Ucpsa Mileage Form For Direct Care Staff Transporting Consumers printable pdf download

Ucpsa Mileage Form For Direct Care Staff Transporting Consumers

UCPSA Mileage Form for Direct Care Staff Transporting Consumers

Employee

Week

Client

Name:

Of:

To:

Name: _________________________________________

Saturday

Friday

A new mileage form must be completed for each consumer. Use this section to record only those miles accrued while transporting a consumer. Claims for

mileage are due weekly by Sunday, no later than 11:59 p.m.

**ALL COLUMNS MUST BE COMPLETED FOR EACH ENTRY, ONLY ONE STOP PER LINE**

Beginning

Ending

Total

Date

odometer

Beginning address

odometer

Ending address

Reason

miles

mm/dd/yr

reading

TOTAL:

__________ miles x $.38 = $_________________

By signing I agree that the following statements are true.

I have the permission of my supervisor to transport this consumer and to run the errands or take the outings listed below.

I have a current valid driver’s license, and a copy of it is on file with UCPSA.

I have current car insurance on the vehicle used to transport, and proof of the insurance coverage is on file with UCPSA.

I have current registration on the vehicle used to transport, and proof of current registration in on file with UCPSA

My vehicle has working seat belts and safe storage for any equipment.

If my daily total mileage per consumer exceeds 15 miles, I have received permission from my supervisor to go over the maximum allowable

mileage.

Employee Signature

______________________________________________ Date ________________

Client Signature

______________________________________________ Date ________________

DCW Mileage Form Revised June 2015

Ucpsa Mileage Form For Direct Care Staff Transporting Consumers