Form 3683, Day Activity and Health Services Daily Attendance Record
Effective Date: 10/2004
- To provide a daily record of client attendance.
- To be used as a resource document for fiscal, auditing, and service control (not all inclusive).
When to Prepare
Complete Form 3683 weekly, recording client attendance daily.
Number of Copies
Complete an original only, in ink.
Retain Form 3683 according to the terms of the contract.
This form must be photocopied from the Community Care Provider Forms Manual.
Detailed Instructions (complete form in ink)
Name of Facility — Enter the name of the facility.
Vendor No. — Enter the four-digit vendor number.
Page ___ of ___ — Enter the page number and number of pages, consecutively.
Client Name — Enter the client’s complete name.
Date — For each day of the week specified on the form, enter the month, day, and year that corresponds to the day.
Time — In — Enter the time the client begins receiving care from the facility. This should be the time the client
- walks into the center (walk-ins);
- is picked up at home; or
- is picked up unescorted at a facility approved to provide therapy.
If transportation is provided, use the time the client is picked up (from Form 3682, Day Activity and Health Services Daily Transportation Record) as the time-in on this form.
Time — Out — Enter the time the client stops receiving care from the facility. This should be the time the client
- leaves the facility;
- is dropped off at home; or
- is dropped off unescorted at a facility approved to provide therapy.
If transportation is provided, use the time the client is dropped off (from Form 3682 as the time-out on this form.
Time In/Out cannot be preprinted on the form.
- If transportation is provided to a facility approved to provide therapy, do not log out the client if the client was escorted.
- Since a facility does not have to provide transportation to non-therapy services, such as routine medical exams, podiatry services, eye exams, etc., the client must be logged out from the time the client leaves the facility, regardless of whether the client is escorted or not.
Total Units of Service — Enter the weekly total units for each client using all of the time-in and time-out entries for each day.
Signature Facility Representative — The last page of the reporting period must be signed and dated on or after the last day of service. The date must include the month, day, and year. If you use a signature stamp, the stamped signature must be initialed.
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.