Form 4119 dads-2026

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The document is a service delivery log form from the Texas Department of Aging and Disability Services, specifically for Home and Community-based Services/Texas Home Living Services. It is used to record the activities and support provided to individuals receiving Residential Support Services (RSS) or Supervised Living (SL) during a specified week. The form includes sections for documenting daily living activities, skill development, and any incidents or special events that occur.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the individual’s name in the 'Individual Name' field, ensuring you include both first and last names.
Select the appropriate place of service and enter the Local Case Number or Case ID for accurate tracking.
Indicate the week of service by filling in the corresponding dates for each day from Sunday to Saturday.
Check either 'RSS' or 'SL' based on the services provided. At the end of your shift, mark all completed items under Activities of Daily Living and other relevant sections.
If there were any incidents or special events during your shift, document them at the bottom of the form.
Ensure that staff initials are recorded where necessary, along with comments and signatures for verification.

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