Free operator template
Daily Staffing Record Template
Keep a dated record of who actually worked and their hours. This blank one-page form separates the daily caregiver information required by R9-10-806(A)(7) from optional fields for coverage review.
Download the blank template
Choose a fillable PDF for a consistent layout or Word to adapt the blank template to your facility. No sign-up required.
How to use this template
- Save a blank master copy. Review it against your facility policies and applicable requirements before use.
- For the PDF, download it and open it in a PDF reader that supports fillable forms. Save a working copy, then reopen it to check that your entries were retained. You can also print a blank copy.
- For Word, edit a copy in a compatible word processor. Check page breaks and print preview after making changes.
- Use one record per facility and calendar date. Record actual hours, use separate rows for separate work periods, and split shifts at midnight. Use continuation sheets as needed. Optional fields do not replace written designations, backup policies, or resident-specific nighttime checks.
Keep completed records private
These downloads are blank operator templates. This public resource library does not accept completed records. Do not upload completed forms or send resident, staff, or other sensitive information through the public website or demo request form. Store completed copies in your facility's approved secure record system, with access limited to authorized people.
Use alongside your policies and current requirements
This is a practical starting point, not a state-approved form, legal advice, or a guarantee of compliance or survey results. Your facility is responsible for required documentation, reporting, review, and retention. R9-10-806(A)(7) requires documentation of caregivers and assistant caregivers working each day, including their hours, retained at least 12 months after the last date on the documentation. This form does not calculate hours, determine wage-and-hour obligations, or establish that staffing meets resident needs.
Related guides
- Arizona Assisted Living Staffing Requirements
- Arizona Assisted Living Survey Readiness Guide
- Employee Files & Hiring Checklist
Looking for software to support daily operations? Explore Tendera or see how Tendera fits Arizona assisted living.