Missed Clock In/Out?Fill out this form to submit your missed time in and/or out.Caregiver Name *Participant Name *Missed Date *Missed Time In *Missed Out Time *Total Hours *0 / 8Select a reason(s) for adjustment. *Unable to connect to EVV, System down.Forget to clock in/out but worked all hour(s).Failed to clock in/out due to system error.Clock in/out of EVV system too early/Late.Member received service outside of home.Member won’t let caregiver to use phone.Member registered phone is not working.Address not linked to the member (GPS).Client request different time for service.Failed to report to Client’s home.Shopping for client, in/out from store.Client’s appointment, in/out from hospital.OtherOther *Select a service you provided. *HygieneMeal PrepLight HousekeepingShoppingHousework/ChoreManaging FinanceManaging MedicationTransportationDressing UpperDressing LowerLocomotionTransferToilet UseBed MobilityEatingIncontinenceBowel IncontinencePersonal CareBathingLotion/OintmentLaundrySupervisionHair CareSocial/leisure activitiesSupervised walkRange of MotionAmbulatingPhone UseCaregiver Consent *Caregiver: By my signature below, I attest that the record of time is true and accurate and that I provided the services indicated above.Caregiver Signature *Sign hereYour browser does not support e-Signature field.Participant Consent *Participant: I confirm that the caregiver worked the hours mentioned above on the date and time indicated.Participant Signature *Sign hereYour browser does not support e-Signature field.Submission Date *Submit FormPlease do not fill in this field.
