Personal Support Worker Request Step 1 of 4 25% Name(Required) First Last Email(Required) When do you require support?(Required) Morning Afternoon Evening Overnight Which days do you require morning support?(Required) Monday Tuesday Wednesday Thursday Friday Saturday Sunday Click all that applyWhich days do you require afternoon support?(Required) Monday Tuesday Wednesday Thursday Friday Saturday Sunday Click all that applyWhich days do you require evening support?(Required) Monday Tuesday Wednesday Thursday Friday Saturday Sunday Click all that applyWhich days do you require overnight support?(Required) Monday Tuesday Wednesday Thursday Friday Saturday Sunday Click all that apply What time should the morning shift begin?(Required) Hours : Minutes AM PM AM/PM What time should the morning shift finish?(Required) Hours : Minutes AM PM AM/PM What time should the afternoon shift begin?(Required) Hours : Minutes AM PM AM/PM What time should the afternoon shift finish?(Required) Hours : Minutes AM PM AM/PM What time should the evening shift begin?(Required) Hours : Minutes AM PM AM/PM What time should the evening shift finish?(Required) Hours : Minutes AM PM AM/PM What time should the overnight shift begin?(Required) Hours : Minutes AM PM AM/PM What time should the overnight shift finish?(Required) Hours : Minutes AM PM AM/PM How many support workers do you require?(Required) one worker two workers What does your Personal Routine look like in the morning?(Required) First Showering, drying, brushing teeth, shaving, personal grooming Assisted hoist transfers Assisted slide board transfers Set up chair/cushions Set up drinking system Assistance with meal preparation Assistance with eating meals Assistance with medication Apply/remove leg/arm splints or gloves Skin checks and monitoring Passive movement exercises Charge wheelchair Rolling and positioning in bed Set up respiratory equipment Please select the support you require during your stay (tick all that apply)What does your personal routine look like in the afternoon?(Required) First Showering, drying, brushing teeth, shaving, personal grooming Assisted hoist transfers Assisted slide board transfers Set up chair/cushions Set up drinking system Assistance with meal preparation Assistance with eating meals Assistance with medication Apply/remove leg/arm splints or gloves Skin checks and monitoring Passive movement exercises Charge wheelchair Rolling and positioning in bed Set up respiratory equipment Please select the support you require during your stay (tick all that apply)What does your personal routine look like in the evening?(Required) First Showering, drying, brushing teeth, shaving, personal grooming Assisted hoist transfers Assisted slide board transfers Set up chair/cushions Set up drinking system Assistance with meal preparation Assistance with eating meals Assistance with medication Apply/remove leg/arm splints or gloves Skin checks and monitoring Passive movement exercises Charge wheelchair Rolling and positioning in bed Set up respiratory equipment Please select the support you require during your stay (tick all that apply)What does your personal routine look like overnight?(Required) First Showering, drying, brushing teeth, shaving, personal grooming Assisted hoist transfers Assisted slide board transfers Set up chair/cushions Set up drinking system Assistance with meal preparation Assistance with eating meals Assistance with medication Apply/remove leg/arm splints or gloves Skin checks and monitoring Passive movement exercises Charge wheelchair Rolling and positioning in bed Set up respiratory equipment Please select the support you require during your stay (tick all that apply)Any personal care requirements? Overnight bag/bottle or leg bag change Bowel care requiring administration of enemas and/or suppositories Bowel care requiring anal irrigation Catheter flush and/or clean Pressure wound care and dressing Dressing Suprapubic Catheter (SPC) site or stoma care Tracheostomy suctioning and ventilator cleaning PEG fluid meals/enteral fluids
