DEPARTMENT OF HEALTH SERVICES
Division of Quality Assurance F-62158 (Rev. 07/08)
STATE OF WISCONSIN
LIVING UNIT DIRECT CARE STAFFING REPORT NIGHT SHIFT
Name Facility NIGHT Shift Usual Hours
Name Living Unit
Review Dates From
To
INSTRUCTIONS List the name of direct care staff (do not include nurses or other professionals) who worked on the living unit during the time period specified above. Indicate the number of hours worked for each day, i.e., 8, 7.5, 6. Total the columns at the completion of each page and if more than one page is required for a shift, carry the subtotal forward, and provide a total on completion. Express fractions as decimals rounded to the each quarter, i.e., .25, .5 or .75. Refer to DQA form F-62155I for more information.
Name Direct Care Staff Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat
Subtotal / Total