CARE PLUS Home Health & Training

  

          Name:___________________________                 ___CNA  ___LPN  ___RN         

          Client:____________________________              Month____________2012

          Pay periods     1^st – 15^th        16^th-31^st      -   write in dates.      Round times to nearest ¼ hour. 

Overtime, Holiday, mileage must be preapproved.

Sun	Mon	Mail	Tues	Wed	Thurs	Fri	Sat	Office Use
	Time in _____ Time Out_____ Total Hr _____	Mail	Time in _____ Time Out_____ Total Hr _____	Time in _____ Time Out_____ Total Hrs _____	Time in _____ Time Out_____ Total Hrs _____	Time in _____ Time Out_____ Total Hrs _____	Time in _____ Time Out_____ Total  _____
	Time in _____ Time Out_____ Total Hr _____	Mail	Time in _____ Time Out_____ Total Hr _____	Time in _____ Time Out_____ Total Hrs _____	Time in _____ Time Out_____ Total Hrs _____	Time in _____ Time Out_____ Total Hrs _____	Time in _____ Time Out_____ Total Hr _____
	Time in _____ Time Out_____ Total Hr _____	Mail	Time in _____ Time Out_____ Total Hr _____	Time in _____ Time Out_____ Total Hrs _____	Time in _____ Time Out_____ Total Hrs _____	Time in _____ Time Out_____ Total Hrs _____	Time in _____ Time Out_____ Total Hr _____

Payroll Notes:____________________________________________________________
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Client/Representative Signature:______________________________________________________

Client - Please confirm information given is accurate.  Mileage is billed directly to you unless other arrangements have been made.  Contact the office with any questions or concerns