<p>Page 1 WEBSTER CENTRAL SCHOOL DISTRICT Please return to Jay Gargana @ DAO DAILY SERVICE REPORT</p><p>NAME: BUILDING: ADDRESS: PHONE: FREQ. OF SERVICE FROM IEP: DOB: SEX: M F</p><p>Check below for service provided: ____ Occupational Therapy ____ Physical Therapy ____ Speech Services ____ Psychological Evaluation Basic</p><p>____ Psych Eval Comprehensive ____ Psychological/Counseling Services (with social history)</p><p>Service Month/Year 1 2 3 4 5 6 7 8 9 10 11 12</p><p>13 14 15 16 17 18 19 20 21 22 23 24</p><p>25 26 27 28 29 30 31 X = billable service A = student absent Total Days Billed: (for confirmation) TA = teacher absent</p><p>Daily Progress Notes: REQUIRED Date: Note:</p><p>Revised 7/19/10 Page 2</p><p>Date: Note:</p><p>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.</p><p>Provider’s Title: Print Provider’s Name:</p><p>Provider’s Signature Date (mm/dd/yy):</p><p>Under the Direction of: Signature if required Date (mm/dd/yy):</p><p>Revised 7/19/10</p>