VDC Employee Log – Aging & Disability Resource Center

Instructions

Effective 10/1/20, the Veteran or their designated Authorized Representative and each Employee are required to complete this log on a monthly basis. The Veteran or Authorized Representative is required to submit a log for EACH employee, who worked during the month within 7 business days after the last day of the month. Failure to comply could result in suspension or termination of services. Please note that services through the VDC program focus on Activities of Daily Living (ADL)/personal care services. The amount of time spent on chore services should be limited.

Acknowledgement*

I have read and understood these Instructions.

Veteran Information

First Name*

Last Name*

Employee Information

First Name*

Last Name*

Service Dates

Month/Year of Services*

I. To be completed by the Employee

Did you help the Veteran with any of the below tasks? (check all that apply):

Services Provided*

OTHER: Please explain*

SPECIAL TREATMENTS: Please explain*

*Special Treatments include the following: Tube Feeding, IV Fluids, IV Medications, Blood Transfusions, Drainage Tubes, Symptom Control for Terminally Ill, Isolation Precautions, Hyperalimentation/Hickman Catheter, Oxygen/Respiratory Therapy/Suctioning, Ostomy/Catheter Care, Wound Care/Decubiti, and Skin Care.

II. To be completed by the Veteran/Authorized Representative

Have there been any changes in the Veteran’s health/functional ability over this period?*

Yes

No

Please Explain*

Was the Veteran hospitalized during this period?*

Yes

No

Please provide dates of hospitalization*

Please provide dates of hospitalization (type in N/A if not applicable):*

Are you satisfied with your employee’s performance?*

Yes

No

Does the employee follow the care plan established (if any) or assigned tasks?*

Yes

No

Does the employee require additional training to meet the needs of the Veteran?*

Yes

No

Area(s) of Concern/Comments (if any):

Confirmation of Services and Supports

By initialing this monthly employee log, I am confirming that the services and supports provided by my employee are true and correct. Please type in your initials below:

Veteran/Authorized Representative Initials*

Finish Options

Click 'Submit' to send form to the Executive Office on Aging.

Email

This field is for validation purposes and should be left unchanged.