• Timesheet

  • Date of Service Day 1:
     / /
    2 digit month, 2 digit day, 4 digit year
  • Time IN*
  • Time Out*
    • Day 2 
    • Date of Service 2:
       / /
      2 digit month, 2 digit day, 4 digit year
    • Time IN
    • Time Out
    • Day 3 
    • Date of Service 3:
       / /
      2 digit month, 2 digit day, 4 digit year
    • Time IN
    • Time Out
    • Day 4 
    • Date of Service 4:
       / /
      2 digit month, 2 digit day, 4 digit year
    • Time IN
    • Time Out
    • Signature Panel: 
    • Date
       - -
      2 digit month, 2 digit day, 4 digit year
    • Date
       - -
      2 digit month, 2 digit day, 4 digit year

    • I, the undersigned Direct Care Worker, attest that I provided Personal Assistance Services, as described above, to the Participant listed on the timesheet above, and that the hours are true and correct.

    • Date
       - -
      2 digit month, 2 digit day, 4 digit year

    • Note: All sections of the time sheet must be completed and signed by the Direct Care Worker, Participant, and Agency Designee. By signing in the designated area(s) above, you are confirming that the hours shown and the services provided were performed by the Direct Care Worker whose name appears on the time sheet.
      Do not sign blank time and activity sheets.

    • EVV Direction: Call 833-369-1211 from the client's phone. Press 1 to Clock-in or 2 to Clock-out and you will enter your assignment ID.

    •   
    • Should be Empty: