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 / 8Reason for Missed In / Out. *Service you provided. *Fall Risk PrecautionGroomingAssist with ExercisesSupervisionMedication ReminderToilet UseEatingLaundryFeedingBowel IncontinenceLight HousekeepingMeal PrepPersonal CareBathingLotion/OintmentMouth/Hair CareDressing LowerIncontinence CareSocial/leisure activitiesDressing UpperPhone UsePersonal HygieneSkin/Foot CareHair CareBed MobilitySupervised walkMonitor SafetyShoppingCaregiver 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 FormSave as DraftPlease do not fill in this field.
