Missed Punch / Time Correction Request - Annapurna Home Care Agency

Employee & Consumer Information

Name of DCW:		Name of Consumer:
Service Address:

Time Entry

Date	Start Time	End Time	Hours

Reason for Missing (check all that apply)

Internet Issue
Forgot to clock out
Early or Late call in or out of the EVV system
Service received outside home
EVV system down
Other:

Activities

Code	Activity	Code	Activity
1	Hygiene	139	Reading/Writing
3	Light Housekeeping	140	Supervision/Coaching/Cueing
4	Shopping	141	Incontinence Care
5	Dressing	142	Catheter Care
115	Meal Preparation	143	Wound Care
120	Transportation	202	Via Telephone
125	Locomotion	203	Other
126	Transfer	209	Hair Care
127	Toilet Use	214	Skin Care
130	Bladder Incontinence	215	Foot Care
131	Bowel Incontinence	217	Toileting-Commode
132	Personal Care T1019	225	Assist with Feeding
134	Bathing	246	Medication Reminders
137	Lotion/Ointment	253	Accompany Patient to Appointment
138	Laundry	256	Assist with Exercises

Consumer Signature Date

Worker Signature Date