Clemens Health | Overnight staffing confirmation sheet
Updated 2026-10-05 | (651) 354-1196

Download this editable worksheet, add your notes, and bring it to the relevant planning conversation. Leave unknown details blank and identify who can confirm them.

Assistance needed
What overnight help has the responsible team identified?
Your notes: ________________________________________

Awake or asleep arrangement
What has been requested, reviewed and explicitly confirmed?
Your notes: ________________________________________

Shift pattern
Which dates, nights and start/end times are being discussed?
Your notes: ________________________________________

Person’s preferences
What privacy, noise and communication preferences need agreement?
Your notes: ________________________________________

Confirmation owner
Who can confirm the arrangement and communicate a change?
Your notes: ________________________________________

Illustrative example
A referral says “overnights,” while a family expects someone awake throughout. The intake contact asks the case manager to clarify the requirement and checks staffing for the proposed nights before a date is treated as confirmed.

Next step
Ask the case manager and provider to reconcile any different expectations. Keep a copy of the agreed arrangement with the contacts you use for schedule changes.

This is an optional discussion worksheet, not an official assessment, authorization, service plan, or emergency plan. Keep completed copies private and share through an agreed channel.