HHA Activity Sheet

Client's Name:

Employee’s Name:

DAY

DATE

TIME IN

TIME OUT

TOTAL

EMPLOYEE’S SIGNATURE DAILY

CLIENT SIGNATURE DAILY

Sun

Sunday Date:

Sunday In:

Sunday Out:

Sunday Total:

Sunday Employee Signature:

Sunday Client Signature:

Mon

Monday Date:

Monday In:

Monday Out:

Monday Total:

Monday Employee Signature:

Monday Client Signature:

Tue

Tuesday Date:

Tuesday In:

Tuesday Out:

Tuesday Total:

Tuesday Employee Signature:

Tuesday Client Signature:

Wed

Wednesday Date:

Wednesday In:

Wednesday Out:

Wednesday Total:

Wednesday Employee Signature:

Wednesday Client Signature:

Thu

Thursday Date:

Thursday In:

Thursday Out:

Thursday Total:

Thursday Employee Signature:

Thursday Client Signature:

Fri

Friday Date:

Friday In:

Friday Out:

Friday Total:

Friday Employee Signature:

Friday Client Signature:

Sat

Saturday Date:

Saturday In:

Saturday Out:

Saturday Total:

Saturday Employee Signature:

Saturday Client Signature:

Employee's Total Hours Weekly:

Signature:

TASK

SUN

MON

WED

THU

FRI

SAT

CLIENTS INITIALS

HANDS ON CARE

Bathing – Shower/ BB/ Sponge

Bathing – Shower/ BB/ Sponge Sunday:

Bathing – Shower/ BB/ Sponge Monday:

Bathing – Shower/ BB/ Sponge Tuesday:

Bathing – Shower/ BB/ Sponge Wednesday:

Bathing – Shower/ BB/ Sponge Thursday:

Bathing – Shower/ BB/ Sponge Friday:

Bathing – Shower/ BB/ Sponge Saturday:

Bathing – Shower/ BB/ Sponge Client Initials:

Perinea Care

Perinea Care Sunday:

Perinea Care Monday:

Perinea Care Tuesday:

Perinea Care Wednesday:

Perinea Care Thursday:

Perinea Care Friday:

Perinea Care Saturday:

Perinea Care Client Initials:

Shampoo Hair

Shampoo Hair Sunday:

Shampoo Hair Monday:

Shampoo Hair Tuesday:

Shampoo Hair Wednesday:

Shampoo Hair Thursday:

Shampoo Hair Friday:

Shampoo Hair Saturday:

Shampoo Hair Client Initials:

Shave

Shave Sunday:

Shave Monday:

Shave Tuesday:

Shave Wednesday:

Shave Thursday:

Shave Friday:

Shave Saturday:

Shave Client Initials:

Skin Care / Lotion

Skin Care Sunday:

Skin Care Monday:

Skin Care Tuesday:

Skin Care Wednesday:

Skin Care Thursday:

Skin Care Friday:

Skin Care Saturday:

Skin Care Client Initials:

Nail Care – Cleaning / Filin

Nail Care Sunday:

Nail Care Monday:

Nail Care Tuesday:

Nail Care Wednesday:

Nail Care Thursday:

Nail Care Friday:

Nail Care Saturday:

Nail Care Client Initials:

Dressing – Assist

Dressing Assist Sunday:

Dressing Assist Monday:

Dressing Assist Tuesday:

Dressing Assist Wednesday:

Dressing Assist Thursday:

Dressing Assist Friday:

Dressing Assist Saturday:

Dressing Assist Client Initials:

Elastic Stocking

Elastic Stocking Sunday:

Elastic Stocking Monday:

Elastic Stocking Tuesday:

Elastic Stocking Wednesday:

Elastic Stocking Thursday:

Elastic Stocking Friday:

Elastic Stocking Saturday:

Elastic Stocking Client Initials:

Foot Care – Cleaning / Filing

Foot Care Sunday:

Foot Care Monday:

Foot Care Tuesday:

Foot Care Wednesday:

Foot Care Thursday:

Foot Care Friday:

Foot Care Saturday:

Foot Care Client Initials:

Oral Care – Brush/Denture

Oral Care Sunday:

Oral Care Monday:

Oral Care Tuesday:

Oral Care Wednesday:

Oral Care Thursday:

Oral Care Friday:

Oral Care Saturday:

Oral Care Client Initials:

MOBILITY

Ambulation – Assist

Ambulation Assist Sunday:

Ambulation Assist Monday:

Ambulation Assist Tuesday:

Ambulation Assist Wednesday:

Ambulation Assist Thursday:

Ambulation Assist Friday:

Ambulation Assist Saturday:

Ambulation Assist Client Initials:

