Form 3682, Day Activity and Health Services Daily Transportation Record
Effective Date: 10/2004
- To provide a daily record of individual transportation.
- To be used as a resource document for fiscal, auditing, and service control (not all inclusive).
When to Prepare
Complete Form 3682 daily for each driver that provides transportation to individuals.
Number of Copies
Complete an original only, in ink.
Retain Form 3682 according to the terms of the contract.
This form must be photocopied from the Community Care Provider Forms Manual.
(Complete form in ink.)
Name of Facility — Enter the name of the facility.
Vendor No. — Enter the four-digit vendor number.
Date — Enter the calendar month, day, and year of service.
Page ___ of ___ — Enter page number and number of pages, consecutively.
individual Name — Enter the individual’s complete name.
Time — Pick Up — Enter the time the individual is picked up at:
- home; or
- a facility approved to provide therapy as required in the individual’s plan of care, if the individual is unescorted.
Time — Drop Off — Enter the time the client is dropped off at:
- home; or
- a facility approved to provide therapy as required in the client’s plan of care, if the individual is unescorted.
Note: Transfer pick up and drop off times to Form 3683, Daily Attendance Record, as appropriate.
Signature — Driver — The driver must sign.
CORRECTIONS TO ENTRIES
To correct an error:
- line through the error,
- write the correct entry, and
- initial the correction.
Do not use liquid paper or correction fluid. Original entries, corrections, and initials must be legible.
Time In/Out cannot be preprinted on the form.