1.

Title of Activity: ______________________________________

The Activity Director’s Office
2. Date of Activity: ___________ 3. Time of Activity: _________ New Activity Planning Sheet
4. Type of Activity: 5. Intended Population: 6. Location needed 7. Stimulation:
(i.e. size appropriate)
___ Small Group _ _ _ Male ___ Mental
___ Large Group ___ Female ___ Large group area ___ Physical
___ Individual Physical Status: ___ Small group area ___ Creative
___ ___ Independent ___ Quiet room ___ Social
___ ___ Minimal assist ___ ___
___ ___ Complete assist
___ Mental Status:
9. Staffing needed:
___ Alert & oriented ___ Activity Staff
8. Results Expected: ___ Gently confused ___ Volunteers
___ Disoriented Other Departmental Assistance:
___ Improve socialization
Age Appropriate: ___ Need Date Note Sent Response
___ Improve mental health Nursing _________________________________
___ All ___
status Dietary _________________________________
___ Under 60 ___
___ Boost morale Social services _________________________________
___ Under 50 ___
___ Improve physical health Administration _________________________________
___ Under 40 ___
___ Pride in creativity Housekeeping _________________________________
___ Other _________ ___
___ Maintenance _________________________________
___ ___
___

10. Supplies Needed: 11. Pre-preparation:

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12. Steps for Doing the Activity

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Copyright 2006 The Activity Director’s Office, http://www.theactivitydirectorsoffice.com . Permission is granted to duplicate this form without restrictions.