Transfer – Assist

Transfer Assist Sunday:

Transfer Assist Monday:

Transfer Assist Tuesday:

Transfer Assist Wednesday:

Transfer Assist Thursday:

Transfer Assist Friday:

Transfer Assist Saturday:

Transfer Assist Client Initials:

Exercise – Assist

Exercise Assist Sunday:

Exercise Assist Monday:

Exercise Assist Tuesday:

Exercise Assist Wednesday:

Exercise Assist Thursday:

Exercise Assist Friday:

Exercise Assist Saturday:

Exercise Assist Client Initials:

NUTRITION

Meal Planning

Meal Planning Sunday:

Meal Planning Monday:

Meal Planning Tuesday:

Meal Planning Wednesday:

Meal Planning Thursday:

Meal Planning Friday:

Meal Planning Client Initials:

Meal Prep – B L D S

Meal Prep Sunday:

Meal Prep Monday:

Meal Prep Tuesday:

Meal Prep Wednesday:

Meal Prep Thursday:

Meal Prep Friday:

Meal Prep Saturday:

Meal Prep Client Initials:

Remind Oral Supplement

Remind Oral Supplement Sunday:

Remind Oral Supplement Monday:

Remind Oral Supplement Tuesday:

Remind Oral Supplement Wednesday:

Remind Oral Supplement Thursday:

Remind Oral Supplement Friday:

Remind Oral Supplement Saturday:

Remind Oral Supplement Client Initials:

Feeding Assist

Feeding Assist Sunday:

Feeding Assist Monday:

Feeding Assist Tuesday:

Feeding Assist Wednesday:

Feeding Assist Thursday:

Feeding Assist Friday:

Feeding Assist Saturday:

Feeding Assist Client Initials:

Force Fluids / Intake

Force Fluids Sunday:

Force Fluids Monday:

Force Fluids Tuesday:

Force Fluids Wednesday:

Force Fluids Thursday:

Force Fluids Friday:

Force Fluids Saturday:

Force Fluids Client Initials:

ELIMINATION

Assist to Toilet/ BSC

Assist to Toilet Sunday:

Assist to Toilet Monday:

Assist to Toilet Tuesday:

Assist to Toilet Wednesday:

Assist to Toilet Thursday:

Assist to Toilet Friday:

Assist to Toilet Saturday:

Assist to Toilet Client Initials:

Empty Catheter/Ostomy

Empty Catheter Sunday:

Empty Catheter Monday:

Empty Catheter Tuesday:

Empty Catheter Wednesday:

Empty Catheter Thursday:

Empty Catheter Friday:

Empty Catheter Saturday:

Empty Catheter Client Initials:

Incontinence Care

Incontinence Care Sunday:

Incontinence Care Monday:

Incontinence Care Tuesday:

Incontinence Care Wednesday:

Incontinence Care Thursday:

Incontinence Care Friday:

Incontinence Care Saturday:

Incontinence Care Client Initials:

ENVIRONMENTAL

Cleaning – Kit,BR,LR,BA

Cleaning Sunday:

Cleaning Monday:

Cleaning Tuesday:

Cleaning Wednesday:

Cleaning Thursday:

Cleaning Friday:

Cleaning Saturday:

Cleaning Client Initials:

Make Bed/Bed Linen Change

Bed Linen Change Sunday:

Bed Linen Change Monday:

Bed Linen Change Tuesday:

Bed Linen Change Wednesday:

Bed Linen Change Thursday:

Bed Linen Change Friday:

Bed Linen Change Saturday:

Bed Linen Change Client Initials:

Laundry

Laundry Sunday:

Laundry Monday:

Laundry Tuesday:

Laundry Wednesday:

Laundry Thursday:

Laundry Friday:

Laundry Saturday:

Laundry Client Initials:

Garbage Removal

Garbage Removal Sunday:

Garbage Removal Monday:

Garbage Removal Tuesday:

Garbage Removal Wednesday:

Garbage Removal Thursday:

Garbage Removal Friday:

Garbage Removal Saturday:

Garbage Removal Client Initials:

MISCELLANEOUS

Medication Reminder

Medication Reminder Sunday:

Medication Reminder Monday:

Medication Reminder Tuesday:

Medication Reminder Wednesday:

Medication Reminder Thursday:

Medication Reminder Friday:

Medication Reminder Saturday:

Medication Reminder Client Initials:

Pick up Prescription

Pick up Prescription Monday:

Pick up Prescription Tuesday:

Pick up Prescription Wednesday:

Pick up Prescription Thursday:

Pick up Prescription Friday:

Pick up Prescription Saturday:

Pick up Prescription Client Initials:

