Please complete this read confirmation for every new family assigned to you. Please regularly check for updates to case notes and complete a read confirmation.

Caregiver Name

Full Name

Client Name

First Name Last Initial ONLY

I have read and understand the service plan notes for this family. I will ask my supervisor if I have any questions or need clarification regarding the expectations of this assignment.

Yes

No, and I will contact my supervisor by phone.

Attendant instructed to report to supervisor:

Incidents that affect the client's condition Hospitalization of the client Client's absence or relocation Suspected Abuse, Neglect or Exploitation Change in client's needs

Yes

Case Notes Read Confirmation

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