Timesheet 11/16

Detailed Description of Service*
I followed the plan given to me by the client or their primary caregiver and worked on the client's support plan goals. Everything I did today I got verbal permission from my client or their primary caregiver.

Were there any health, behavior and/or safety concerns today with your client?*

NoOther

Integrity Statement

TO GUIDE OUR CLIENTS AND OURSELVES TO BE INDIVIDUALS THAT WILL DO THE RIGHT THING. I will act with the utmost integrity and pursue my work in an honest and ethical manner. I will obey the letter and spirit of the law. I will take responsibility for my actions and consider the effects on others. I will strive to create a sustainable economic and social environment.
I understand*

That if I falsify my duration of service, details of service, etc. I will be deemed for immediate termination as stated in Section IV in Employee or Independent contractor Contract
Service Provider Signature*

Clear
Service Provider's Email*

Verification of Service

Signed by Primary Care-giver, Group home staff or client. ONLY
Please put your email below and you will receieve a copy of this timesheet.

PLEASE CHECK EMAIL PERIODICALLY TO MAKE SURE THE INFORMATION REPORTED IS CORRECT

If there are any discrepences in this timesheet (incorrect hours and/or details) please contact Manager Amanda Campbell (321-544-5152)
Signed off By*

Primary Care-giverClientFamily MemberOther
Name*

First NameLast Name
Primary Care-givers's Email*
The primary caregiver, group home staff or client email. CAN NOT be the Service provider's email.
Primary Care-giver's Signature*

Clear
Should be Empty:

Master Care-Givers Service Log