ERRANDS

To Doctor App/Assist

To Doctor App Sunday:

To Doctor App Monday:

To Doctor App Tuesday:

To Doctor App Wednesday:

To Doctor App Thursday:

To Doctor App Friday:

To Doctor App Saturday:

To Doctor App Client Initials:

To Grocery Store/Assist

To Grocery Store Sunday:

To Grocery Store Monday:

To Grocery Store Tuesday:

To Grocery Store Wednesday:

To Grocery Store Thursday:

To Grocery Store Friday:

To Grocery Store Saturday:

To Grocery Store Client Initials:

Personal Care Time

Personal Care Time Sunday:

Personal Care Time Monday:

Personal Care Time Tuesday:

Personal Care Time Wednesday:

Personal Care Time Thursday:

Personal Care Time Friday:

Personal Care Time Saturday:

Personal Care Time Client Initials:

Homemaking Time

Homemaking Time Sunday:

Homemaking Time Monday:

Homemaking Time Tuesday:

Homemaking Time Wednesday:

Homemaking Time Thursday:

Homemaking Time Friday:

Homemaking Time Saturday:

Homemaking Time Client Initials:

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[field id="sun_date"]

[field id="mon_date"]

[field id="tue_date"]

[field id="wed_date"]

[field id="thu_date"]

[field id="fri_date"]

[field id="sat_date"]

[field id="sun_in"]

[field id="mon_in"]

[field id="tue_in"]

[field id="wed_in"]

[field id="thu_in"]

[field id="fri_in"]

[field id="sat_in"]

[field id="sun_out"]

[field id="mon_out"]

[field id="tue_out"]

[field id="wed_out"]

[field id="thu_out"]

[field id="fri_out"]

[field id="sat_out"]

[field id="sun_total"]

[field id="mon_total"]

[field id="tue_total"]

[field id="wed_total"]

[field id="thu_total"]

[field id="fri_total"]

[field id="sat_total"]

[field id="employee_total_weekly"]

[field id="sun_bath"]

[field id="mon_bath"]

[field id="tue_bath"]

[field id="wed_bath"]

[field id="thu_bath"]

[field id="fri_bath"]

[field id="sat_bath"]

[field id="sun_perinea"]

[field id="mon_perinea"]

[field id="tue_perinea"]

[field id="wed_perinea"]

[field id="thu_perinea"]

[field id="fri_perinea"]

[field id="sat_perinea"]

[field id="sun_shampoo"]

[field id="mon_shampoo"]

[field id="tue_shampoo"]

[field id="wed_shampoo"]

[field id="thu_shampoo"]

[field id="fri_shampoo"]

[field id="sat_shampoo"]

[field id="sun_shave"]

[field id="mon_shave"]

[field id="tue_shave"]

[field id="wed_shave"]

[field id="thu_shave"]

[field id="fri_shave"]

[field id="sat_shave"]

[field id="sun_skincare"]

[field id="mon_skincare"]

[field id="tue_skincare"]

[field id="wed_skincare"]

[field id="thu_skincare"]

[field id="fri_skincare"]

[field id="sat_skincare"]

[field id="sun_nailcare"]

[field id="mon_nailcare"]

[field id="tue_nailcare"]

[field id="wed_nailcare"]

[field id="thu_nailcare"]

[field id="fri_nailcare"]

[field id="sat_nailcare"]

[field id="sun_dressing"]

[field id="mon_dressing"]

[field id="tue_dressing"]

[field id="wed_dressing"]

[field id="thu_dressing"]

[field id="fri_dressing"]

[field id="sat_dressing"]

[field id="sun_elastic"]

[field id="mon_elastic"]

[field id="tue_elastic"]

[field id="wed_elastic"]

[field id="thu_elastic"]

[field id="fri_elastic"]

[field id="sat_elastic"]

[field id="sun_footcare"]

[field id="mon_footcare"]

[field id="tue_footcare"]

[field id="wed_footcare"]

[field id="thu_footcare"]

[field id="fri_footcare"]

[field id="sat_footcare"]

[field id="sun_oralcare"]

[field id="mon_oralcare"]

[field id="tue_oralcare"]

[field id="wed_oralcare"]

[field id="thu_oralcare"]

[field id="fri_oralcare"]

[field id="sat_oralcare"]

[field id="sun_ambulation"]

[field id="mon_ambulation"]

[field id="tue_ambulation"]

[field id="wed_ambulation"]

[field id="thu_ambulation"]

[field id="fri_ambulation"]

[field id="sat_ambulation"]

[field id="sun_transfer"]

[field id="mon_transfer"]

[field id="tue_transfer"]

[field id="wed_transfer"]

[field id="thu_transfer"]

