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Sweet home healthcare timeshee... Employee Signature Date Timesheets are due by 12 p.m. Monday. Please drop off fax to 267-639-9615 or email to timesheets sweethomehealthcare. com. You will NOT be paid without your timesheet. CONDITIONS Consumer agrees to terms of NET UPON RECEIPT and understands that unpaid accounts will be considered in default after thirty 30 days after which a default charge will be imposed at 1 per month on unpaid balances Annual rate of 18. or the legal interest whichever is lower. Client agrees to pay default charge and reasonable attorney s fee for cost of collection. Client recognizes the rights of Sweet Home HealthCare as the employer and agrees to NOT employ the person named herein for a period of 90 days following termination of this assignment unless assessment fee is paid. Fee is 2500. Sweet Home Primary Care LLC TIME SHEET Time Period thru Monday through Sunday PRINT EMPLOYEE NAME PRINT CONSUMER NAME CLASSIFICATION DCW / HHA / CNA DAY Mon Tues Wed Thu Fri Sat Sun DATE START TIME FINISH TOTAL TIME LESS BREAK AUTHORIZED CONSUMER SIGNATURE ACTIVITY RECORD Directions This is a legal document. Check the assignment/care plan* Check each activity that is completed* Indicate by R if an assigned activity is refused by the consumer. Use the comments section below for refusal reason* Consumer changes should be called to the supervisor. Use H for hospitalizations. ACTIVITY Bath Chair. Bed*. Tub Shower/Partial Bath Shampoo/ Hair set up Nail Care set up Dressing Oral Hyg/Dentures Shave set up Skin Care Lotion set up TOTAL HOURS CONSUMER NOTE By your signature you certify that hours shown are correct work was completed satisfactorily and you agree to the terms listed below. EMPLOYEE NOTE By your signature you certify that the hours recorded for the above dates are true and accurate and are properly verified by the client. Employee Signature Date Timesheets are due by 12 p*m* Monday. Please drop off fax to 267-639-9615 or email to timesheets sweethomehealthcare. com* You will NOT be paid without your timesheet. CONDITIONS Consumer agrees to terms of NET UPON RECEIPT and understands that unpaid accounts will be considered in default after thirty 30 days after which a default charge will be imposed at 1 per month on unpaid balances Annual rate of 18. or the legal interest whichever is lower. Client agrees to pay default charge and reasonable attorney s fee for cost of collection* Client recognizes the rights of Sweet Home HealthCare as the employer and agrees to NOT employ the person named herein for a period of 90 days following termination of this assignment unless assessment fee is paid* Fee is 2500. 00 for individuals 25 of projected annual wage for facilities. DO NOT pay the employee directly. No credit can be assured against the current invoice. Employee BONDING claims are only assured if claims are made in writing and to the local police within 14 days after notice of loss. FORM Foot Care set up Meal preparation Eating/drinking Laundry/Linen Light housekeeping Shopping Remind to take meds Reading/writing Social activities Telephone/devices Transportation/Escort Appt scheduling Personal possessions Seasonal clothing ROM Ambulating Supervised walks Supervise/coach/cue Transfers Bowel/bladder mgt.

Form timesheet_template englis... Contract Management Team 12/F., Fortis Tower, 7779 Gloucester Road, Wanchai, HK Hotline: +852 2830 0148 Fax: +852 2895 3673 contract.hk adecco.com (General Enquiry) timesheet.hk adecco.com (Timesheet)

Time sheet time sheet edway la... TIME SHEET ABN: 37 127 531 186 To avoid delay with payment, time sheet MUST be EMAILED (timesheets edwaylabourhire.com.au) or FAXED (02 9687 8490) by SUNDAY NIGHT of the working week. Subject heading

Timesheet attendant care palco... www.palcofirst.com Arkansas SDSB Biweekly Timesheet Make plenty of copies of this timesheet. This is the only timesheet that will be accepted. If you make a mistake, mark a single line through the

Ppl timesheet form PCG PUBLIC PARTNERSHIPS, LLC ATTENDANT TIME SHEET (Fiscal Intermediary for the VA DMAS & CCC Consumer Direction Programs) PPL Attendant ID: Service Type(fill one)Attendant 's Name:RespiteConsumer

