edition | May 2019-E |
| Other names | 4119, Form 4119, service delivery log, RSS service delivery log, SL service delivery log, Supervised Living Service Delivery Log |
| Official source | Form 4119 May 2019-E, Home and Community-based Services/Texas Home Living Services |
Form 4119 isn’t the one you’re looking for?