Employee Flow Sheet

Employee & Client Information
Employee Name*
First Last
Email*
Client First Name*
Client Last Name*
Office Location*
- Grand Rapids
- Saginaw
- St. Louis
Employee Clock
Time In*

: HH

MM
Time Out*

: HH

MM
Employee Time Worked*

: HH

MM
Today's Date*
Date Format: MM slash DD slash YYYY
Actual Minutes Worked
Actual Hours Worked
Personal Hygiene
Tasks Completed*
HHA/CNA completed HHA/CNA Assisted Completed by Client Completed by Family Refused Not Applicable
Tub Bath
Shower
Sponge Bath
Peri Care
Shampoo
Hair Care
Skin Care
Oral Hygiene
Shave
Dressing
Tasks Completed*
HHA/CNA completed HHA/CNA Assisted Completed by Client Completed by Family Refused Not Applicable
Upper
Lower
Movement
Tasks Completed*
HHA/CNA completed HHA/CNA Assisted Completed by Client Completed by Family Refused Not Applicable
Walk
Transfer
Reposition
Exercise Prog
Housekeeping
Tasks Completed*
HHA/CNA completed HHA/CNA Assisted Completed by Client Completed by Family Refused Not Applicable
Dust
Vacuum
Clean Bathroom
Clean Kitchen
Clean Bedroom
Wash Clothes
Wash Linens
Wash Dishes
Meal Prep
Tasks Completed*
HHA/CNA completed HHA/CNA Assisted Completed by Client Completed by Family Refused Not Applicable
Breakfast
Lunch
Supper
Snacks
Appetite*
- Good
- Fair
- Poor
Medication*
HHA/CENA's are not licensed to administer or "set up" any prescription or non-prescription medication.
- Yes
- No
Precautions Taken*
Yes No
Equipment used properly:
Walkways clear and well lit:
Universal Precautions followed:
Daily Comments*
Signatures
Employee Signature*
Client Signature*
Name
This field is for validation purposes and should be left unchanged.

	HHA/CNA completed	HHA/CNA Assisted	Completed by Client	Completed by Family	Refused	Not Applicable
Tub Bath
Shower
Sponge Bath
Peri Care
Shampoo
Hair Care
Skin Care
Oral Hygiene
Shave

	HHA/CNA completed	HHA/CNA Assisted	Completed by Client	Completed by Family	Refused	Not Applicable
Upper
Lower

	HHA/CNA completed	HHA/CNA Assisted	Completed by Client	Completed by Family	Refused	Not Applicable
Walk
Transfer
Reposition
Exercise Prog

	HHA/CNA completed	HHA/CNA Assisted	Completed by Client	Completed by Family	Refused	Not Applicable
Dust
Vacuum
Clean Bathroom
Clean Kitchen
Clean Bedroom
Wash Clothes
Wash Linens
Wash Dishes

Employee & Client Information

Employee Clock

Personal Hygiene

Dressing

Movement

Housekeeping

Meal Prep

Signatures

Primary Home Care covers the following counties: Arenac, Bay, Clare, Gladwin, Gratiot, Isabella, Kent, Midland and Saginaw Counties.