Sunday end date form Timecards are due EVERY Monday before 10 am. We accept faxed or emailed timecards. For reference always keep a copy of the timecard. Timecards must be legible and completely filled out. Two signatures are required to have your timecard processed yours and the property managers. PROPERTY NAME SUNDAY END DATE ADDRESS CITY PRINT YOUR NAME 877 203-8667 timecards bgstaffing. com SOCIAL SECURITY NO. DAY DATE HOURS TO NEAREST QUARTER HOUR START LUNCH HOURS MON EMPLOYEE I CERTIFY THAT THE HOURS SHOWN HEREIN REPRESENT THE TOTAL HOURS WORKED THIS WEEK BY ME AND WILL BE ADVANCED BY BG STAFFING UNTIL PROPERLY VERIFIED BY THE CLIENT. 4 This agreement is entered into and performable in the State of Texas. In the event enforcement becomes necessary then venue will be in the courts of Dallas County Texas. DAY DATE HOURS TO NEAREST QUARTER HOUR START LUNCH HOURS MON EMPLOYEE I CERTIFY THAT THE HOURS SHOWN HEREIN REPRESENT THE TOTAL HOURS WORKED THIS WEEK BY ME AND WILL BE ADVANCED BY BG STAFFING UNTIL PROPERLY VERIFIED BY THE CLIENT. I AGREE TO CALL THE BG STAFFING OFFICE BETWEEN THE HOURS OF 8 00 AM AND 9 00 AM THE NEXT REGULAR WORK DAY FOLLOWING THE CONCLUSION OF MY ASSIGNMENT WITH THE CLIENT TO MAKE MYSELF AVAILABLE FOR NEW ASSIGNMENTS. I UNDERSTAND AND ACKNOWLEDGE THAT IF I FAIL TO DO SO BG STAFFING MAY ASSUME THAT I HAVE VOLUNTARILY QUIT WITHOUT GOOD CAUSE ASSOCIATED WITH WORK AND THAT SUCH A VOLUNTARY QUIT MAY RESULT IN MY BEING DENIED UNEMPLOYMENT BENEFITS. TUE DRAW LINE THROUGH DAYS NOT WORKED WED YOUR SIGNATURE THU X FRI CLIENT YOUR SIGNATURE REPRESENTS THAT YOU ARE IN AGREEMENT WITH ALL THE TERMS AND CONDITIONS ON FRONT AND REVERSE SIDE HEREOF AND THAT THE HOURS SHOWN ARE CORRECT AND THE WORK WAS COMPLETED SATISFACTORILY. FINISH SAT TITLE SUN QTR. HR. TOTAL HOURS PURCHASE ORDER NUMBER FORM BG - TC5001 REV 2/14 EMPLOYEE INFORMATION Employee Information NEVER CALL THE CLIENT IF YOU ARE LATE OR CANNOT WORK THE ASSIGNED HOURS CALL US. DO NOT CALL THE CLIENT. Performed in a satisfactory manner and Example Timecard Jane Doe Dallas 1 2 3 4 5 6 7 8 9 John Doe 1/18 1/19 1/20 ABC Property 1/21 1/22 1/23 1/24 DRAW 6 LINE CLIENT Mgr YELLOW COPY - EMPLOYEE 1212 Yellow Drive 1 24 10 PINK COPY - CLIENT WHITE COPY - BG STAFFING vices that - a The Client shall not entrust the Service s employees with cash. IT IS YOUR RESPONSIBILTY to get a signature from the client and turn in your time card in a timely manner. Payment shall be due within ten 10 days of Agency s invoice. If Customer employs directly or indirectly at any location or property owned or managed by the customer any individual submitted by Agency within 180 days of introduction Customer shall pay the fee to Agency.

