Activity sheets must reach our office by 5pm every Wednesday for processing.

Clients Name (First, Last)
Home Health Aides Name:

	SUN	MON	TUE	WED	THU	FRI	SAT
DATE
MEAL BREAKS* TOTAL 3 HOURS/DAY
PERSONAL BREAKS* TOTAL 3 HOURS/DAY
NIGHT BREAKS* TOTAL 8 HOURS/DAY
TOTAL # OF HOURS WORKED EACH DAY	10-HRS	10-HRS	10-HRS	10-HRS	10-HRS	10-HRS	10-HRS

TOTAL HOURS WORKED PER WEEK (70 Hours) ***

*All Meal & Personal Breaks must last a minimum of 30-minutes each
** All Night-Time Breaks are a maximum of eight (8) hours interrupted or continuous sleep per night and a minimum of (5) hours of continuous sleep time per night.
***All Live-In “Active Work Time” over 70 hours is deemed “Overtime” under Federal Law and such Overtime will be invoiced at $45.00 per hour to and paid by our Client/Responsible party.

CLIENT SIGNATURE I certify that Peace & Joy’s Employee worked the above time shown above.	DATE
EMPLOYEE SIGNATURE I certify under penalty of perjury that I worked and took my breaks as stated above.	DATE
Received by Peace & Joy:	DATE

DAILY ACTIVITIES	SUN	MON	TUE	WED	THUR	FRI	SAT
1. POSITIONING A.Up as tolerated B.T&P every 2 hours	A B	A B	A B	A B	A B	A B	A B
2. BATHING A.Shower B.Sponge C.Bed Bath D.Chair	A B C D	A B C D	A B C D	A B C D	A B C D	A B C D	A B C D
3. HAIR CARE A.Shampoo B.Shower C.Bed D.Groom	A B C D	A B C D	A B C D	A B C D	A B C D	A B C D	A B C D
4. MOUTH CARE A.Denture B.Brush Teeth C.Rinse	A B C	A B C	A B C	A B C	A B C	A B C	A B C
5. SKIN CARE A.Lotion B.Nail care C.Shave	A B C	A B C	A B C	A B C	A B C	A B C	A B C
6. DRESSING A.Assist B.Complete C.Day D.Evening	A B C D	A B C D	A B C D	A B C D	A B C D	A B C D	A B C D
7. AMBULATION A.Walking B.Cane C.Walker D.Wheelchair	A B C D	A B C D	A B C D	A B C D	A B C D	A B C D	A B C D
8. ROM A.Active B.Passive C.Elevate	A B C	A B C	A B C	A B C	A B C	A B C	A B C
9. TRANSFER A.Bed to chair B.Hoyer Lift C.Pivot	A B C	A B C	A B C	A B C	A B C	A B C	A B C
10. DIET A.Fluids B.Encourage C.Restrict D.Regular E.Low Salt F.Low Fat G.Diabetic H.Other	A B C D E F G H	A B C D E F G H	A B C D E F G H	A B C D E F G H	A B C D E F G H	A B C D E F G H	A B C D E F G H
11. MEAL PREP A.Breakfast B.Lunch C.Dinner D.Feed E.Cut F.Supervise	A B C D E F	A B C D E F	A B C D E F	A B C D E F	A B C D E F	A B C D E F	A B C D E F
12. MEDICATIONS A.Remind Medications	A	A	A	A	A	A	A
13. ELIMINATION A.Toilet B.Commode C.Bed Pan D.Measure E.Catheter F.Depends/pads	A B C D E F	A B C D E F	A B C D E F	A B C D E F	A B C D E F	A B C D E F	A B C D E F
14. LIGHT HOUSEKEEPING A.Bedroom B.Bathroom C.Kitchen D.Make Bed Linen Change E.Laundry	A B C D E	A B C D E	A B C D E	A B C D E	A B C D E	A B C D E	A B C D E
15. SHOPPING
16. PAIN MANAGEMENT (0-10)
16. OTHER DUTIES

ANY CHANGE IN PATIENT STATUS, CONTACT RN IMMEDIATELY.

Submit Time Sheet