[field id="fri_transfer"]

[field id="sat_transfer"]

[field id="sun_exercise"]

[field id="mon_exercise"]

[field id="tue_exercise"]

[field id="wed_exercise"]

[field id="thu_exercise"]

[field id="fri_exercise"]

[field id="sat_exercise"]

[field id="sun_mealplanning"]

[field id="mon_mealplanning"]

[field id="tue_mealplanning"]

[field id="wed_mealplanning"]

[field id="thu_mealplanning"]

[field id="fri_mealplanning"]

[field id="sat_mealplanning"]

[field id="sun_mealprep"]

[field id="mon_mealprep"]

[field id="tue_mealprep"]

[field id="wed_mealprep"]

[field id="thu_mealprep"]

[field id="fri_mealprep"]

[field id="sat_mealprep"]

[field id="sun_remind"]

[field id="mon_remind"]

[field id="tue_remind"]

[field id="wed_remind"]

[field id="thu_remind"]

[field id="fri_remind"]

[field id="sat_remind"]

[field id="sun_feeding"]

[field id="mon_feeding"]

[field id="tue_feeding"]

[field id="wed_feeding"]

[field id="thu_feeding"]

[field id="fri_feeding"]

[field id="sat_feeding"]

[field id="sun_force"]

[field id="mon_force"]

[field id="tue_force"]

[field id="wed_force"]

[field id="thu_force"]

[field id="fri_force"]

[field id="sat_force"]

[field id="sun_assisttoilet"]

[field id="mon_assisttoilet"]

[field id="tue_assisttoilet"]

[field id="wed_assisttoilet"]

[field id="thu_assisttoilet"]

[field id="fri_assisttoilet"]

[field id="sat_assisttoilet"]

[field id="sun_empty"]

[field id="mon_empty"]

[field id="tue_empty"]

[field id="wed_empty"]

[field id="thu_empty"]

[field id="fri_empty"]

[field id="sat_empty"]

[field id="sun_incontinence"]

[field id="mon_incontinence"]

[field id="tue_incontinence"]

[field id="wed_incontinence"]

[field id="thu_incontinence"]

[field id="fri_incontinence"]

[field id="sat_incontinence"]

[field id="sun_cleaning"]

[field id="mon_cleaning"]

[field id="tue_cleaning"]

[field id="wed_cleaning"]

[field id="thu_cleaning"]

[field id="fri_cleaning"]

[field id="sat_cleaning"]

[field id="sun_makebed"]

[field id="mon_makebed"]

[field id="tue_makebed"]

[field id="wed_makebed"]

[field id="thu_makebed"]

[field id="fri_makebed"]

[field id="sat_makebed"]

[field id="sun_laundry"]

[field id="mon_laundry"]

[field id="tue_laundry"]

[field id="wed_laundry"]

[field id="thu_laundry"]

[field id="fri_laundry"]

[field id="sat_laundry"]

[field id="sun_garbage"]

[field id="mon_garbage"]

[field id="tue_garbage"]

[field id="wed_garbage"]

[field id="thu_garbage"]

[field id="fri_garbage"]

[field id="sat_garbage"]

[field id="sun_medication"]

[field id="mon_medication"]

[field id="tue_medication"]

[field id="wed_medication"]

[field id="thu_medication"]

[field id="fri_medication"]

[field id="sat_medication"]

[field id="sun_pickup"]

[field id="mon_pickup"]

[field id="tue_pickup"]

[field id="wed_pickup"]

[field id="thu_pickup"]

[field id="fri_pickup"]

[field id="sat_pickup"]

[field id="sun_doctorapp"]

[field id="mon_doctorapp"]

[field id="tue_doctorapp"]

[field id="wed_doctorapp"]

[field id="thu_doctorapp"]

[field id="fri_doctorapp"]

[field id="sat_doctorapp"]

[field id="sun_grocery"]

[field id="mon_grocery"]

[field id="tue_grocery"]

[field id="wed_grocery"]

[field id="thu_grocery"]

[field id="fri_grocery"]

[field id="sat_grocery"]

[field id="sun_personalcare"]

[field id="mon_personalcare"]

[field id="tue_personalcare"]

[field id="wed_personalcare"]

[field id="thu_personalcare"]

[field id="fri_personalcare"]

[field id="sat_personalcare"]

[field id="sun_homemaking"]

[field id="mon_homemaking"]

[field id="tue_homemaking"]

[field id="wed_homemaking"]

[field id="thu_homemaking"]

[field id="fri_homemaking"]

[field id="sat_homemaking"]

HHA Activity Sheet

Site Links

Our Services

HHA Activity Sheet

Site Links

Our Services

Let's Talk

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