Fin del periodo 15 28 30 31 in... Si trabaja en ambos periodos usted necesita entregar una tarjeta de tiempo por periodo y por cliente. Un buz n est disponible despu s de horas de trabajo y fines de semana para entregar tarjetas de tiempo. Quarter/Primer Trimestre 3rd. Quarter/Tercer Trimestre PAY PERIOD Periodos de Pago TIME CARD DUE Tarjetas de Tiempo se Vencen 01/01/17 - 01/15/17 01/16/17 01/31/17 02/01/17 02/15/17 02/16/17 02/28/17 02/15/17 02/28/17 03/31/17 Sun Tues Wed Fri PAY DATE D a de Pago 03/26/17 04/10/17 Thur Mon Tarjetas de Tiempo se Vencen 09/16/17 09/30/17 07/15/17 Sat 07/31/17 Mon 08/15/17 Tues 08/31/17 Thur 09/15/17 Fri 09/30/17 Sat 07/26/17 Wed 08/26/17 Sat 09/10/17 Sun 09/26/17 Tues 2nd. Com Pay Period Ending Circle One Circule uno Year A o Fin del Periodo IN-HOME RESPITE WORKER TIME RECORD Month Mes Look in the back of your time card to see when your time card is due / Revise al reverso de su tarjeta de tiempo para verificar cuando es la fecha limite para entregarla. Your time card is due even if the due date is a Saturday or Sunday / Su tarjeta de tiempo se vence aunque el d a de entregar sea s bado o domingo. Cuando el d a de pago cae en s bado domingo o d a festivo usted recibir su pago el siguiente d a h bil. 2017 HOLIDAYS no Respite is provided New Year s Day January 1 - Sunday Dr. Para proveer servicios de respite se requieren certificados vigentes de RCP y Primeros Auxilios de una agencia autorizada. Employee Signature/Firma del Empleado X Date/Fecha Comments/Corrections Authorized Office Signature Date In-Home Respite Worker Time Record PP -Inland 1-1-17 Title PAY PERIOD SCHEDULE 2017/PERIODO DE PAGO 2017 1st. NOTAS IMPORTANTES Cambio de Nombre Traer su nueva tarjeta de Seguro Social y su Licencia de Manejo con el cambio de nombre Cambio de Direcci n Llene la forma de Informaci n Personal de Empleado. INLAND RESPITE Indio Office 43430 Monroe Street Suite F Indio CA. 92201 Tel. 760 342-2290 Fax 760 863-1034 Preferred Provider indiopayroll invlrespite. I certify that respite was provided at the client s home. I Respite Worker certify that the hours shown above are correct and that I performed satisfactorily my duties and met the terms and conditions set forth in the respite regulations. Address Change Complete an Employee Personal Information form* If you worked on both pay periods you need to submit one time card per pay period per client. A drop box is available after hours and on weekends to turn in your time card. Parent/Caregivers are not allowed by Regional Center to give hours away that have not been worked* This is Fraud. Address Change Complete an Employee Personal Information form* If you worked on both pay periods you need to submit one time card per pay period per client. A drop box is available after hours and on weekends to turn in your time card. Parent/Caregivers are not allowed by Regional Center to give hours away that have not been worked* This is Fraud.

Officer weekly time sheet fmc... Officer Weekly Time Sheet Period of / / to / /First Name:Middle Int.:Last Name:EE ID#Regular Hours Worked DateDayINOutHrs WorkedInmate Name/ # / / Monday : : / / Tuesday : : / / Wednesday : : / /

Free timesheet template excel... Registrar\'s Office San Francisco State University 1600 Holloway Avenue San Francisco, CA 94132 Phone: (415)3382350 Fax: (415)3380588 Email: records@sfsu.eduSan Francisco State University Request

