• PCA Timesheet

    Time and Activity Documentation

  • If you are unable to successfully submit your visit using the HHA Mobile App, you must submit this backup timesheet within 24 hours so your time can be entered for the current pay period. 

    Complete and submit this Timesheet and fill in all areas per the client's care plan. Both you and the Client or Responsible Party must sign the form in order for it to be valid.

    Agency Name: A Chance To Grow, Inc.
    Agency Phone Number: (612) 789-1236

  • Has the recipient been hospitalized or incarcerated overnight in the past month?*
  • Date of Service (Visit/Shift Date):*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Activities:*
    Rows
  • Was this shared care?*
  • Where was the share care provided? (Select all the apply)
  • What was the ratio of PCA to Clients?
  • Time In:*
  • Time Out:*

  • Acknowledgement and Required Signatures
    After the employee has documented his/her time and activity, the Client/Responsible Party must review the completed time sheet for accuracy before signing.

  • Fraud statement: 

    I declare under penalty of perjury that all hours worked and descriptions of work performed contained in the submitted shifts are true and correct with full knowledge that all of this information may be subject to investigation and that any false or dishonest information contained on these shifts may be grounds for denial of payment and/or reporting of findings to the investigation unit of the Department of Human Services.
  • Date:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Caregiver Title:*
  • Birth Date of Client:*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Fraud statement: 

    I declare under penalty of perjury that all hours worked and descriptions of work performed contained in the submitted shifts are true and correct with full knowledge that all of this information may be subject to investigation and that any false or dishonest information contained on these shifts may be grounds for denial of payment and/or reporting of findings to the investigation unit of the Department of Human Services.
  • Date:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: