Missed Time Form Missed Time Form for Personal Care Aides to complete when not able to complete EVV on-site. X/TwitterThis field is for validation purposes and should be left unchanged.PERSONAL CARE AIDE Name(Required) First Last PERSONAL CARE AIDE Email(Required) Enter Email Confirm Email PERSONAL CARE AIDE Office(Required)Select the office you work for.BerwickBethlehemCamp HillDunmoreEast StroudsburgHonesdaleMontrosePottsvilleShamokin DamState CollegeWilkes-BarreWilliamsportCLIENT Full Name(Required)Total Hours Worked(Required)Service Time In(Required) Hours : Minutes AM PM AM/PM Service Time Out(Required) Hours : Minutes AM PM AM/PM Hand Washing(Required)Have you washed your hands today, before or during client care? Performed Not Performed BATH(Required)Bath/Shower, Sponge/Bed Bath, Shampoo, Shave, Oral/Denture Care, Dressing Performed Refused AMBULATION(Required)Distance, Frequency, Transfers, Bedbound, Cane/Crutches, Walker/Wheelchair Performed Refused BLADDER(Required)Catheter, Toilet/Commode, Bedpan/Urinal, Brief/Pad, Incontinent, Peri Care Performed Refused RANGE OF MOTION(Required)Assist with Movement, Apply Limb Prothesis, Braces, TEDS/Ace Wraps Performed Refused MEALS(Required)Restrict/Push Fluids, Feed Client, Meal Prep, Supplement Given, Weight Performed Refused SKIN(Required)Lotion, Nail Care, Turn & Position, Foot Soak, Dressing Change, Glasses, Hearing Aide Performed Refused HOUSEHOLD(Required)Vacuum, Laundry, Kitchen/Dishes, Bathrooms, Garbage, Make Bed/Linens Performed Refused IADL(Required)Shopping, Transportation, Appointments, Social Interaction, Companionship Performed Refused ADL Duties(Required)Please include any other duties performed: Hygiene Assistance, Incontinence Care, Medication Reminders, or Other. If other, please list the activity.CLIENT Signature(Required)Sign here.CLIENT Sign Date(Required) MM slash DD slash YYYY PERSONAL CARE AIDE SignaturePERSONAL CARE AIDE Sign Date(Required) MM slash DD slash YYYY