Daily Tasksheet Report

Choose Reporting State *

Aide First Name *

Aide Last Name *

Patient First Name *

Patient Last Name *

Work Week (e.g. Work week 1,2,3,4) *

Time In

Time Out

Total Time Worked Today

Activity Codes Performed (comma-separated, e.g. 20, 21, 27 — see LarCare's Activity Code reference sheet for the full list)

Notes

Patient Classification

Patient Address or Service Area *

Any Notes or Observations

Services Provided According to Service Plan *

Any Patient Concerns or Special Requests

Provider (e.g. LarCare LLC) *

Case Manager First Name

Case Manager Last Name

Nurse First Name

Nurse Last Name

Patient or Caregiver First Name

Patient or Caregiver Last Name

Patient Signature — type your full legal name to sign *

Date-Time

I confirm the above signature is authentic and electronically executed *