Manual Timesheet for Electronic Visit Verification

Manual Timesheet for Electronic Visit Verification (EVV)
Client's Name*

Clients First NameLast Name
Direct Care Worker Name*

Direct Care Worker First NameLast Name
Service Date*

MonthDayYear
Date
Clock In

Hour Minutes

AM/PM Option
Clock-Out*

Hour Minutes

AM/PM Option
Total Hours*
Reason for missed clock in/out*
Please check all the POC service completed during the visit.*

Meal PreparationHousework/ChoreManaging FinancesManaging MedicationShoppingTransportationHygieneDressing UpperDressing LowerLocomotionTransferToilet UseBed MobilityEatingBladder IncontinenceBowel IncontinencePersonal Care T1019BathingLotion/OintmentLaundryReading/WritingSupervision/CoachingIncontinence CareCatheter CareWound CareStairsPhone Use
Participant Acknowledgement

By sigining below, I certify that the hours are accurate, and service was provided on the mention date above.
Clients Signature*

Clear
Date*

MonthDayYear
Date
DWC Caregiver Signature*

Clear
Date*

MonthDayYear
Date
*All caregivers who failed clock in or out must fill out this form within 24 hours.

*Please complete this form and return to the office within 24 hours. Failure to submit the timesheets will be delay the payments.

*If there any questions regarding this form, please contact us on 412-254-2586.
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Manual Timesheet for Electronic Visit Verification (EVV)