Sandata Electronic Visit Verification
Clock-In / Out Time Missing
Clock-In / Out and Missing Task ID(s) Request Form
Complete this form for all clock-in / out updates and missing Task ID requests. If your clock-in / out was unsuccessful due to system / phone issues, you forgot to clock-in / out, or if client care was needed upon arrival. Note: If you are unable to enter Task ID(s) for all tasks performed during your visit, select Task IDs below.
Caregiver Name
*
First Name
Last Name
Client Name
*
First Name
Last Name
Clock-in Date and Time
/
Month
/
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Clock-out Date and Time
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Today's Date
*
-
Month
-
Day
Year
Date
Select Task(s) Performed During Client Viist
N/A - Already entered at Clock-out
Task 1 - Bath – Bed / Sponge Bath
Task 2 - Bath – Shower / Tub
Task 3 - Dress – Assist w/Dressing
Task 4 - Hygiene – Hair Care / Clean
Task 5 - Hygiene – Mouth Care
Task 6 - Hygiene – Nail Care
Task 7 - IADLs – Meal Prep
Task 8 - IADLs – Light House Clean
Task 9 - IADLs - Laundry
Task 10 - IADLs – Errands
Task 11 - IADLs – Med Reminders
Task 12 - Mobility – Ambulation
Task 13 - Mobility – In / Out Bed
Task 14 - Mobility – Transfer
Task 15 - Toilet – Bathroom
Task 16 - Toilet – Bedside Commode
Task 17 - Toilet – Urinal / Bedpan
Task 18 - Toilet - Incontinence
Comments / Notes:
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