Form 4119-2026

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4.8 out of 5

51 votes

The document is a Respite Service Delivery Log form from the Texas Department of Aging and Disability Services, designed for tracking the services provided to individuals receiving Home and Community-based Services or Texas Home Living Services. It includes sections for documenting daily activities, staff initials, incidents, and employee signatures over a week-long period.

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Click ‘Get Form’ to open the form 4119 in the editor.
Begin by entering the individual’s name in the designated fields for First and Last names.
Select the appropriate service type by checking either 'RSS' or 'SL'.
Fill in the Place of Service(s) and Local Case No./Case ID as required.
Indicate the week of service by entering the date range in 'Week Of'.
At the end of your shift, mark (initial or check) all completed items under each day of the week, ensuring to document any incidents or special events at the bottom of the form.
For individuals receiving SL services, remember that night initials or check marks are not necessary.
Complete staff initials and signatures where indicated, along with any comments or additional notes.

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Versions	Form popularity	Fillable & printable
2012	4.8 Satisfied (51 Votes)

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