Family Person-Centered Support 1:1
WEST VIRGINIA I/DD WAIVER DIRECT SUPPORT SERVICE LOG
Client Name A
CLIENT - First Name
*
Client First Name
CLIENT - Last Name
*
Client Last Name, Including Jr, II, etc.
Please use Jr, II, etc.
WHO IS BILLING? - First Name
*
WHO IS BILLING? - Last Name
*
PLEASE SELECT HOW MANY TIME ENTRIES YOU NEED
*
Please Select
1 Entry For Each Day
2 Entries For Each Day
3 Entries For Each Day
SATURDAY
Saturday - Time #1
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Saturday - Time #2
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Saturday - Time #3
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Saturday #1 - Training Provided?
Please Select
N
Y
Saturday #2 - Training Provided?
Please Select
N
Y
Saturday #3 - Training Provided?
Please Select
N
Y
Saturday #1 - Provider Initials
Saturday #2 - Provider Initials
Saturday #3 - Provider Initials
THIS IS THE TOTAL NUMBER OF HOURS YOU ENTERED FOR SATURDAY
SUNDAY
Sunday - Time #1
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Sunday - Time #2
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Sunday - Time #3
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Sunday #1 - Training Provided?
Please Select
N
Y
Sunday #2 - Training Provided?
Please Select
N
Y
Sunday #3 - Training Provided?
Please Select
N
Y
Sunday #1 - Provider Initials
Sunday #2 - Provider Initials
Sunday #3 - Provider Initials
THIS IS THE TOTAL NUMBER OF HOURS YOU ENTERED FOR SUNDAY
MONDAY
Monday - Time #1
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Monday - Time #2
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Monday - Time #3
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Monday #1 - Training Provided?
Please Select
N
Y
Monday #2 - Training Provided?
Please Select
N
Y
Monday #3 - Training Provided?
Please Select
N
Y
Monday #1 - Provider Initials
Monday #2 - Provider Initials
Monday #3 - Provider Initials
THIS IS THE TOTAL NUMBER OF HOURS YOU ENTERED FOR MONDAY
TUESDAY
Tuesday - Time #1
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Tuesday - Time #2
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Tuesday - Time #3
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Tuesday #1 - Training Provided?
Please Select
N
Y
Tuesday #2 - Training Provided?
Please Select
N
Y
Tuesday #3 - Training Provided?
Please Select
N
Y
Tuesday #1 - Provider Initials
Tuesday #2 - Provider Initials
Tuesday #3 - Provider Initials
THIS IS THE TOTAL NUMBER OF HOURS YOU ENTERED FOR TUESDAY
WEDNESDAY
Wednesday - Time #1
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Wednesday - Time #2
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Wednesday - Time #3
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Wednesday #1 - Training Provided?
Please Select
N
Y
Wednesday #2 - Training Provided?
Please Select
N
Y
Wednesday #3 - Training Provided?
Please Select
N
Y
Wednesday #1 - Provider Initials
Wednesday #2 - Provider Initials
Wednesday #3 - Provider Initials
THIS IS THE TOTAL NUMBER OF HOURS YOU ENTERED FOR WEDNESDAY
THURSDAY
Thursday - Time #1
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Thursday - Time #2
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Thursday - Time #3
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Thursday #1 - Training Provided?
Please Select
N
Y
Thursday #1 - Provider Initials
Thursday #2 - Training Provided?
Please Select
N
Y
Thursday #2 - Provider Initials
Thursday #3 - Training Provided?
Please Select
N
Y
Thursday #3 - Provider Initials
THIS IS THE TOTAL NUMBER OF HOURS YOU ENTERED FOR THURSDAY
FRIDAY
Friday- Time #1
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Friday - Time #2
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Friday - Time #3
Hour Minutes
AM
PM
AM/PM Option
Until
until
Hour Minutes
AM
PM
AM/PM Option
Friday #1 - Training Provided?
Please Select
N
Y
Friday #1 - Provider Initials
Friday #2 - Training Provided?
Please Select
N
Y
Friday #2 - Provider Initials
Friday #3 - Training Provided?
Please Select
N
Y
Friday #3 - Provider Initials
THIS IS THE TOTAL NUMBER OF HOURS YOU ENTERED FOR FRIDAY
THIS IS THE TOTAL NUMBER OF HOURS YOU HAVE ENTERED ON THIS FORM
Total Units
THE PERSON BILLING NAME CANNOT BE THE SAME AS THE WAIVER CLIENT NAME
Provider Name 2 New
First Initial
Last Initial
Provider Initials
ID
ID Sat
ID Sun
ID Mon
ID Tues
ID Wed
ID Thur
ID Fri
Provider E-Mail
*
Provider Cell Phone Number
*
This is to ensure we have your current contact number.
Format: (000) 000-0000.
Do You Complete Task Analysis For A Behavior Support Professional?
*
Please Select
N
Y
Person Billing Signature
*
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