Individual's Name:  
Staff:  Date:  

Community & Interest (Support Activities):

What activities did the individual participate in today with staff assist/support in meeting their person-centered goals during this shift. (Outcome #1):

Health & Safety (Support Activities):

What activities did the individual participate in today with staff assist/support in meeting their person-centered goals during this shift. (Outcome #2):

Home (Support Activities):

What activities did the individual participate in today with staff assist/support in meeting their person-centered goals during this shift. (Outcome #3)

Learning & Other Pursuits (Support Activites)

What activities did the individual participate in today with staff assist/support in meeting their person-centered goals during this shift. (Outcome #4)

Active Behavioral Need (Support Activities):

What activities did the individual participate in today with staff assist/support in meeting their person-centered goals during this shift. (Outcome #5)

Active Behavioral Need (Support Activities):

What activities did the individual participate in today with staff assist/support in meeting their person-centered goals during this shift. (Outcome #6)

Active Behavioral Need (Support Activities):

What activities did the individual participate in today with staff assist/support in meeting their person-centered goals during this shift. (Outcome #7)

Active Behavioral Need (Support Activities):

What activities did the individual participate in today with staff assist/support in meeting their person-centered goals during this shift. (Outcome #8)

Please Answer the gollowing questions for this shift period by clicking YES or NO

Did the Individual have a Bowel Movement during this shift?  Yes  NO

If YES indicate on this line:

Did the Individual any seizures during this shift?  Yes  NO

If YES what did you do to control the seizures?:

Did the Individual have any new body morks? (Bruises, Scratches, Bite Marks)  Yes  NO

If YES indicate on this line:

TIME IN:  OUT:  

Additional Notes: