Support Worker Time Sheet
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1Fax signed timesheets to: 507-281-6117 or
Sign, scan and email to: or
Mail or deliver to:
PossAbilities of Southern Minnesota
1808 3
rd
Ave. SE
Rochester, MN 55904
SUPPORT WORKER TIME SHEET
Program:
Consumer Support Grant (CSG) Agency with Choice (CDCS)
Personal Support/Respite
(circle one)
Support Worker Name __________________________________________________
Consumer Name _______________________________________________________
For the Week of _____/_____/_____ to _____/_____/_____
If the individual was hospitalized during this pay period please indicate date entered ____/____/____ and date
released ___/___/___. Support workers cannot be paid for any hours in a day that the individual was
hospitalized or in a nursing home.
Instructions: Record the actual number of hours worked. YOU MUST DOCUMENT YOUR TIME IN AND TIME OUT FOR
EACH DAY YOU WORK. All overtime hours must be pre-approved by the County. Send the timesheet for the
previous week to PossAbilities by the end of the workday every Thursday. NOTE: Any late timecards will be
processed in the next payroll cycle.
SUNDAY
Time In __________
Time In __________
Total Hours Worked
___/___/___
Time Out ________
Time Out ________
For the Day __________
MONDAY
Time In __________
Time In __________
Total Hours Worked
___/___/___
Time Out ________
Time Out ________
For the Day __________
TUESDAY
Time In __________
Time In __________
Total Hours Worked
___/___/___
Time Out ________
Time Out ________
For the Day __________
WEDNESDAY
Time In __________
Time In __________
Total Hours Worked
___/___/___
Time Out ________
Time Out ________
For the Day __________
THURSDAY
Time In __________
Time In __________
Total Hours Worked
___/___/___
Time Out ________
Time Out ________
For the Day __________
FRIDAY
Time In __________
Time In __________
Total Hours Worked
___/___/___
Time Out ________
Time Out ________
For the Day __________
SATURDAY
Time In __________
Time In __________
Total Hours Worked
___/___/___
Time Out ________
Time Out ________
For the Day __________
Support Worker Signature _______________________________________________
Total Hours ________________
My signature means that the hours I have recorded are true. I understand that if I put down the wrong hours
on purpose it is fraud.
Managing Employer Signature _________________________________________________
(signature verifies that these are actual hours worked)
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