NEW LEAF: LIVING AND LEARNING TOGETHER INC.
FARM RESIDENCE: NIGHT CHECK LIST
OVERNIGHT AWAKE STAFF
DATE: ______NIGHT STAFF: ______
INSTRUCTIONS FOR NIGHT: ISSUED BY: ______
______
______
______
INSTRUCTIONS RE: RESIDENTS: ______
______
______
______
HOUSE CHECK AT 11:00 P.M.______
FORM SIGNED THAT ALL RESIDENTS ARE PRESENT…………………………...………...□
OUTSIDE DOORS-ALARMS SWITCHED ON:…………………………………….………….□
REMARKS: ______
______
______
PORTABLE MONITOR & TELEPHONE CHECKED & WORKING: …………………………………□
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ALL KEYS AND PAGERS ACCOUNTED FOR: ………………………………………………………………………………….□
TUESDAY & FRIDAY NIGHT: COLLECT ALL ELECTRIC RAZORS: CLEAN & REPLACE HEADS (WHEN NECESSARY)
SPECIAL CHECK:
STORE ROOM: CHECK FOR FIRE AND / OR WATER LEAKS □
ALL EXIT DOORS / LIGHTS, REPORT BURNT OUT LIGHTS □
FREEZER PLUGGED IN □
ALL TOILETS NOT RUNNING OR PLUGGED □
VISUALLY CHECK EVERY HOUR ALL THE BUILDINGS ON THE
FARM PROPERTY FOR ANY SIGNS OF FIRE (Smoke, Flames,…) BY LOOKING OUT OF THE WINDOWS □
TIMEPHONE IN COMMENTS
11:00 PM______
______
Visual Fire Check …………………………………………………....……..□
12:00______
______
Visual Fire Check …………………………………………..………….…...□
01:00______
______
Visual Fire Check …………………………………………………....……..□
02:00______
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Visual Fire Check …………………………………………….……...……..□
03:00______
______
Visual Fire Check ……………………………………………….………… □
04:00______
______
Visual Fire Check ………………………………………………………..... □
05:00______
______
Visual Fire Check………………………………………………………….. □
06:00______
______
Visual Fire Check………………………………………………………...... □
SPECIAL OBSERVATIONS DURING NIGHT: ______
______
______
______
MEDICATION (P.R.N.) ADMINISTERED:
RESIDENTDOSAGETIME
______
______
______
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SHIFT TRANSFERRED TO: ______SHIFT SUPERVISOR ______
TIME: ______
COMMENTS: (SHIFT SUPERVISOR): ______
______
______
______
*MUST BE FORWARDED TO RESIDENTIAL PROGRAM MANAGER’S ATTENTION AT THE END OF EACH SHIFT
SUPPLEMENTAL DUTIES FOR OVERNIGHT AWAKE STAFF
Clean stove top and range hood ______
Check interior of fridges…clean as required ______
Clean microwave oven… interior/exterior as required _____
Clean and disinfect kitchen counter tops and sinks ______
Cell phones; ______
Signature of staff: ______
Take out meat for next day’s meal as required______
Sweep and wash all floors______
Organize kitchen / pantry / pot cupboards as required______
Tidy all sitting rooms______
Empty all garbage containers______
Complete house laundry______
Make milk and juice for breakfast______
Set table for breakfast______
RESIDENT NEEDS
MichaelAssist with morning hygiene, including shaving
TonyAssist with morning hygiene, including shaving, brushing teeth, showering
EdmundAssist with morning hygiene, including shaving, brushing teeth, bath
RobAssist with all aspects of morning hygiene FARM RESIDENCE
OVERNIGHT AWAKE STAFF
TRANSFER OF ACCOUNTABILITY FOR PRESENCE OF RESIDENTS
I,______HAVE RECEIVED CONFIRMATION
NAME OF NIGHT AWAKE STAFF (PRINT)
FROM ______, THAT ALL RESIDENTS RESIDING AT THE FARM
NAME OF EVENING STAFF (PRINT)
RESIDENCE WERE PHYSICALLY ACCOUNTED FOR AT ______HRS. AFTER THE ALARMS ON
THE OUTSIDE DOORS WERE SWITCHED ON.
RESIDENTS ON PREMISES: RESIDENTS ABSENT:REASONS:
Antonio Burdo______
John Couto______
Edmund Demers______
Kyle Fisher______
Allen Freedman______
Robert J Hill ______
Mike Hretchka______
Edna Kohn______
Rose Kozak______
Brien O'Grady______
Sangeeta Parihar______
Lou Beth Edebiri______
Safe Bed______
DATE:______20_____TIME:___2000 hrs – 2200 hrs ______
DAY MONTH
SIGNATURE: ______SIGNATURE: ______
EVENING STAFF NIGHT STAFF
Farm Overnight Awake Checklist
revised January, 11 2016