MISSED EVV TIMESHEET

EMPLOYEE

First NameLast Name

EMPLOYEE Last 4 digits of Social Security Number:

PARTICIPANT FIRST AND LAST NAME:

First NameLast Name

PARTICIPANT MEDICAID #:

SERVICE ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

REASON FOR MISSED EVV:

Rows	DATE SERVICES RENDERED	SHIFT START TIME	SHIFT END TIME	TOTAL HOURS WORKED
1
2
3
4
5
6
7
8
9
10

DUTIES PROVIDED

Rows	1	2	3	4	5	6	7	8	9	10
Bath #134
Shower #205
Hair Care- Shampoo #106
Oral Care #208
Light Housekeeping #249
Prepare Breakfast #221
Prepare Lunch #222
Prepare Dinner #223
Prepare Snack #224
Shopping/errands #252
Pet Support
Clean Bathroom #250
Clean Patient Care Equipment #251
Accompany Patient to Medical Appointments #253
Monitor Patient Safety #257
Fall Risk Precautions #262
Assist with Walking #229
Other
Bladder/Bowl Incontinence #130+ #131
Dressing Upper/Lower #123+#124
Change Bed Linen #247
Remind to Take Medication #244

EMPLOYEE SIGNATURE:

PARTICIPANT SIGNATURE:

Date

832080671/30914335

DISCLAIMER: By signing in the designated area(s) above I am confirming that the hours shown and the services provided were performed by the Direct Care Worker whose name appears on this time sheet. I hereby attest that all information listed on this form is accurate to the best of my knowledge and I understand that any falsification will subject me to criminal and or civil charges.

TIMESHEETS ARE DUE WITHIN 24 HOURS OF A MISSED EVV.