C728

HOME HEALTH CARE SERVICES

P.O. BOX 2415
EDMONTON, AB T5J 2S5 Homemaking Plan
FAX: 780 427-5863
1-800-661-1993

WCB Claim Number

WORKER & PLAN DETAILS
Surname First Name and Initial Date of Birth (yyyy/mm/dd) Date of Accident (yyyy/mm/dd)

Address City/Town Province Postal Code Telephone Number

Claim Owner’s Name Telephone Number

Provider’s Name Telephone Number

Date of Assessment (yyyy/mm/dd) Provider Reference Number

SHOPPING

Preparing shopping list

Putting away purchases
Going to purchase and/or pick up items

Other shopping tasks (specify below)

Length of Time Required

Task Frequency

MEAL PREPARATION

Planning meals
Cooking full meals
Warming up prepared food
Serving food
Helping to prepare meals
Cutting worker’s food for eating
Grinding/Pureeing food

Other meal preparation tasks (specify below)

Length of Time Required

Task Frequency

THIS DOCUMENT MAY BE EXAMINED BY ANY PERSON WITH DIRECT INTEREST IN A CLAIM THAT IS UNDER REVIEW.
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Home Health Services Homemaking Plan
(Surname) (First Name and Initial) Claim Number

CLEANING

Cleaning up after personal care tasks

Dusting
Emptying and cleaning bedside commode
Cleaning bathroom (tub/shower, floor, etc.)
Cleaning durable medical equipment
Cleaning stovetop, counters and washing dishes
Carrying out trash for pickup
Cleaning floors of living areas used by worker
Changing bed linens / Making the bed
Cleaning refrigerator and stove
Cleaning bedroom

Other cleaning tasks (specify below)

Length of Time Required

Task Frequency

LAUNDRY

Using laundromat services

Hand washing of clothing
Gathering and sorting clothes
Hanging clothes to dry
Loading/Unloading machines in the residence
Folding and putting away clothes

Other laundry tasks (specify below)

Length of Time Required

Task Frequency

THIS DOCUMENT MAY BE EXAMINED BY ANY PERSON WITH DIRECT INTEREST IN A CLAIM THAT IS UNDER REVIEW.

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Home Health Services Homemaking Plan
(Surname) (First Name and Initial) Claim Number

ADDITIONAL TASKS

1.

2.

3.

4.

5.

Length of Time Required

Task Frequency

COMMENTS

Assessor’s Name (Print) Telephone Number

Note to Assessor
Fax this report to WCB with C727 Care Authorization Form

RN Coordinator’s signature

THIS DOCUMENT MAY BE EXAMINED BY ANY PERSON WITH DIRECT INTEREST IN A CLAIM THAT IS UNDER REVIEW.

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