TIMESHEET

Employee First and Last Name

Employee Phone Number

EMPLOYEE Last 4 Digits of SSN#

Consumer First and Last Name

Consumer Medicaid #

Location Services (Address)

SHIFT

DATE

SHIFT TIME IN

SHIFT TIME OUT

TOTAL HOURS WORKED

Ex: 01/15/26 8:00am 5:00pm 9

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Time

HoursMinutes

Shift 1 Time Out

Time

HoursMinutes

Shift 1 Total Hrs

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Time

HoursMinutes

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Time

HoursMinutes

Shift 2 Total Hrs

Shift 3 Date

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Time

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Time

HoursMinutes

Shift 3 Total Hrs

Shift 4 Date

Shift 4 Time In

Time

HoursMinutes

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Time

HoursMinutes

Shift 4 Total Hrs

Shift 5 Date

Shift 5 Time In

Time

HoursMinutes

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Time

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Shift 5 Total Hrs

Shift 6 Date

Shift 6 Time In

Time

HoursMinutes

Shift 6 Time Out

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Shift 7 Date

Shift 7 Time In

Time

HoursMinutes

Shift 7 Time Out

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HoursMinutes

Shift 7 Total Hrs

REASON FOR MISSED EVV

DUTIES

EMPLOYEE NOTE: By my signature, I do hereby attest that this information is true, accurate, and complete to the best of my knowledge and I understand that any falsification may subject me to administrative, civil or criminal liability.

If a consumer is hospitalized, admitted to a nursing facility or other residential setting, temporarily absent from the home for any reason, or deceased, you must notify the assigned ADHHC Coordinator immediately by calling 215-688-2705.

Employee Signature

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Consumer Signature

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TODAYS DATE

TIMESHEET

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DUTIES

Timesheets are due Immediately after receiving notification.