Cdcr 998 timesheet form OFFICE OF PEACE OFFICER SELECTION CDCR 1902 Rev. 11/2012 CALIFORNIA DEPARTMENT OF CORRECTIONS AND REHABILITATION PERSONAL HISTORY STATEMENT CONFIDENTIAL INSTRUCTIONS FOR COMPLETING THE PERSONAL HISTORY STATEMENT Document must be typed. Handwritten documents will not be accepted. Complete all required fields if nothing applies input N/A to move to the next question. Use Section 17 Supplemental Page to expand on any answers. All employees regardless of assignment shall be clean and well groomed. Specific personal grooming standards pertaining to facial hair hair length hair color fingernails cosmetics and jewelry can be found in the Department Operations Manual Chapter 3 Section 33020. 6. 1. NO HOSTAGE POLICY The CDCR has a no hostage policy. The policy states Employees must not permit inmates or others to use hostages to escape from custody or otherwise interfere with orderly institutional operations. Hostages will not be recognized for bargaining purposes. All inmates visitors and staff will be informed of this regulation. USE OF FORCE POLICY The CDCR has a use of force policy. As a peace officer you may be required to use a variety of reasonable force techniques to ensure the safety and security of the institution in which you work. This could range from the use of verbal instructions and orders to the use of firearms. If the need arises in the course of your employment as a peace officer to shoot another human being would you refuse or delay doing so for personal political religious or other reasons or delay doing so for personal political religious or other reasons I certify that I have read and understand the above information and policies. ISSUING CITY/STATE CITATION REASON CONVICTED OF CONVICTED OF Have you been the driver in a motor vehicle accident within the past 7years DATE OF INJURY ACCIDENT CITED POLICE AGENCY NAME ACCIDENT POLICE INVESTIGATE CITED SECTION 13 INMATE/PAROLEE/GANG ASSOCIATION/MEMBERSHIP Corrections and Rehabilitation Have you any family relative or friend ever been the victim of a violent crime in which the offender was/is currently an inmate or ward under the jurisdiction of the California Department of Corrections and Rehabilitation INMATE/PAROLEE S FRIEND/RELATIVE/ASSOCIATE S NAME OF INMATE/WARD/PAROLEE PRISON NUMBER NAME OF PRISON/FACILITY INCARCERATED OR PAROLED DATES To and From RELATIONSHIP TO YOU Has any of your friends family or relatives ever been a member of or associated with a street or prison gang Have you ever attended a gathering function or party of a street or prison gang overthrow of the United States Government or the State of California by force or violence or any unlawful means Are you willing to take an oath to support the United States Constitution and the California State Constitution SECTION 14 GENERAL QUESTIONS Have you used a fake ID or the ID of another person Did you omit lie or commit fraud on any documents you submitted for evaluation for a peace officer position with CDCR Are you freely willing to work split shifts nights weekends and holidays as a CDCR peace officer SECTION 15 CERTIFICATION OF UNDERSTANDING GROOMING STANDARDS The CDCR has a grooming standard for Peace Officers. All employees regardless of assignment shall be clean and well groomed. Specific personal grooming standards pertaining to facial hair hair length hair color fingernails cosmetics and jewelry can be found in the Department Operations Manual Chapter 3 Section 33020. Personal History Statements must be notarized. See page 2. Please submit the following documents along with the Personal History Statement o Certified United States Birth Certificate or Original Naturalization Certificate Documents reflecting any name changes from your Birth Certificate. This includes marriage certificates divorce decrees court adoption documents etc. Certified and Sealed High School Transcripts or Certified proof of GED or passing California High School Proficiency exam DD214 Military Discharge documents Member 4 long form if you served in the Military. Copy of current/valid automobile insurance Current dated within 30 days of turning in documents Credit Report from one of the following Experian Equifax Transunion Professional License or Credential if applicable to position I have read and fully understood the instructions LOCATION AND CONTACT INFORMATION Northern Field Office 9838 Old Placerville Road Suite B Sacramento CA 95827 916 255-2500 Central Field Office 2510 S. East Avenue Suite 360 Fresno CA 93706 559 445-5770 9055 Haven Avenue Suite 100 Rancho Cucamonga CA 91730 909 944-6676 AUTHORIZATION TO RELEASE INFORMATION PLEASE SIGN AND INITIAL THIS DOCUMENT IN THE PRESENCE OF A NOTARY PUBLIC A photocopy of t his A uthorization t o Release Information shall be as binding as t he original and will be sent t o all employers and law enf orcement agencies during the course of the background investigation under the authority of California Government Code 1031.

Gifted healthcare timesheet fo... 2748 Metairie Lawn Dr., Ste. B * Metairie, LA 70002 Tel 504.831.2123 * Fax 504.831.2820 www.giftednurses.com * 1.877.83NURSE * email: payroll giftednurses.com 114 Northpark Blvd., Ste. 4 * Covington,

Aris solutions electronic time... ARIS Solutions Electronic Timesheet Submission Registration Form Name: * Required (Please print clearly) Email Address: * Required (Please print clearly) Telephone Number: I am registering as an Employer

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