Timesheet

Time Sheet Documentation for Manual Electronic Visit Verification (EVV) Entries/Edits

Were there any hospitalizations this week?YesNo

Monday

ADL

Please check all that apply:

BathingDressingEating/FeedingGroomingMobility/WalkingToilet/Bowel/Bladder CareTransferring

IADL

Please check all that apply:

Cueing/Reminders for Self-medicationHousekeepingLaundryMeal Prep/PlanningShoppingAccompany to appointmentsConversation

Reason for missed EVV?Phone not workingDate Entry ErrorCall in no outCall out no inForgot to clock in and outCall didn't linkWifi IssuesClock in later or too early EVV

Tuesday

ADL

Please check all that apply:

BathingDressingEating/FeedingGroomingMobility/WalkingToilet/Bowel/Bladder CareTransferring

IADL

Please check all that apply:

Cueing/Reminders for Self-medicationHousekeepingLaundryMeal Prep/PlanningShoppingAccompany to appointmentsConversation

Reason for missed EVV?Phone not workingDate Entry ErrorCall in no outCall out no inForgot to clock in and outCall didn't linkWifi IssuesClock in later or too early EVV

Wednesday

ADL

Please check all that apply:

BathingDressingEating/FeedingGroomingMobility/WalkingToilet/Bowel/Bladder CareTransferring

IADL

Please check all that apply:

Cueing/Reminders for Self-medicationHousekeepingLaundryMeal Prep/PlanningShoppingAccompany to appointmentsConversation

Reason for missed EVV?Phone not workingDate Entry ErrorCall in no outCall out no inForgot to clock in and outCall didn't linkWifi IssuesClock in later or too early EVV

Thursday

ADL

Please check all that apply:

BathingDressingEating/FeedingGroomingMobility/WalkingToilet/Bowel/Bladder CareTransferring

IADL

Please check all that apply:

Cueing/Reminders for Self-medicationHousekeepingLaundryMeal Prep/PlanningShoppingAccompany to appointmentsConversation

Reason for missed EVV?Phone not workingDate Entry ErrorCall in no outCall out no inForgot to clock in and outCall didn't linkWifi IssuesClock in later or too early EVV

Friday

ADL

Please check all that apply:

BathingDressingEating/FeedingGroomingMobility/WalkingToilet/Bowel/Bladder CareTransferring

IADL

Please check all that apply:

Cueing/Reminders for Self-medicationHousekeepingLaundryMeal Prep/PlanningShoppingAccompany to appointmentsConversation

Reason for missed EVV?Phone not workingDate Entry ErrorCall in no outCall out no inForgot to clock in and outCall didn't linkWifi IssuesClock in later or too early EVV

Saturday

ADL

Please check all that apply:

BathingDressingEating/FeedingGroomingMobility/WalkingToilet/Bowel/Bladder CareTransferring

IADL

Please check all that apply:

Cueing/Reminders for Self-medicationHousekeepingLaundryMeal Prep/PlanningShoppingAccompany to appointmentsConversation

Reason for missed EVV?Phone not workingDate Entry ErrorCall in no outCall out no inForgot to clock in and outCall didn't linkWifi IssuesClock in later or too early EVV

Sunday

ADL

Please check all that apply:

BathingDressingEating/FeedingGroomingMobility/WalkingToilet/Bowel/Bladder CareTransferring

IADL

Please check all that apply:

Cueing/Reminders for Self-medicationHousekeepingLaundryMeal Prep/PlanningShoppingAccompany to appointmentsConversation

Reason for missed EVV?Phone not workingDate Entry ErrorCall in no outCall out no inForgot to clock in and outCall didn't linkWifi IssuesClock in later or too early EVV

Direct Care Worker Signature

Participant Signature

I, the undersigned Direct Care Worker, attest that I provided Personal Assistance Services, as described above, to the Participant listed on the time sheet above, and that the hours are true and correct.