EMPLOYEE:  %employee_name%  (%employee_id%)

WAIVER RECIPIENT:  %consumer_name%  (%consumer_id%)

EMAIL:  %email%

RATE:  %rate%

# IN GROUP:  %Number_in_Group%

DATE 1  (%date1%)

DATE 2  (%date2%)

Time In: %hrin_1%:%minin_1% Time Out: %hrout_1%:%minout_1%

Time In: %hrin_2%:%minin_2% Time Out: %hrout_2%:%minout_2%

Hours Worked: %total1%

Hours Worked: %total2%

SUMMARY

TOTAL HOURS WORKED: %total_worked%

Employee Electronic Signature: %ESignature1%

(I certify that my time sheet is accurate and true...that I worked these exact hours with the Waiver Recipient named above.)

Consumer/Guardian Signature:____________________________________________________

(I attest by my signature that the Waiver Staff named above provided services during the hours indicated.)

Form Submission Time: %_sfm_form_submision_time_%