| Document Date |
{hm_date} |
| Original Work Location |
{hm_location} |
| Temporary Work Location |
{ReportLabel2} |
| Coordinator |
{hm_coordinator} |
| Individuals |
{hm_individuals} |
| In the Home..... |
| 1. My discussed responsibilities for the upcoming week are: |
{hm_h_my_discussion} |
| 2. On goings in the household that I am satisfied with (Ex.Housemates, Food Menu, Environment, Procedure etc.) |
{hm_h_ongoing1} |
| 3. On goings in the household in which I would like to see changes made: |
{hm_h_ongoing2} |
| 4. My accomplishments for the past week: |
{hm_h_my_accomplishments} |
| 5. Things I need: |
{hm_h_things} |
| At Work/School..... |
| 1. What I did at SChool/Work this week: |
{hm_w_what1} |
| 2. Things in School/Work that I am satisfied with (ex.Transportation, Co-Workers/Classmates, Curriculum,/Tasks, Environment, Supervisors etc.): |
{hm_w_things1} |
| 3. Things in School/Work that I have concerns about: |
{hm_w_things2} |
| In the Community..... |
| 1. My Interest and Preferences are: |
{hm_c_my_interest} |
| 2. Activities I would like to participate in thsi upcoming week/weekend: |
{hm_c_activities} |
| 3. What Activities did I participate in this past week: |
{hm_c_what_activities} |
| Additional Comments (To be filled out by Staff if needed): |
{hm_addl_comments} |
| Follow up Action (To be filled out by Coordinator): |
{hm_follow_up} |
| Data Entered on: {ReportLabel1} |
| No records |
|