Webster Central School District
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Page 1 WEBSTER CENTRAL SCHOOL DISTRICT Please return to Jay Gargana @ DAO DAILY SERVICE REPORT
NAME: BUILDING: ADDRESS: PHONE: FREQ. OF SERVICE FROM IEP: DOB: SEX: M F
Check below for service provided: ____ Occupational Therapy ____ Physical Therapy ____ Speech Services ____ Psychological Evaluation Basic
____ Psych Eval Comprehensive ____ Psychological/Counseling Services (with social history)
Service Month/Year 1 2 3 4 5 6 7 8 9 10 11 12
13 14 15 16 17 18 19 20 21 22 23 24
25 26 27 28 29 30 31 X = billable service A = student absent Total Days Billed: (for confirmation) TA = teacher absent
Daily Progress Notes: REQUIRED Date: Note:
Revised 7/19/10 Page 2
Date: Note:
I hereby certify that the list of services provided on this form is a true and accurate representation of the facts and that all services were performed in compliance with the laws and agreements governing SSHSP.
Provider’s Title: Print Provider’s Name:
Provider’s Signature Date (mm/dd/yy):
Under the Direction of: Signature if required Date (mm/dd/yy):
Revised 7/19/10