EVV Time Adjustment Form
Employee Full Name
*
Employee ID
Phone Number
*
Email
*
example@example.com
Employee Email
Client Full Name
*
Select Month
*
Please Select
January
February
March
April
May
June
July
August
September
October
November
December
Service
Please Select
Respite
DAYCARE
Reason for Time Adjustment or Manual Time Entry
*
Please Select
I forgot to clock in/clock out
I clocked in /out at the wrong time
My client has additional hours to use
My phone or tablet was not working
Other (Specify in notes below)
Explain the reason selected above in more detail:
Rows
Date (MM/DD/YY)
Start Time
End Time
Total Hours
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Rows
Date (MM/DD/YY)
Start Time
End Time
Total Hours
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Rows
Date (MM/DD/YY)
Start Time
End Time
Total Hours
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Signature
*
Continue
Continue
Should be Empty: