Homemaker Timesheet	Choice One: S5130 or S5130.TF or S5130.TG
WEEK 1	Sun	Mon	Tues	Wed	Thurs	Fri	Sat	WEEK 2	Sun	Mon	Tues	Wed	Thurs	Fri	Sat
Month/Day/Year
Month/Day/Year
SHIFT 1
SHIFT 1
TIME IN	AM PM	AM PM	AM PM	AM PM	AM PM	AM PM	AM PM	TIME IN	AM PM	AM PM	AM PM	AM PM	AM PM	AM PM	AM PM
TIME OUT	AM PM	AM PM	AM PM	AM PM	AM PM	AM PM	AM PM	TIME OUT	AM PM	AM PM	AM PM	AM PM	AM PM	AM PM	AM PM
Shift 1 hours:
Shift 1 hours:
SHIFT 2
SHIFT 2
TIME IN	AM PM	AM PM	AM PM	AM PM	AM PM	AM PM	AM PM	TIME IN	AM PM	AM PM	AM PM	AM PM	AM PM	AM PM	AM PM
TIME OUT	AM PM	AM PM	AM PM	AM PM	AM PM	AM PM	AM PM	TIME OUT	AM PM	AM PM	AM PM	AM PM	AM PM	AM PM	AM PM
Shift 2 hours:
Shift 2 hours:
Total Daily Hrs:
Total Daily Hrs:
Week 1 Total Hours:
Week 2 Total Hours:
Activities	Employee: initial all activities you assisted the client with	Activities	Employee: initial all activities you assisted the client with
Wash dishes
Wash dishes
Clean kitchen
Clean kitchen
Empty garbage
Empty garbage
Clean bathroom
Clean bathroom
Make bed
Make bed
Change linens
Change linens
Vacuum
Vacuum
Dust
Dust
Laundry
Laundry
Mop floors
Mop floors
Meal prep (B, L, D)
Meal prep (B, L, D)
Grocery shopping
Grocery shopping
Errands
Errands
Shower
Shower
Socialization
Socialization
Recreation
Recreation
Transportation
Transportation
Acknowledgments and signatures:

After the employee has documented his or her time and activity, the recipient must draw a line through any dates and times he or she did not receive services from the employee. Review the completed timesheet for accuracy before signing -- do not sign a blank timesheet. Providing false information on billings for Medical Assistance payment is a federal crime. Your signature certifies the time and services entered above are accurate and that the services were performed as specified in your Care Plan.
Client name (printed):	Client date of birth:

Please use standard 12-hour time, in 15-minute increments, with time entered as decimals, not hours (e.g., 4.75 hours for 4 hours and 45 minutes). Indicate AM or PM for every "TIME IN" and every "TIME OUT." Every date box must have month/day/year entered for the entire timesheet. Staff must fill out the timesheet each shift and may never pre-fill the timesheet. The timesheet must be an original timesheet, not photocopied.

Incomplete, incorrect, or illegible timesheets cannot be accepted for billing. Use only black or blue ink
Client/responsible party signature:	Date:
Employee name (printed):	UMPI:	Care on Wheels Home Care FAX: 763-566-3029 or email: outreach@careonwheelshc.com

Call the office to verify your time sheet was received: 763-566-3038
Employee signature:	Date:
Timesheet due day is every other Tuesday at 3:00 PM. (See payroll calendar.)

MasterTimesheets2.4_PCADeadlinesLinked

Miata Getaweh

2023-07-05