Time Log

Community and Home-Based Supports

Time Log/Progress Notes

Individual's Name:*

First Name

Last Name

Support Provider's Name:*

First Name

Last Name

Date of Visit*

(Total) Start Time:*

(Total) End Time:*

Detailed Progress Notes

ISP Outcome:*

Service Strategies (Check all that apply):*

Assistance with Activities of Daily Living (such as getting dressed, eating, personal hygiene, etc.) Assistance with Increasing Community Participation (such as daily errands, attending events, going to a restaurant, purchasing items, travel training, etc.) Assistance with Increasing Independence (such as helping the individual learn to do laundry, cook, clean, dress, grocery shop, pay for items, etc.) Assistance with On-The-Job Support (such as safety awareness, using the restroom, attending to task, lunch/breaks, etc.) Assistance with Learning Activities (such as basic tutoring – math, reading, writing; support in attending a class, etc.)

**Please include the start and end time of each activity

(First Activity) Start Time:*

(First Activity) End Time: *

Individualized Activity*

Describe how the activities will help the individual reach the above outcome:*

(Second Activity) Start Time:

(Second Activity) End Time:

Individualized Activity

Describe how the activities will help the individual reach the above outcome:

(Third Activity) Start Time:

(Third Activity) End Time:

Individualized Activity

Describe how the activities will help the individual reach the above outcome:

Would you like to add a fourth activity?

Yes No

(Fourth Activity) Start Time:

(Fourth Activity) End Time:

Individualized Activity

Describe how the activities will help the individual reach the above outcome:

Would you like to add a fifth activity?

Yes No

(Fifth Activity) Start Time:

(Fifth Activity) End Time:

Individualized Activity

Describe how the activities will help the individual reach the above outcome:

Submitted by:*

Email Address:*

Guardian Email Address*