KENTUCKY CONSUMER DIRECTED OPTION Week #1
Employee Timesheet
Employee: Representative: Pay Period Begins:
Employer: Support Broker: Pay Period Ends:
Service Date
[R4] CLS [81] [K1] RSP [77] [R2] HMK [82] [R1] PSC [83]
Time In Time Out Total Time In Time Out Total Time In Time Out Total Time In Time Out Total
0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00
Total: 0.00 Total: 0.00 Total: 0.00 Total: 0.00
By signing below, I certify that I have performed the work
listed above and attached service documentation.
__________________________________________ __________________________________________ __________________________________________
Representative Signature Date Employee Signature Date Support Broker Signature Date
KENTUCKY CONSUMER DIRECTED OPTION Week #2
Employee Timesheet
Employee: Representative: Pay Period Begins:
Employer: Support Broker: Pay Period Ends:
Service Date
[R4] CLS [81] [K1] RSP [77] [R2] HMK [82] [R1] PSC [83]
Time In Time Out Total Time In Time Out Total Time In Time Out Total Time In Time Out Total
0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00
0.00 0.00 0.00 0.00
Total: 0.00 Total: 0.00 Total: 0.00 Total: 0.00
By signing below, I certify that I have performed the work
listed above and attached service documentation.
__________________________________________ __________________________________________ __________________________________________
Representative Signature Date Employee Signature Date Support Broker Signature Date