Pathways Of Sw Pa Awc Hourly Time Sheet
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1Pathways of SW PA
AWC Hourly Time Sheet
Service: Check ONLY one service per timesheet
Home & Community Habilitation
Respite In-Home 15 minutes
Respite Out of Home 15 minutes
Companion
Respite-In Home 24 hour
Respite Out of Home 24 hour
Supported Employment
Employee: ______________________________________
Consumer: ______________________________
Pay Period: ___________________to__________________
County: ______________________________
Week #1
Sunday
Monday
Tuesday
Wednesday Thursday Friday
Saturday
Date
In
Out
In
Out
In
Out
Total Hours
Week #1
Total hours
per day
Week #1
Week #2
Sunday
Monday
Tuesday
Wednesday Thursday Friday
Saturday
Date
In
Out
In
Out
In
Out
Total Hours
Week #2
Total hours
per day
Week #2
My signature certifies that I received/provided service listed above. I understand that payment for this service will
be from Federal and State funds, and that any false claims, statements, or documents or
Total Hours
concealment of material facts may be prosecuted under applicable Federal and State Laws.
Employee Signature______________________________________________ Date_________________
Consumer/Managing Employer Approval_____________________________ Date_________________
AWC Director Approval____________________________________________ Date_________________
(12/2014 ly)
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Parent category: Business