Personal Care Service Time Study (Use 10-day time span) Addendum M - EXAMPLE
Student Name: Susie Girl School: XYZX, ISD 0123 Year: 13-14
Date of Birth: 00-00-0000 Case Manager: Mrs. Goodie
Time Span of Sampling: September 1 – 5, 2013 September 8-13, 2013
Assistance Needed:
Eating: See PCA Training Documentation outlining process/procedures for assisting student with eating including meals/snacks.
______
______
Total: 30 avg.minutes/day
SS / SS / MJ / SS / SS / MJ / SS / SS / MJ / SS / SS / MJ / SS / SS / MJ9 / 8 / 11 / 11 / 9 / 8 / 8 / 8 / 13 / 10 / 11 / 9 / 10 / 10 / 10
Monday | Tuesday | Wednesday | Thursday | Friday
Initials: 145 min/5 days=29/day
Time spent:
SS / SS / MJ / SS / SS / MJ / SS / SS / MJ / SS / SS / MJ / SS / SS / MJ11 / 8 / 9 / 12 / 10 / 8 / 10 / 10 / 10 / 9 / 9 / 13 / 10 / 11 / 9
Monday | Tuesday | Wednesday | Thursday | Friday 151 min/5 days=30/day
Initials: 151/15
Time spent:
Toileting: ______
______
Total:______avg.minutes/day Monday | Tuesday | Wednesday | Thursday | Friday
Initials:
Time spent:
Monday | Tuesday | Wednesday | Thursday | Friday
Initials:
Time spent:
Grooming: ______
______
Total:______avg.minutes/day
Monday | Tuesday | Wednesday | Thursday | Friday
Initials:
Time spent:
Monday | Tuesday | Wednesday | Thursday | Friday
Initials:
Time spent:
Page 2
Dressing: See PCA Training documentation for description of process/procedures for assisting student with his dressing needs.
______
______
Total:_30__avg.minutes/day
SS / SS / MJ / SS / SS / MJ / SS / SS / MJ / SS / SS / MJ / SS / SS / MJ9 / 8 / 11 / 11 / 9 / 8 / 8 / 8 / 13 / 10 / 11 / 9 / 10 / 10 / 10
Monday | Tuesday | Wednesday | Thursday | Friday
Initials: 145 min/5 days=29
Time spent:
Initials:
SS / SS / MJ / SS / SS / MJ / SS / SS / MJ / SS / SS / MJ / SS / SS / MJ11 / 8 / 9 / 12 / 10 / 8 / 10 / 10 / 10 / 9 / 9 / 13 / 10 / 11 / 9
Monday | Tuesday | Wednesday | Thursday | Friday 151 min/5 days=30
Initials: 151/15
Time spent:
Transfers: ______
______
Total:______avg.minutes/day
Monday | Tuesday | Wednesday | Thursday | Friday
Initials:
Time spent:
Monday | Tuesday | Wednesday | Thursday | Friday
Initials:
Time spent:
Positioning: ______
______
Total:______avg.minutes/day
Monday | Tuesday | Wednesday | Thursday | Friday
Initials:
Time spent:
Monday | Tuesday | Wednesday | Thursday | Friday
Initials:
Time spent:
Mobility: ______
______
______
Total:______avg.minutes/day
Monday | Tuesday | Wednesday | Thursday | Friday
Initials:
Time spent:
Monday | Tuesday | Wednesday | Thursday | Friday
Initials:
Time spent:
Page 3
Prosthotics: ______
Orthotics ______
______
Total:______avg.minutes/day
Monday | Tuesday | Wednesday | Thursday | Friday
Initials:
Time spent:
Monday | Tuesday | Wednesday | Thursday | Friday
Initials:
Time spent:
Behavior: (Redirection/intervention for Level 1 Behaviors or behaviors as qualifies:
See PCA Training Documentation and ITP for process/procedures for assisting student with behavior issues.
Total:__ 200 avg.minutes/day
See new data collection sheet for Time Study for Level 1 Behaviors.
Health Related functions (through hands-on assistance, supervision and cueing) provided by a paraprofessional under the supervision and direction of a qualified professional-e.g. range of motion and passive exercise, assist with self-administered medications. ______
______
Total:______avg.minutes/day
Monday | Tuesday | Wednesday | Thursday | Friday
Initials:
Time spent:
Monday | Tuesday | Wednesday | Thursday | Friday
Initials:
Time spent:
Total average minutes per day of personal care = ___260 min/day
“It is a federal crime to provide false information on personal care service billings for medical assistance payment.”
Provider Name: Susan Smith Intials: SS
Provider Name: Mary Johnson Intials: MJ
Provider Name: Alias Amy Intials: AA