Missed Clock In/Out?Fill out this form to submit your missed time in and/or out.Office Location *Please select an optionPittsburgh OfficeHarrisburg OfficeErie OfficeCaregiver Name *Participant Name *Caregiver CodeMember IDService Location *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).App connection failed due to internet issues.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).Member request different time for service.Failed to report to Client’s home.Errands with member, address outside of home.Member’s appointment, in/out from hospital.Internet issues, but worked all the hours.OtherOther *Select a service you provided. *Personal HygieneMeal PrepLight HousekeepingToilet UseBed MobilityEatingFeedingMedication ReminderMonitor SafetyLotion/OintmentMouth/Hair CarePersonal CareFall Risk PrecautionSkin/Foot CareBathingDressing UpperIncontinence CareBowel IncontinenceDressing LowerSupervisionPhone UseGroomingLaundrySocial/leisure activitiesSupervised walkHair CareAssist with ExercisesShoppingCaregiver Consent *Caregiver: By my signature below, I confirm that the record of date/time is accurate and that I provided the services indicated above.Caregiver Signature *Sign hereYour browser does not support e-Signature field.Member Consent *Participant: I confirm that the Direct Care Worker provided services 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.
