2000 Linglestown Rd, Suite 101 Harrisburg, PA 17110
Phone: 717-298-3555
Pay Period (Dates)
Thru
Shift One
Shift Two
Directions: This is a legal document. Check the assignment/care plan. Check each activity that is completed. Indicate “R” if an assigned activity is refused by the consumer. Indicate “H” for hospitalizations. Consumer changes, including hospitalizations should be called in to the Case Manager, IMMEDIATELY. 717-298-3555 Ex. 2
Consumer Note: By your signature, you certify that hours shown are correct, and work was completed satisfactorily for the days and time documented:
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.
