Employee Timesheet Page 2
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1
2Section 1:
Employee Timesheet Instructions and Sample
Print service provider name,
participant name, Medicaid
number and employer name
if different from Participant
(Client).
Section 2:
Select one
program and
one service.
Section 4:
Total the hours
worked each day.
Section 3:
Record the hours
Section 5:
worked for the day.
Total weekly hours
Select AM or PM for
will be calculated
time in and time out.
automatically. If not
filled out electroni-
cally, please add
total hours here.
Section 6:
Check if
1/17/2016 - 1/18/2016
Section 8:
applies
Record dates if the
participant was
admitted to a facility.
Remember an
employee cannot
work these days.
F an S natra
Mark Jacobs
Section 9:
Both the employer or designated
Section 10:
representative and
Timesheets MUST be signed and
employee must sign for
dated AFTER the work is completed.
the work time to be paid.
Advance time sheets will not be accepted.
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Parent category: Business