EVV Timesheet | Decent Home Care

1. Worker and participant

Direct Care Worker's Name

Participant's Name

Last 4 digits SSN Only the last 4 digits. Never enter a full Social Security number.

Medicaid Id

2. Service details

Date of Service

Service Location

Start Time

End Time

Total Hours Suggested from Start/End Time — review and adjust if needed.

3. Activities performed

Mark Yes or No for each activity that applies. You may leave an activity unanswered if it does not apply.

Duty of Code Activity Performed

115 Meal Preparation Yes No

116 Housework/Chore Yes No

117 Managing Finance Yes No

118 Managing Medication Yes No

119 Shopping Yes No

120 Transportation Yes No

122 Hygiene Yes No

123 Dressing upper Yes No

124 Dressing Lower Yes No

125 Locomotion Yes No

126 Transfer Yes No

127 Toileting Yes No

128 Bed Mobility Yes No

129 Eating Yes No

130 Bladder/Incontinence Yes No

131 Bowel Incontinence Yes No

132 Personal Care T1019 Yes No

134 Bathing Yes No

137 Lotion/Ointment Yes No

138 Laundry Yes No

139 Reading/Writing Yes No

140 Supervision/Coaching/Cueing Yes No

141 Incontinence Care Yes No

142 Catheter Care Yes No

143 Wound Care Yes No

144 G-Tube Feeding Yes No

145 Stair Yes No

201 In person Yes No

202 Phone Use Yes No

204 Bath-Tube Yes No

205 Bath-Shower Yes No

206 Bed-Bath Yes No

208 Mouth Care/Denture Yes No

209 Hair Care Yes No

210 Grooming-Shave Yes No

211 Grooming-Nails Yes No

214 Skin Care Yes No

215 Foot Care Yes No

216 Toileting-commode Yes No

221 Prepare Breakfast Yes No

222 Prepare Lunch Yes No

223 Prepare-dinner Yes No

224 Prepare Snack Yes No

225 Assist with feeding Yes No

226 Record intake- Food Yes No

227 Record Intake-fluid Yes No

228 Transferring Yes No

229 Assist with walking Yes No

232 Range of Motion Yes No

233 Turning and Positioning Yes No

244 Remind to take Medication Yes No

247 Change bed linen Yes No

249 Light Housekeeping Yes No

250 Clean Bathroom Yes No

256 Assist with exercise Yes No

257 Monitor Patient Safety Yes No

265 Safe Transfer Precaution Yes No

266 Other Helps Yes No

4. Missed punch reason

Select all reasons that apply

Internet Problem Attendant call in or call out of the Evv system early or late. Attendant fail to call In Attendant fail to call Out EVV system Down Data entry error. Attendant unable to use the mobile device Address did not link to the client (GPS) Attendant fail to call in and call out Others

5. Attestations and signatures

Direct Care Worker: By signing this form, I acknowledged that the hours I missed for Punch In/ Punch Out shown in this form are true and correct and the work was performed according to the Participant's plan of Care.

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By signing, I confirm the information and attestation shown above.

Direct Care Worker signature date

Consumer Note: By signing this timesheet, I agree that I have received care as per the plan of care:

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By signing, I confirm the information and attestation shown above.

Participant signature date

Provider Signature, Agency Role, and Provider Date are completed by Decent Home Care staff and are not collected on this page.

Email copy (optional)

Email address

Confirm email address

Email me a copy of my completed form.

Support for everyday life at home

Resources for families and caregivers

Paying for care

Working with us

EVV Missed Punch Timesheet

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This form contains sensitive personal information