Case Note Form

This form must be completed by the Direct Support Worker (DSW) to record what occurred on shift; to demonstrate how the individual’s goals are being met and for accountability for services provided. Each section MUST be completed. Write N/A where not applicable. Circle choices as relevant. Participant/Carer signature is required at end of shift.
Gifts MUST NOT be accepted from participants under any circumstances.

Link to Support Worker Basics Guide

Was there an incident

Is there a new risk to report

PARTICIPANT NAME:

First NameLast Name

SUPPORT WORKER NAME:

First NameLast Name

PARTICIPANT ADDRESS:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

TYPE OF SHIFT:

TRAVEL DURING SHIFT (km) Does not include travel to and from your own home.

charged at the NDIS recommended rate of 97 cents per km

DATE

Date

START TIME

Hour Minutes

AM/PM Option

Until

until

Hour Minutes

AM/PM Option

Length of Shift (Hours)

Does not include travel to and from your own home.

DETAIL OF SERVICE (RECORD WHAT ACTIVITIES WERE UNDERTAKEN WITH/OR FOR THE PARTICIPANT)

PARTICIPANT PARTICIPATION (RECORD HOW THE PARTICIPANT PARTICIPATED AND/OR BEHAVED IN ACTIVITIES ON SHIFT)

IF THE SHIFT IS CANCELLED AT SHORT NOTICE, PLEASE NOTE DATE, TIME & REASON:

ANY RISK: YES / NO (IF YES, RECORD ANY CHANGES OR PROBLEMS THAT MAY IMPACT ON FUTURE SERVICE DELIVERY SO OTHER STAFF CAN BE INFORMED. IF THE ISSUE NEEDS IMMEDIATE ATTETION, PLEASE CALL THE OFFICE TO REPORT).

ANY INCIDENTS: YES / NO (IF YES, REPORT TO OFFICE IMMEDIATELY AND TEXT A PHOTO OF THIS FORM. COMPLETE AN INCIDENT REPORT AS DIRECTED BY DIRECTOR, AND SUBMIT TO OFFICE WITHIN 24 HOURS)

I, Participant First Name* Participant Last Name* acknowledge that the above service took place and authorize MADE TO HELP PTY LTD to draw down the hours and fees for service from the participant’s NDIA plan or from the chosen Plan Management Service as per the Service Agreement.

Signed Participant/Family Carer

I, Support Worker First Name* Support Worker Last Name* agree that this is an accurate record of what occurred during this shift.

Direct Support Worker Signature