TOPEKA INDEPENDENT LIVING RESOURCE CENTER

PERSONAL ASSISTANT MANAGEMENT SERVICES – P.D. WAIVER

NIGHT SUPPORT

Consumer: Personal Assistant:

DATE / TIME
IN
PM / TIME
OUT
PM / TIME
IN
PM / TIME
OUT
PM / TIME
IN
AM / TIME OUT AM / TIME IN
AM / TIME OUT AM / TOTAL
PER
NIGHT
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31

WORKED MONTH OF ______YEAR OF ______MAIL ON 1st

Signature of Signature of

Consumer X______P.A. X______

Address______Address______

City/Zip______City/Zip______

Phone ( ) ______Phone ( ) ______

BY SIGNING THIS TIME SHEET WE AGREE THAT THE HOURS WERE WORKED, ARE ACCURATE AND WITHIN THE PLAN OF CARE. KNOWINGLY SUBMITTING TIME SHEET WITH FALSE INFORMATION IS CONSIDERED FRAUD, AND IS A PUNISHABLE CRIME. TIME SHEETS WILL BE RETURNED FOR CORRECTIONS IF OVER THE PLAN OF CARE.

TOPEKA (785) 233-4572 FAX (785) 233-1561 OUTSIDE TOPEKA 1-800-443-2207

TOPEKA INDEPENDENT LIVING RESOURCE CENTER

PERSONAL ASSISTANT MANAGEMENT SERVICES – P.D. WAIVER

NIGHT SUPPORT

Consumer: Personal Assistant:

DATE / TIME
IN
PM / TIME
OUT
PM / TIME
IN
PM / TIME
OUT
PM / TIME
IN
AM / TIME OUT AM / TIME IN
AM / TIME OUT AM / TOTAL
PER
NIGHT
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

WORKED MONTH OF ______YEAR OF ______MAIL ON 16TH

Signature of Signature of

Consumer X______P.A. X______

Address______Address______

City/Zip______City/Zip______

Phone ( ) ______Phone ( ) ______

BY SIGNING THIS TIME SHEET WE AGREE THAT THE HOURS WERE WORKED, ARE ACCURATE AND WITHIN THE PLAN OF CARE. KNOWINGLY SUBMITTING TIME SHEET WITH FALSE INFORMATION IS CONSIDERED FRAUD, AND IS A PUNISHABLE CRIME. TIME SHEETS WILL BE RETURNED FOR CORRECTIONS IF OVER THE PLAN OF CARE.

TOPEKA (785) 233-4572 FAX (785) 233-1561 OUTSIDE TOPEKA 1-800-443-2207