Central Arizona Council On Developmental Disabilities
3687 S. Royal Palm Rd. P.O.Box 3670 Apache Junction, AZ 85117
Phone: 480-982-5015
Toll Free: 800-240-4131
Fax: 480-982-0679
ALL BOXES MUST BE COMPLETELY FILLED IN. IF YOU DON'T KNOW, ASK.
Provider Full Name
Consumer Full Name
Parent/Guardian Name
Service:
Staffing Ratio
Beginning Date:
Ending Date:
Pay periods run from the 1st through the 15th of every month and the 16th through the last day of the month.
Paydays are the 5th and the 21st of each month.
In the location box, enter a 1 if service is in the home of consumer or 2 for all others.
Date In Time In AM/PM
Date Out Time Out AM/PM
Hours
Location
Mileage/Other
Total
Parent/Guardian: Please sign the above entries only
after services are fully completed. Your signature
indicates the above entries are accurate and have been
carried out in accordance with service guidelines.
Please verify service code is correct.
Signature:
Date:
Provider: By signing this form you certify that you have
agreed to and have completed the service specifications
as agreed upon by the ISP team. Your signature also
certifies that the above entries are accurate and have been
performed in accordance with such guidelines.
Signature:
Special Instructions:
TIME SHEET IS NOT VALID UNLESS SIGNED BY ALL PARTIES
Date: