Guiding Angels at Home Care — Caregiver Attendance & Missed Clock-In/Clock-Out Form

Guiding Angels at Home Care — Caregiver Attendance & Missed Clock-In/Clock-Out Form

Complete this form right away if you couldn’t clock in or out in EVV to document the issue for payroll and compliance.
Employee Information
Employee Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Client Information
Client Name

First NameLast Name
Service Location Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Date & Time
Date of Service

MonthDayYear
Date
Arrival Time

Hour Minutes

AM/PM Option
Departure Time

Hour Minutes

AM/PM Option
Total Hours Worked
Unusual Occurrence
Was there an unusual occurrence?
Describe the unusual occurrence
Supervisor Notification
Did you notify your supervisor?
Supervisor Name
Time Supervisor Was Contacted

Hour Minutes

AM/PM Option
Method of Contact
Verification
Were you physically present providing care for the entire shift?
Client Verification
Was the client present during the entire shift?
Did the client or responsible party verify services were provided?
Responsible Party Name
Electronic Signature
Certification Statement
Employee Signature
Today’s Date

MonthDayYear
Date
Internal Office Use Only
Attendance Correction Approved?
Approved By
Date Reviewed

MonthDayYear
Date
Payroll Updated?
EVV Corrected?
Compliance Notes
Authorization Verified?
Should be Empty: