This form will provide the total number of care hours/shift/client. You will fill out a new form each shift.
For shifts that cross over to the following day (example: 9pm to 6am) please indicate the number of hours you worked each day.
USE THE FORM BELOW
ONLY IF YOUR SHIFT CONTINUED PAST MIDNIGHT
By signing, you are agreeing that all of the information provided is accurate and correct and that providing false information may result in termination.
Failure to turn this form in may result in delayed payment for the services.