EVV Exception Form

EVV EXCEPTON FORM
This form is required for any instance in which you fail to clock in or out at your scheduled time. Please ensure that the form is completed immediately after the incident occurs.
EMPLOYEE INFORMATION:
Employee Full Name*
Client Full Name*
SHIFT DETAILS:
Scheduled shift date*

MonthDayYear
Date
What was your scheduled shift time? Every time listed in caresmartz is here. If you cannot find yours, choose other.*
Please select which exception applies:*

Missed Clock In (You did not clock in)Missed Clock Out (You did not clock out)Clocked In Late (You were late, or you clocked in when you realized you missed a clock in)Clocked Out Late (You forgot to clock out as you were leaving, or you clocked out when you realized you missed a clock out)Clocked In EarlyClocked Out Early
Briefly explain the reason for the error. (Example I was late to my shift)*
Employee Signature*

Clear
Date*

MonthDayYear
Date
HR Signature*
Date*

MonthDayYear
Date
HR USE ONLY:*

recorded and submittedVerbal DAWritten DA
Should be Empty:

SHIFT DETAILS: