Form 4122 PDF Details

In today's rapidly aging society, the Texas Department of Aging and Disability Services has taken a significant step towards ensuring that individuals receiving home and community-based services receive the care they need in a structured and accountable manner. Introduced in February 2012, Form 4122, also known as the Home and Community-based Services Foster/Companion Service Delivery Log, serves as a crucial tool in this endeavor. This form is meticulously designed to track the daily activities and services provided to individuals, ranging from basic activities of daily living like bathing, dressing, and eating to more complex needs such as habilitation, community integration, and health monitoring. Each section of the form offers a checkbox or space for initials, allowing foster or companion service providers to document the completion of tasks, any incidents, concerns, or special events that occur during service delivery. This detailed log not only promotes transparency and accountability but also fosters a deeper sense of responsibility and dedication among service providers towards their clients' well-being. By mandating the use of this form, the Texas Department of Aging and Disability Services ensures that every individual under its care benefits from a comprehensive, tailored approach to service delivery that respects their autonomy and addresses their unique needs.

QuestionAnswer
Form NameForm 4122
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namestexas department of aging and disabilty services form 4122 april 2014 e, department of aging form 4122, form 4120 dads, form 4122 april 2014 e

Form Preview Example

Texas Department of Aging

Form 4122

and Disability Services

February 2012

Home and Community-based Services

Foster/Companion Service Delivery Log

Individual Name (First, Last)

Location

Local Case No./CARE ID

Week Of

At the end of the day, mark (initial or check) all items that you completed with the individual. If there were any incidents, concerns or special events, document on the bottom of the form.

mm/dd/yy

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Activities of Daily Living

Bathing

Dressing

Personal Hygiene

Eating

Meal Planning

Meal Preparation

Housekeeping

Habilitation

Develop and Improve Independent Living Skills

Community Integration

Develop Socially Valued Behaviors

Use of Natural Supports

Participation in Leisure Activities

IP Skill Development

Assisting With

Ambulation and Mobility

Administration of Medication

Reinforcing Specialized Therapies

Transportation

Supervising Safety and Security

Monitoring Health

Monitoring Personal Hygiene

Not in Home (comments required)

Temporary Discharge

Active on Leave

Foster/Companion Initials

Date

Initials

Comments

Foster/Companion Printed Name

Foster/Companion Staff Signature

Staff ID No.

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Step 2: After you start the PDF editor, there'll be the document all set to be filled out. Other than filling in various blank fields, you may also do other sorts of things with the PDF, namely adding custom text, changing the original textual content, inserting graphics, affixing your signature to the PDF, and more.

It will be an easy task to complete the pdf using this detailed guide! Here is what you should do:

1. It is critical to complete the department of aging form 4122 accurately, thus take care when filling out the sections comprising these blanks:

Filling out section 1 in form 4122 april 2014 e

2. Once your current task is complete, take the next step – fill out all of these fields - Assisting With, Ambulation and Mobility, Administration of Medication, Reinforcing Specialized Therapies, Transportation, Supervising Safety and Security, Monitoring Health, Monitoring Personal Hygiene, Not in Home comments required, Temporary Discharge, Active on Leave, FosterCompanion Initials, Date, Initials, and Comments with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Completing part 2 of form 4122 april 2014 e

3. Your next part is easy - complete every one of the form fields in FosterCompanion Printed Name, FosterCompanion Staff Signature, and Staff ID No to finish this segment.

Filling in section 3 in form 4122 april 2014 e

Those who use this PDF often get some things incorrect when completing FosterCompanion Printed Name in this area. Be sure you re-examine what you type in right here.

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