Form 3054-2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the 'Month and Year of Service' at the top of the form. This sets the context for the service delivery record.
3. Fill in the 'Employee Name' and 'Employee Mailing Address'. If multiple employees are involved, list their names in the designated area.
4. Next, provide the 'Client Name' and 'Client No.' along with the relevant 'County'.
5. In the section labeled 'TASK(S) ASSIGNED', check all applicable tasks such as Bathing, Meal Preparation, etc. Ensure you specify any additional tasks under 'Other'.
6. Record scheduled or authorized hours for each day of the week. Fill in 'In' and 'Out' times for each day, ensuring totals are calculated accurately.
7. Document daily time records by entering time in and out for each day of the month. Calculate total daily time and monthly totals accordingly.
8. Finally, both employee and timekeeper must sign where indicated to certify that all information is accurate.

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