Attach B_DSS Form 30141.pdf

PDF 430 KB Posted Jul 6, 2026

Attached to: APS - ETPS - HOMEMAKER - CNAS -PCAS
Solicitation number: 5400029952
Issued by: Richland County, South Carolina

About this file

Written by GovTribe AI · Jul 6, 2026

This is a DSS Form 30141, a verification and documentation form used by the South Carolina Department of Social Services for Adult Advocacy programs involving Personal Care and Certified Nursing Assistant (CNA) services. The form serves as a required submission by contractors alongside detailed invoices for each Adult Protective Services (APS) client receiving sitter services to authorize payment processing. The form must be completed legibly and signed by the Personal Care/CNA provider (sitter) for each week of service provided.

The form requires comprehensive documentation of weekly services including client name, sitter name, service dates, and total hours worked broken down by day. Sitters must document a general overview of the client's overall condition, attitude, and interactions, and provide detailed daily notes categorized by personal care services (bathing, diaper changes, etc.), medication monitoring with specific times and medication names, behavioral observations and any disruptive incidents, relevant client comments pertaining to case planning, nurse services rendered (blood pressure monitoring, insulin injections, bandage changes), and meals and snacks provided with times and food items. The form accommodates multiple pages for in-depth documentation and requires the sitter's signature certifying the accuracy of all information provided. This documentation standard applies to the APS-ETPS-Homemaker-CNAs-PCAs contract opportunity in South Carolina.

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Other files

File	Type	Posted
Solicitation.docx	DOCX document	Jul 6, 2026
Attach C_ DSS Form 1580.pdf	PDF	Jul 6, 2026
Attach A_ DSS Form 2433.pdf	PDF	Jul 6, 2026
Attach D_DSS Form 3797.pdf	PDF	Jul 6, 2026

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DSS Form 30141 (3/23/26)

Adult Advocacy

PERSONAL CARE/CERTIFIED NURSING ASSISTANT VERIFICATION OF

CARE

To be completed by the Personal Care/Certified Nursing Assistant (Sitter) and submitted by the Contractor along with a detailed invoice for each APS client receiving Sitter services in order for payment to be processed. Form must be complete, legible and signed.

Client’s Name: __________________________________ Sitter’s Name: _______________________________

PRINT NAME PRINT NAME

Services Provided for the Week Ending: _________________________

DAY Date Month/Date

Time (Circle AM/PM) Total

Hours General Overview of Client’s Day

(Client’s overall condition, attitude, interactions with the Sitter) In Out

SUNDAY /

AM AM

PM PM

MONDAY /

AM AM

PM PM

TUESDAY / AM AM

PM PM

WEDNESDAY / AM AM

PM PM

THURSDAY /

AM AM

PM PM

FRIDAY / AM AM

PM PM

SATURDAY / AM AM

PM PM

Total Hours for the Week

When date/time in/out goes over midnight, show time as:

For each care day, please use the next section to indicate:

• Personal care services provided to the client, (shower, bath, change diaper, etc.)

• Medication monitoring, i.e. what time the client took medication and what medication was taken - Did the client take the medication or refuse?

• Any occurrences of outbursts or other disruptive behavior

• Anything the client may say that is pertinent to case planning

• Visit with nurse-services received for high blood pressure, insulin injections (how much), changing bandages

(time), etc.

• Meals and snacks that are provided to the client (time and food items)

Signature of Sitter: ________________________________________ Date: _____________________ By signing, I certify that all information provided is accurate.

Page 1 of ____ pages

Client’s Name: __________________________________ Sitter’s Name: _______________________________

PRINT NAME PRINT NAME

Day of Week & Month/Date Care Item Sitter’s Notes – include times as appropriate

Day of week:

Month/Date:

Personal Care

Medication Monitoring

Behavioral Observations

Client’s Comments

Nurse Services

Meals/Snacks

Day of week:

Month/Date:

Personal Care

Medication Monitoring

Behavioral Observations

Client’s Comments

Nurse Services

Meals/Snacks

Use additional pages as necessary to provide more in-depth information. Specify day/date/category.

Page ____ of ____ pages

Client’s Name: __________________________________ Sitter’s Name: _______________________________

PRINT NAME PRINT NAME

Day of Week & Month/Date Care Item Sitter’s Notes – include times as appropriate

Day of week:

Month/Date:

Personal Care

Medication Monitoring

Behavioral Observations

Client’s Comments

Nurse Services

Meals/Snacks

Day of week:

Month/Date:

Personal Care

Medication Monitoring

Behavioral Observations

Client’s Comments

Nurse Services

Meals/Snacks

Use additional pages as necessary to provide more in-depth information. Specify day/date/category.

Page ____ of ____ pages

Clients Name:

Sitters Name:

Services Provided for the Week Ending:

Total HoursRow1:

General Overview of Clients Day Clients overall condition attitude interactions with the SitterRow1:

Total HoursRow2:

General Overview of Clients Day Clients overall condition attitude interactions with the SitterRow2:

Total HoursRow3:

General Overview of Clients Day Clients overall condition attitude interactions with the SitterRow3:

Total HoursRow4:

General Overview of Clients Day Clients overall condition attitude interactions with the SitterRow4:

Total HoursRow5:

General Overview of Clients Day Clients overall condition attitude interactions with the SitterRow5:

Total HoursRow6:

General Overview of Clients Day Clients overall condition attitude interactions with the SitterRow6:

Total HoursRow7:

General Overview of Clients Day Clients overall condition attitude interactions with the SitterRow7:

Total HoursTotal Hours for the Week:

of:

Clients Name_2:

Sitters Name_2:

Sitters Notes include times as appropriatePersonal Care:

Day of week:

Sitters Notes include times as appropriateMedication Monitoring:

Sitters Notes include times as appropriateBehavioral Observations:

MonthDate:

Sitters Notes include times as appropriateClients Comments:

Sitters Notes include times as appropriateNurse Services:

Sitters Notes include times as appropriateMealsSnacks:

Sitters Notes include times as appropriatePersonal Care_2:

Day of week_2:

Sitters Notes include times as appropriateMedication Monitoring_2:

Sitters Notes include times as appropriateBehavioral Observations_2:

MonthDate_2:

Sitters Notes include times as appropriateClients Comments_2:

Sitters Notes include times as appropriateNurse Services_2:

Sitters Notes include times as appropriateMealsSnacks_2:

Page:

of_2:

Clients Name_3:

Sitters Name_3:

Sitters Notes include times as appropriatePersonal Care_3:

Day of week_3:

Sitters Notes include times as appropriateMedication Monitoring_3:

Sitters Notes include times as appropriateBehavioral Observations_3:

MonthDate_3:

Sitters Notes include times as appropriateClients Comments_3:

Sitters Notes include times as appropriateNurse Services_3:

Sitters Notes include times as appropriateMealsSnacks_3:

Sitters Notes include times as appropriatePersonal Care_4:

Day of week_4:

Sitters Notes include times as appropriateMedication Monitoring_4:

Sitters Notes include times as appropriateBehavioral Observations_4:

MonthDate_4:

Sitters Notes include times as appropriateClients Comments_4:

Sitters Notes include times as appropriateNurse Services_4:

Sitters Notes include times as appropriateMealsSnacks_4:

Page_2:

of_3:

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File details come from the government source that posted it. Updated Jul 6, 2026.