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Get Sweet Home Health Care Time Sheet

Employee Signature Date Timesheets are due by 12 p.m. Monday. Please drop off fax to 267-639-9615 or email to timesheets sweethomehealthcare. com. You will NOT be paid without your timesheet. CONDITIONS Consumer agrees to terms of NET UPON RECEIPT and understands that unpaid accounts will be considered in default after thirty 30 days after which a default charge will be imposed at 1 per month on unpaid balances Annual rate of 18. or the legal interest whichever is lower. Client agrees to pay default charge and reasonable attorney s fee for cost of collection. Client recognizes the rights of Sweet Home HealthCare as the employer and agrees to NOT employ the person named herein for a period of 90 days following termination of this assignment unless assessment fee is paid. Fee is 2500. Sweet Home Primary Care LLC TIME SHEET Time Period thru Monday through Sunday PRINT EMPLOYEE NAME PRINT CONSUMER NAME CLASSIFICATION DCW / HHA / CNA DAY Mon Tues Wed Thu Fri Sat Sun DATE START TIME FINISH TOTAL TIME LESS BREAK AUTHORIZED CONSUMER SIGNATURE ACTIVITY RECORD Directions This is a legal document. Check the assignment/care plan* Check each activity that is completed* Indicate by R if an assigned activity is refused by the consumer. Use the comments section below for refusal reason* Consumer changes should be called to the supervisor. Use H for hospitalizations. ACTIVITY Bath Chair. Bed*. Tub Shower/Partial Bath Shampoo/ Hair set up Nail Care set up Dressing Oral Hyg/Dentures Shave set up Skin Care Lotion set up TOTAL HOURS CONSUMER NOTE By your signature you certify that hours shown are correct work was completed satisfactorily and you agree to the terms listed below. EMPLOYEE NOTE By your signature you certify that the hours recorded for the above dates are true and accurate and are properly verified by the client. Employee Signature Date Timesheets are due by 12 p*m* Monday. Please drop off fax to 267-639-9615 or email to timesheets sweethomehealthcare. com* You will NOT be paid without your timesheet. CONDITIONS Consumer agrees to terms of NET UPON RECEIPT and understands that unpaid accounts will be considered in default after thirty 30 days after which a default charge will be imposed at 1 per month on unpaid balances Annual rate of 18. or the legal interest whichever is lower. Client agrees to pay default charge and reasonable attorney s fee for cost of collection* Client recognizes the rights of Sweet Home HealthCare as the employer and agrees to NOT employ the person named herein for a period of 90 days following termination of this assignment unless assessment fee is paid* Fee is 2500. 00 for individuals 25 of projected annual wage for facilities. DO NOT pay the employee directly. No credit can be assured against the current invoice. Employee BONDING claims are only assured if claims are made in writing and to the local police within 14 days after notice of loss. FORM Foot Care set up Meal preparation Eating/drinking Laundry/Linen Light housekeeping Shopping Remind to take meds Reading/writing Social activities Telephone/devices Transportation/Escort Appt scheduling Personal possessions Seasonal clothing ROM Ambulating Supervised walks Supervise/coach/cue Transfers Bowel/bladder mgt. .

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