Missed Clock & Adjustment Form

Clocking In & Out effectively is an important part of your job as a Caregiver. Accurately clocking in and out ensures we are billing and paying shifts accurately. Clocking In & Out through the app or telephony provides us with an EVV- Electronic Visit Verification. The EVV protects you. It shows that you were there in the home and it shows the times you were in that home. If you don't clock in, and you call the office so that we can do it for you, there is no EVV and you are now missing that layer of protection. This form is to be completed when a caregiver misses a clock in or out or needs to make an adjustment to their time or mileage. This form is required to process your pay for your shift. Failure to clock in and out of your shifts in an excessive manner can result in disciplinary action.

First Name

Last Name

Phone

Reason For Completing This Form

Missed Clock-In

Missed Clock-Out

Adjustment Needed (Time, Mileage, or Tasks)

Did not Complete Required Documentation

Clocking In & Out effectively is an important part of your job as a Caregiver. Accurately clocking in and out ensures we are billing and paying shifts accurately. Please explain why you missed your clock in or out, or why you need an adjustment to your time or mileage.

Do you need additional training on the WellSky App or Telephony?

No, I know how to use it.

Yes, I need assistance it is not working for me.

Client Name

Select a date

Clock-In Time

Clock-Out Time

Did you update your tasks and complete a log note for this shift? Documentation is required for every shift.

Yes

If no, please explain in detail what you completed during your shift for your Client. Please include any ADLs completed or refused by the client.

Mileage? (Driving that took place DURING your shift. Not in-between your shifts)

Additional Expenses? (If you have additional expenses please email a photo of the receipt to Brenda at: Brenda.Orellana@Homeinstead.com)

Your Signature

Missed Clock & Adjustment Form

Shift Information