Timesheet

This Timesheet is for emergency purposes ONLY!

Caregivers must utilize the approved methods for EVV - via the HHAX app or telephony.

Caregivers must maintain an average clock-in/clock-out rate of 90% and above.

These tools provide secure, real-time data collection, significantly reducing the risk of errors and enhancing overall efficiency.

Requested Date *

Caregiver Name (Timesheet Requested By) *

Caregiver Email *

Reason for Timesheet Request *

Please Select

Address did not link to the client
Caregiver forgot to clock in or out
Issue with EVV system
Address did not link to the client (GPS)
Client received services outside of home
Phone in use by client
Other
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If Other, please specify here

Timesheet Details

Date Services Were Performed *

Client's Name *

Clock-In Time *

Clock-Out Time *

Services Provided Based On Individual Plans Of Care *

Hygiene

Meal Prep

Light Housekeeping

Shopping

Dressing

Locomotion

Transfer

Toilet Use

Bathing

Laundry

Lotion/Ointment

Supervision/Coaching/Cueing

Incontinence Care

Assist with Feeding

Range of Motion Exercises

Assist with Exercises

Other

Do you need to enter in more days? *

Yes

Please read the instructions:

You can submit a maximum of 7 days via this form.
If you require more days, please reach out to the office.
All fields are required for each entry you need.
Once you have completed the number of entries needed, please scroll down and click the "Next" button.

_________________________________________________________________________________________________________

Date Services Were Performed (Second Entry)

Client's Name

Clock-In Time

Clock-Out Time

Services Provided Based On Individual Plans Of Care

Hygiene

Meal Prep

Light Housekeeping

Shopping

Dressing

Locomotion

Transfer

Toilet Use

Bathing

Laundry

Lotion/Ointment

Supervision/Coaching/Cueing

Incontinence Care

Assist with Feeding

Range of Motion Exercises

Assist with Exercises

Other

_________________________________________________________________________________________________________

Date Services Were Performed (Third Entry)

Client's Name

Clock-In Time

Clock-Out Time

Services Provided Based On Individual Plans Of Care

Hygiene

Meal Prep

Light Housekeeping

Shopping

Dressing

Locomotion

Transfer

Toilet Use

Bathing

Laundry

Lotion/Ointment

Supervision/Coaching/Cueing

Incontinence Care

Assist with Feeding

Range of Motion Exercises

Assist with Exercises

Other

_________________________________________________________________________________________________________

Date Services Were Performed (Fourth Entry)

Client's Name

Clock-In Time

Clock-Out Time

Services Provided Based On Individual Plans Of Care

Hygiene

Meal Prep

Light Housekeeping

Shopping

Dressing

Locomotion

Transfer

Toilet Use

Bathing

Laundry

Lotion/Ointment

Supervision/Coaching/Cueing

Incontinence Care

Assist with Feeding

Range of Motion Exercises

Assist with Exercises

Other

_________________________________________________________________________________________________________

Date Services Were Performed (Fifth Entry)

Client's Name

Clock-In Time

Clock-Out Time

Services Provided Based On Individual Plans Of Care

Hygiene

Meal Prep

Light Housekeeping

Shopping

Dressing

Locomotion

Transfer

Toilet Use

Bathing

Laundry

Lotion/Ointment

Supervision/Coaching/Cueing

Incontinence Care

Assist with Feeding

Range of Motion Exercises

Assist with Exercises

Other

_________________________________________________________________________________________________________

Date Services Were Performed (Sixth Entry)

Client's Name

Clock-In Time

Clock-Out Time

Services Provided Based On Individual Plans Of Care

Hygiene

Meal Prep

Light Housekeeping

Shopping

Dressing

Locomotion

Transfer

Toilet Use

Bathing

Laundry

Lotion/Ointment

Supervision/Coaching/Cueing

Incontinence Care

Assist with Feeding

Range of Motion Exercises

Assist with Exercises

Other

_________________________________________________________________________________________________________

Date Services Were Performed (Seventh Entry)

Client's Name

Clock-In Time

Clock-Out Time

Services Provided Based On Individual Plans Of Care

Hygiene

Meal Prep

Light Housekeeping

Shopping

Dressing

Locomotion

Transfer

Toilet Use

Bathing

Laundry

Lotion/Ointment

Supervision/Coaching/Cueing

Incontinence Care

Assist with Feeding

Range of Motion Exercises

Assist with Exercises

Other

Signatures

Caregiver Name *

Caregiver Initials *

Caregiver Signature *

Clear

NOTE

The client must sign this timesheet before approval. Please have your client sign below:

Client's Name *

Client's Signature *

Clear