To serve as the primary time keeping document to record the service delivery activities performed by the provider.
When to Prepare
The service provider/employee completes this form every two weeks or as requested by the employer. The employer reviews and approves the hours worked and the activities conducted and submits it to the Financial Management Services Agency (FMSA) every two weeks as a time sheet.
Number of Copies
Original and one copy.
The Consumer Directed Services (CDS) employer sends the original or a copy to the FMSA and keeps a copy.
This form must be printed or downloaded from the Consumer Directed Services Handbook.
The employer must keep this form for five years after termination of the employee's employment or until resolution of all outstanding litigation, claims and audits.
Program — Enter the name of the program.
Participant Name — Enter the name of the person receiving services.
Pay Period — Enter the dates of service delivery for the pay period as determined by the FMSA.
Employer Name — Enter the employer's name.
Service Provider Name — Enter the name of the person who provided the service.
Service Type — Check the appropriate box for the service that was provided. Enter the name of the service for Other.
Service Date — Enter the date the service was provided in MM/DD/YYYY format.
Time In — Enter the exact time that the service began.
Time Out — Enter the exact time that the service ended.
Total Hours — Enter the number of hours the service was provided. The total hours will automatically calculate at the end of the column.
Place of Service — Enter the place the service was provided.
Written Narrative— The written narrative/summary verifies the delivery of the service event and is written by the provider who delivered the service(s). The provider must complete a written narrative after delivering the service and must always provide sufficient detail to explain the activity(ies) that occurred during the service event.
For Home and Community-based Service (HCS) and Texas Home Living (TxHmL) waivers — The written summary must document how the activities were linked to the service goals on the person’s service plan. The summary addresses progress toward service delivery goals and objectives.
Signature of Service Provider/Date — The provider must sign and date this completed form.
Signature of Employer or Designated Representative (DR)/Date — The employer or DR must sign and date this form.