DSHS 10-638 (REV. 12/2019)
ADULT FAMILY HOME (AFH)
AFH Meaningful Day – Monthly Activities
and Challenging Behavior Log
CLIENT NAME
ADULT FAMILY HOME
COMPLETED BY:
MONTH / YEAR
COUNTY
Monthly Activities
Record in-home and community activities below .
Monthly Challenging Behaviors
List tw o (2) challenging behaviors and record each w eek.
Week 1
Start date:
1
st
– 7
th
NUMBER OF IN-HOME ACTIVITIES
ATTENDED:
RARELY /
OFTEN SOME NEVER
On the w hole:
Client participated?
Client enjoyed?
ACTIVITIES ATTENDED:
RARELY /
OFTEN SOME NEVER
On the w hole:
Client participated?
Client enjoyed?
TARGETED BEHAVIOR 1
TARGETED BEHAVIOR 2
OFTEN SOME DID NOT
OCCUR
Did it happen?
Was it disruptive?
OFTEN SOME DID NOT
OCCUR
Did it happen?
Was it disruptive?
What activities w orked w ell in Week 1:
Week 2
Start date:
8
th
– 14
th
NUMBER OF IN-HOME ACTIVITIES
ATTENDED:
RARELY /
OFTEN SOME NEVER
On the w hole:
Client participated?
Client enjoyed?
ACTIVITIES ATTENDED:
RARELY /
OFTEN SOME NEVER
On the w hole:
Client participated?
Client enjoyed?
OFTEN SOME DID NOT
OCCUR
Did it happen?
Was it disruptive?
OFTEN SOME DID NOT
OCCUR
Did it happen?
Was it disruptive?
What activities w orked w ell in Week 2:
Week 3
Start date:
15
th
– 21
st
NUMBER OF IN-HOME ACTIVITIES
ATTENDED:
RARELY /
OFTEN SOME NEVER
On the w hole:
Client participated?
Client enjoyed?
ACTIVITIES ATTENDED:
RARELY /
OFTEN SOME NEVER
On the w hole:
Client participated?
Client enjoyed?
OFTEN SOME DID NOT
OCCUR
Did it happen?
Was it disruptive?
OFTEN SOME DID NOT
OCCUR
Did it happen?
Was it disruptive?
What activities w orked w ell in Week 3:
Week 4
Start date:
22
nd
– 28
th
NUMBER OF IN-HOME ACTIVITIES
ATTENDED:
RARELY /
OFTEN SOME NEVER
On the w hole:
Client participated?
Client enjoyed?
ACTIVITIES ATTENDED:
RARELY /
OFTEN SOME NEVER
On the w hole:
Client participated?
Client enjoyed?
OFTEN SOME DID NOT
OCCUR
Did it happen?
Was it disruptive?
OFTEN SOME DID NOT
OCCUR
Did it happen?
Was it disruptive?
What activities w orked w ell in Week 4:
Week 5
Start date:
29
th
– 31
st
ONLY IF NEEDED
NUMBER OF IN-HOME ACTIVITIES
ATTENDED:
RARELY /
OFTEN SOME NEVER
On the w hole:
Client participated?
Client enjoyed?
ACTIVITIES ATTENDED:
RARELY /
OFTEN SOME NEVER
On the w hole:
Client participated?
Client enjoyed?
OFTEN SOME DID NOT
OCCUR
Did it happen?
Was it disruptive?
OFTEN SOME DID NOT
OCCUR
Did it happen?
Was it disruptive?
What activities w orked w ell in Week 5:
DSHS 10-638 (REV. 12/2019)
AFH Meaningful Day – Monthly Activities and Challenging Behavior Log
Instructions
Notes about the form generally:
• Each ROW of this form represents one week's worth of activity AND behavior
reporting. You will file one form per month.
• The first two COLUMNS are used to document ACTIVITIES (In-Home /
Community-Based) for the week.
• The last two COLUMNS are used to document BAHAVIORS (Targeted Behavior
1 / Targeted Behavior 2) for the week.
At the top of the form, enter the following information:
• Client Name (First name, then last)
• Completed By (Full name of whoever is completing the form)
• Adult Family Home (Please use your full official home name)
• Month / Year (Like 03/2019)
• County (The county your home is in)
For EACH of the 4 (or 5) weeks, enter:
• In-Home Activities
o Enter the number of in-home activities the resident attended during the
week.
o Considering ALL of the in-home activities for the week, rate how much the
resident:
Participated in the activities
Enjoyed the activities
• Community-Based Activities
o Enter the number of community-based activities the resident attended
during the week.
o Considering ALL of the community-based activities for the week, rate how
much the resident:
Participated in the activities
Enjoyed the activities
• Targeted Behavior 1
o Enter a behavior from the resident’s care assessment.
Rate how often the behavior occurred during the week.
Rate how disruptive the behavior was during the week.
• Targeted Behavior 2
o Enter a second behavior from the resident’s care assessment.
Rate how often the behavior occurred during the week.
Rate how disruptive the behavior was during the week.
• Describe activities that worked well during the current week.
Tips
Please print as neatly as
you can!
Record information at least
weekly. Don’t wait until the
end of the month.
Some months have a
partial 5
th
week. Only
complete that row as
needed.
Enter only a single number
of activities (not a range
like 4-6), and don’t forget to
rate the resident’s
participation and
enjoyment.
Count activities attended by
the resident, even if you
were not present yourself.
When rating how frequently
a client participated in an
activity, reduce the
frequency if the client took
part, but not a very active
part.
When rating how frequently
the client enjoyed weekly
activities, consider both
how often and how much
they enjoyed the activity.
Targeted behaviors should
come from the resident’s
care assessment. They
may be the same from one
month to another, but can
change along with the care
plan.
When rating how
disruptive a behavior was,
consider both how often it
occurred and how
disruptive it was.