PAFE Form

Phone: (945) 766-4551 Email: info@handsofgodhealthcare.org HHA PCA DUTY SHEET SUN MON TUES WED THU FRI SAT Date Shift Started Shift Ended Total Hours Caregiver Signature Shift Notes / OBservations DAILY ACTIVITIES SUN MON TUES WED THU FRI SAT Personal Care Bathing Grooming Oral Care Toileting Meal prep & feeding assistance (incl. special diets) Medication reminders (No medication administration) Mobility / transfers / positioning / fall prevention Community & transportation Appointments Errands Housekeeping & Laundry (light) Companionship / supervision /safety monitoring Behavior support strategies followed as written Sleep monitoring /overnight checks logged Care coordination / communication(family, providers) The employee acknowledges and certifies this to Hands of God Home & Care. That employee has actually worked the number of hours during the specified period, as further certified by the patient or his authorized agent. Unsigned duty sheets will not be accepted. Patient acknowledges and certifies that the hours set forth were actually worked and that the work was performed in a satisfactory manner. The patient should not pay the employee directly under any circumstances. Submit The form was sent successfully. An error occured. Load PDF Template [field id="HHA"] [field id="HHA"] [field id="caregiver-name"] [field id="client-name"] [field id="date-sun"] [field id="date-mon"] [field id="date-tue"] [field id="date-wed"] [field id="date-thu"] [field id="date-fri"] [field id="date-sat"] [field id="shift-started-sun"] [field id="shift-started-mon"] [field id="shift-started-tue"] [field id="shift-started-wed"] [field id="shift-started-thu"] [field id="shift-started-fri"] [field id="shift-started-sat"] [field id="shift-ended-sun"] [field id="shift-ended-mon"] [field id="shift-ended-tue"] [field id="shift-ended-wed"] [field id="shift-ended-thu"] [field id="shift-ended-fri"] [field id="shift-ended-sat"] [field id="total-hours-sun"] [field id="total-hours-mon"] [field id="total-hours-tue"] [field id="total-hours-wed"] [field id="total-hours-thu"] [field id="total-hours-fri"] [field id="total-hours-sat"] [field id="shift-notes-sun"] [field id="shift-notes-mon"] [field id="shift-notes-tue"] [field id="shift-notes-wed"] [field id="shift-notes-thu"] [field id="shift-notes-fri"] [field id="shift-notes-sat"] [field id="personal-sun"] [field id="personal-mon"] [field id="personal-tue"] [field id="personal-wed"] [field id="personal-thu"] [field id="personal-fri"] [field id="personal-sat"] [field id="meal-sun"] [field id="meal-mon"] [field id="meal-tue"] [field id="meal-wed"] [field id="meal-thu"] [field id="meal-fri"] [field id="meal-sat"] [field id="med-remind-sun"] [field id="med-remind-mon"] [field id="med-remind-tue"] [field id="med-remind-wed"] [field id="med-remind-thu"] [field id="med-remind-fri"] [field id="med-remind-sat"] [field id="mobility-sun"] [field id="mobility-mon"] [field id="mobility-tue"] [field id="mobility-wed"] [field id="mobility-thu"] [field id="mobility-fri"] [field id="mobility-sat"] [field id="community-sun"] [field id="community-mon"] [field id="community-tue"] [field id="community-wed"] [field id="community-thu"] [field id="community-fri"] [field id="community-sat"] [field id="housekeeping-sun"] [field id="housekeeping-mon"] [field id="housekeeping-tue"] [field id="housekeeping-wed"] [field id="housekeeping-thu"] [field id="housekeeping-fri"] [field id="housekeeping-sat"] [field id="companionship-sun"] [field id="companionship-mon"] [field id="companionship-tue"] [field id="companionship-wed"] [field id="companionship-thu"] [field id="companionship-fri"] [field id="companionship-sat"] [field id="behavior-sun"] [field id="behavior-mon"] [field id="behavior-tue"] [field id="behavior-wed"] [field id="behavior-thu"] [field id="behavior-fri"] [field id="behavior-sat"] [field id="sleep-sun"] [field id="sleep-mon"] [field id="sleep-tue"] [field id="sleep-wed"] [field id="sleep-thu"] [field id="sleep-fri"] [field id="sleep-sat"] [field id="carecoordination-sun"] [field id="carecoordination-mon"] [field id="carecoordination-tue"] [field id="carecoordination-wed"] [field id="carecoordination-thu"] [field id="carecoordination-fri"] [field id="carecoordination-sat"]