Direct Support Professional Checklist Form
Complete this checklist during or after your shift to document service delivery, tasks performed, observations, and any incidents or follow-up needs.
Date of Shift
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Shift Start Time
*
Hour Minutes
AM
PM
AM/PM Option
Direct Support Professional Name
*
First Name
Last Name
Client Initials or ID
*
Support Tasks Completed (select all that apply)
*
Personal care
Meal preparation
Medication assistance
Mobility support
Household tasks
Community integration
Other
Were there any incidents during the shift?
*
No incidents
Yes, incident(s) occurred
If incidents occurred, please describe
Observations or Notes
Follow-up Needed?
*
No follow-up needed
Yes, follow-up required
If follow-up is required, describe the need
Submit Checklist
Should be Empty: