Time sheet submission

Employee Time Sheet
DSW Name*
Consumer Name*
Beginning of Week - Ending of Week*
Select all the days you worked*

SundayMondayTuesdayWednesdayThursdayFridaySaturday
Hours

Sunday
Sunday: Date

MonthDayYear
Date
Sunday Time In

Hour Minutes

AM/PM Option
Sunday Time Out

Hour Minutes

AM/PM Option
Sunday Time In (Only use if come back at a later time)

Hour Minutes

AM/PM Option
Sunday Time Out (Only use if come back at a later time)

Hour Minutes

AM/PM Option
Sunday Total Hours

Monday
Monday: Date

MonthDayYear
Date
Monday Time In

Hour Minutes

AM/PM Option
Monday Time Out

Hour Minutes

AM/PM Option
Monday Time In (Only use if come back at a later time)

Hour Minutes

AM/PM Option
Monday Time Out (Only use if come back at a later time)

Hour Minutes

AM/PM Option
Monday Total Hours

Tuesday
Tuesday: Date

MonthDayYear
Date
Tuesday Time In

Hour Minutes

AM/PM Option
Tuesday Time Out

Hour Minutes

AM/PM Option
Tuesday Time In (Only use if come back at a later time)

Hour Minutes

AM/PM Option
Tuesday Time Out (Only use if come back at a later time)

Hour Minutes

AM/PM Option
Tuesday Total Hours

Wednesday
Wednesday Date:

MonthDayYear
Date
Wednesday Time In

Hour Minutes

AM/PM Option
Wednesday Time Out

Hour Minutes

AM/PM Option
Wednesday Time In (Only use if come back at a later time)

Hour Minutes

AM/PM Option
Wednesday Time Out (Only use if come back at a later time)

Hour Minutes

AM/PM Option
Wednesday Total Hours

Thursday
Thursday Date

MonthDayYear
Date
Thursday Time In

Hour Minutes

AM/PM Option
Thursday Time Out

Hour Minutes

AM/PM Option
Thursday Time In (Only use if come back at a later time)

Hour Minutes

AM/PM Option
Thursday Time Out (Only use if come back at a later time)

Hour Minutes

AM/PM Option
Thursday Total Hours

Friday
Friday Date

MonthDayYear
Date
Friday Time In

Hour Minutes

AM/PM Option
Friday Time out

Hour Minutes

AM/PM Option
Friday Time In (Only use if come back at a later time)

Hour Minutes

AM/PM Option
Friday Time Out (Only use if come back at a later time)

Hour Minutes

AM/PM Option
Friday Total Hours

Saturday
Saturday Date

MonthDayYear
Date
Saturday Time In

Hour Minutes

AM/PM Option
Saturday Time Out

Hour Minutes

AM/PM Option
Saturday Time In (Only use if come back at a later time)

Hour Minutes

AM/PM Option
Saturday Time Out (Only use if come back at a later time)

Hour Minutes

AM/PM Option
Saturday Total Hours

Week's Total Hours
Please double-check that your total weekly hours match the amount approved by the VA. ***If they do not match the amount approved by the VA, review your time entries and ensure all AM/PM selections are accurate.*** Incorrect hours submitted to Veterans at Home Care will result in a delay of payment, and you will be required to complete and resubmit the entire timesheet.
Weekly Total Hours
If your hours entered are negative. Please return to the previous page to update them. You will NOT be able to submit the form until your hours are positive values.

Please double-check that your total weekly hours match the amount approved by the VA. ***If they do not match the amount approved by the VA, review your time entries and ensure all AM/PM selections are accurate.*** Incorrect hours submitted to Veterans at Home Care will result in a delay of payment, and you will be required to complete and resubmit the entire timesheet.
Consumer Signature*

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Date

MonthDayYear
Date
DSW Signature*

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Date

MonthDayYear
Date
By signing this time sheet I, Signature* , Affirm that the consumer's signature above is not forged and the hours documented above have been worked. I,Signature* , acknowledge that forging a consumer's signature and documenting hours that have not been worked are strictly prohibited by the Department of Veterans Affairs and Veterans At Home Care can result in legal consequences, nonpayment for hours not worked, and disciplinary action including termination of employment

Direct Service Worker's Name
Consumer Name
Sunday Date

MonthDayYear
Date
Monday Date

MonthDayYear
Date
Tuesday Date

MonthDayYear
Date
Wednesday Date

MonthDayYear
Date
Thursday Date

MonthDayYear
Date
Friday Date

MonthDayYear
Date
Saturday Date

MonthDayYear
Date

Tasks (Indicate Tasks Completed Each Day by Signing with Worker's Initials)*

	Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday
Eating
Bathing
Dressing
Grooming
Transferring
Ambulation
Toileting
Light Housekeeping
Food Preparation and Storage
Shopping
Laundry
Medication Reminder
Assist to Scheduled Medical Appointment
Assist to Arrange Medical Transportation
Accompany to Medical

Consumer Signature*

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Date*

MonthDayYear
Date
DSW Signature*

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Date*

MonthDayYear
Date

Providers Name
Direct Service Worker's Name
Consumer Name
Sunday Date

MonthDayYear
Date
Monday Date

MonthDayYear
Date
Tuesday Date

MonthDayYear
Date
Wednesday Date

MonthDayYear
Date
Thursday Date

MonthDayYear
Date
Friday Date

MonthDayYear
Date
Saturday Date

MonthDayYear
Date

Please select the day you worked and choose all tasks completed from the dropdown as outlined in the Plan of Care.*

	Progress Notes: Observed Changes in Physical and mental condition (if applicable) Documentation of any Significant Deviation from what is in terms of Plan of Care Important information for the next worker or caregiver
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Participant/Responsible Representative/Legal Representative's Initials*

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Date*

MonthDayYear
Date
Direct Service Worker's Initials *

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Date *

MonthDayYear
Date
Time Submitted (Any time Sheets Submitted After Monday 12:00pm is late and will not be processed until the next Monday)

Hour Minutes

AM/PM Option
Time Submitted (Any time Sheets Submitted After Monday 12:00pm is late and will not be processed until the next Monday)

MonthDayYear
Date
Hour MinutesAM/PM Option
Should be Empty:

Employee Time Sheet

Hours

If your hours entered are negative. Please return to the previous page to update them. You will NOT be able to submit the form until your hours are positive values.