GSA Request Form

GABRIEL STAFFING ASSOCIATES

Manual EVV Entry or Correction Request
Employee Name*

First NameLast Name
Employee E-mail*
example@example.com
Employee Phone Number*
Please enter a valid phone number.
Client Name*

First NameLast Name
I did not...*
NOTE: If you are unable to clock in or out then IMMEDIATELY submit this form at the exact time you are scheduled to clock in or out. DO NOT SUBMIT CLOCK IN/OUT AFTER YOUR SCHEDULED TIMES HAVE BEGUN OR ENDED. This is unacceptable.
On Date*

MonthDayYear
Date
Only put the Client's Authorized/Scheduled number of hours! Adding additional unauthorized hours may be interpreted as Medicare fraud.
Clock IN Time*

Hour Minutes

AM/PM Option
Clock OUT Time

Hour Minutes

AM/PM Option
Missed Punch Code Reason*
Comments if "Other" is checked
Using this form FREQUENTLY or DAILY will target your visits for audits by the State of Ohio Department of Aging REGARDLESS OF THE EXCUSE. This form is ONLY to be utilized in RARE circumstances and is NOT TO BE USED ON A DAILY OR FREQUENT BASIS! I understand by submitting this form that EVV manual entries should not be used for routine visit verification but only as an exception when other electronic methods are unavailable. Manual entries are subject to increased scrutiny and audits by state agencies due to the higher risk of fraud.
Please verify that you are human*
Should be Empty:

GABRIEL STAFFING ASSOCIATES