Training Checklist for Substitute Care Givers
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| Person
Receiving Care _________________________ Date ____/____/__ |
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| Substitute Care Giver has Information on: | ||
| Emergency Phone Numbers including police and fire | ||
| Where I can be contacted | ||
| People to contact if I can't be | ||
| Doctor for the person receiving care | ||
| Nearest Hospital | ||
| Medical Conditions | ||
| Medications | ||
| Allergies | ||
| Behaviors and Behavior Supports | ||
| Special Care Requirements | ||
| Household Rules | ||
| Special things that the person wants to do during respite care time | ||
| Important schedules--appointments, bus pickup times, etc. | ||
| Important Updates_______________________________________________________ | ||
| ________________________________________________________________________ | ||
| ________________________________________________________________________ | ||
| Other | ||
| Other | ||
Training
Checklist
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| Family Care Book for | ||
| Date | Names of family members | Birth dates |
Important Contacts |
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| Family/Friend/Neighbor | Name | Phone Number | Address | ||
| Family/Friend/Neighbor | |||||
| Doctor/Clinic | |||||
| Doctor/Clinic | |||||
| Dentist | |||||
| Hospital | |||||
| Pharmacy | |||||
| Other | |||||
Important things to know about _______________________ |
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| Page 1 | |||||
| His/Her Likes |
| His/Her Dislikes |
| Schedule and Special Routines |
| Meals and feeding (foods that can't/won't be eaten, preferences, meal times) |
Medications |
| 1. | Medication | Purpose | ||
| Dosage | How Given | |||
| cc/teaspoon/Tablet | Possible/Actual Side Effects |
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| Exact Times Medication Should be Given |
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| 2. | Medication | Purpose | ||
| Dosage | How Given | |||
| cc/teaspoon/Tablet | Possible/Actual Side Effects |
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| Exact Times Medication Should be Given |
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| 3. | Medication | Purpose | ||
| Dosage | How Given | |||
| cc/teaspoon/Tablet | Possible/Actual Side Effects |
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| Exact Times Medication Should be Given |
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| 4. | Medication | Purpose | ||
| Dosage | How Given | |||
| cc/teaspoon/Tablet | Side Effects | |||
| Exact Times Medication Should be Given |
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Medications List |
"At
a Glance" Information |
| I can be reached at:__________________________________________________ _________________________________________________________________________ |
| If I can't be reached,
call: ________________________________________________ ________________________________________________ |
| Doctor's name and number
is: _________________________________________________ |
| Health Insurance Information
is located at: _________________________________________________ _________________________________________________ |
| The nearest hospital is: _________________________________________________ |
| The hospital's address and phone number is: _________________________________________________ |
| Other important information _________________________________________________ |
| _________________________________________________ |
| _________________________________________________ |
"At
a Glance Information" |