Missed Shift

Caregiver Manual Clock Form

Moravia Health expects its Caregivers to clock in daily using the provided tools. Should you be unable to do so, please provide your work details using the form below.

A completed form will be submitted to Payroll and a copy sent to your email.

    Have you washed your hands today, before or during client care? (Required*)

    PerformedNot Performed

    BATH (Required*)
    Bath/Shower, Sponge/Bed Bath, Shampoo, Shave, Oral/Denture Care, Dressing PerformedRefused
    BLADDER (Required*)
    Catheter, Toilet/Commode, Bedpan/Urinal, Brief/Pad, Incontinent, Peri Care PerformedRefused
    AMBULATION (Required*)
    Distance, Frequency, Transfers, Bedbound, Cane/Crutches, Walker/Wheelchair PerformedRefused
    RANGE OF MOTION (Required*)
    Assist with Movement, Apply Limb Prothesis, Braces, TEDS/Ace Wraps PerformedRefused

    SKIN (Required*)
    Lotion, Nail Care, Turn & Position, Foot Soak, Dressing Change, Glasses, Hearing Aide PerformedRefused
    MEALS (Required*)
    Restrict/Push Fluids, Feed Client, Meal Prep, Supplement Given, Weight PerformedRefused
    HOUSEHOLD (Required*)
    Vacuum, Laundry, Kitchen/Dishes, Bathrooms, Garbage, Make Bed/Linens PerformedRefused
    IADL (Required*)
    Shopping, Transportation, Appointments, Social Interaction, Companionship PerformedRefused

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