Forms & Records

The following are sample forms that providers can use for documentation.  If you have any questions, please contact Marci Slifko.

Service Documentation Templates

  • HPC Documentation Template - Word  l  PDF 
  • HPC Documentation Template with 2 Outcomes - Word  l  PDF
  • SAMPLE HPC Documentation Template 2 - Word  
  • Transportation Doc Sheet Template - Word  l  PDF
  • Sample Documentation Form Day Hab 2020 - PDF
  • Shared Living Documentation Template with 2 Outcomes - Word  l  PDF

MUI Reporting Documents - Protocol "C"

  • Unapproved Behavioral Support Form - PDF
  • Law Enforcement Form - PDF
  • Unanticipated Hospitalization Form - PDF

Transportation

  • Vehicle Maintenance Checklist - PDF

Employment Waiver

Provider Health and Safety Pledge

  • Health and Safety Pledge for IPs - XLSX
  • Vendor Application - PDF
  • OPERS PEDACKN Letter - PDF
  • Health and Safety Pledge Invoice Template - PDF
  • DSP Safety Guidelines and Agreements - PDF