Weekly Timecard / Activity Daily Log Sheet Page 2

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WEEKLY TIMECARD /
ACTIVITY DAILY LOG SHEET
Employee Name:
Client Full Name:
Work Week Ending Sunday:
/
/ 20_____
Client Authorized
Employee Telephony Log-In #:
X
Signature:
(Last 4 digits of social security number)
IMPORTANT FOR CLIENT:
By signing this form, client or client rep certifies
LATE
ON TIME
NOT RECEIVED
that hours shown are correct, work was done satisfactorily and all transactions and
Office Use Only:
services were completed fully and are considered final. Please review carefully.
Input Work Date:
Work Day:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Hrs.
Min.
Hrs.
Min.
Hrs.
Min.
Hrs.
Min.
Hrs.
Min.
Hrs.
Min.
Hrs.
Min.
Start Time:
Less Break Time or
Personal Time:
End Time:
Total Hours Worked:
Total Mileage (if any):
Total
Total Hours / Minutes Worked Written Out
Hours
|
Minutes
Mileage
Total Hours Worked
Duties Performed
Mon
Tues
Wed
Thu
Fri
Sat
Sun
Duties Performed
Mon
Tues
Wed
Thu
Fri
Sat
Sun
Home Management / Reminders
Bathing
Grocery Shopping
Shampoo Hair
Light Housekeeping
Dressing/Undress
Laundry / Folding
Bed Bath
Change Linens
Tub Bath
Make Beds
Shower Assist
Medication Reminders
Personal Hygiene
Prepare Meals / Snacks
Toileting
Empty Trash
Change Briefs
Incidental Errands
Incontinence Care
Assist with Plants / Pets
Assist to Bathroom
Bathroom Maintenance
Assist Toileting
Kitchen Maintenance
Personal Clean Up
Transfers / Other
Activities
Transfer From Bed
Light Exercises
Transfer From Chair
Recreational
Hoyer Lift
Transportation
Slide Board
Meals / Eating
Transfer Belt
Meal Planning/Prep
Other (list below)
Feeding Assistance
Additional Notes
Client Use Only
__________________________________________________________________________
__________________________________________________________________________
INVOICE #______________
__________________________________________________________________________
__________________________________________________________________________
SYNERGY Ph #: 281-999-2273
__________________________________________________________________________
IMPORTANT FOR EMPLOYEE: By executing this form, employee agrees to
Employee Signature:
terms and conditions on employee copy of this form and Employee Policy and
Procedures. Employee certifies this form is true, complete and accurate.
X ________________________________________
Employee may be terminated for providing false information. Client/client rep
signature is required. Late timesheets will result in delayed payment of wages.
White Page: Turn into Office
Yellow Page: Give to Client/Client Rep
Pink Page: Employee Copy

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