Form Sr 2a Phv-Ctf-Nurse - Ctf Nurse Paid Hours Verification Worksheet

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CTF NURSE PAID HOURS VERIFICATION WORKSHEET
MONTH:
GROUP HOME:
SR 2A
VERIFIED TIME
REPORTED PAID
VERIFIED PAID
REPORTED TIME
TOTAL
AUDITED
CCS/FIRST LINE
HOURS
CARD HOURS
HOURS
HOURS
GROSS
AUDITED
CARD HOURS
HOURS
DIFF.FROM
COMMENTS *
SUPERVISOR NAME
REPORTED
WAGES
HOURLY
ALLOWED
REPORTED
1st
1st
2nd
2nd
1st
2nd
1st
2nd
PAID
RATE
SR 2A
Period
Period
Period
Period
Period
Period
Period
Period
TOTAL
*LEGEND
1.
Per Payroll Hours
2.
Per time card hours
3.
54-hour limitation
4.
Did not meet CCL requirements
5.
Minimum wage requirement
6.
No allocation between functions
Page____ of ____
SR 2A PHV-CTF-NURSE (1/03)

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