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Month Of: by 3YMS37H8

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									                                                                          Project Insight Inc.                                            Service Log
Month Of:

                                                                                                                       Client /
             Begin                         End                                                             Type of
 Date                                                                  Hours           Client                         Guardian    Comments & Observations
             Time                          Time                                                            Service
                                                                                                                       Initial
                           am      pm                    am       pm
                           am      pm                    am       pm
                           am      pm                    am       pm
                           am      pm                    am       pm
                           am      pm                    am       pm
                           am      pm                    am       pm
                           am      pm                    am       pm
                           am      pm                    am       pm
                           am      pm                    am       pm
                           am      pm                    am       pm
                           am      pm                    am       pm
                           am      pm                    am       pm
                           am      pm                    am       pm
                           am      pm                    am       pm
                           am      pm                    am       pm


Note: Staff and Client / Guardian Signatures confirm that the hours shown above are a true and accurate account of the length and type of
service provided. Services not authorized by DDD, Project Insight and initialed by client or guardian will not be paid. Completed Service
Logs must be received in the Tucson office by 9:00 AM on the 1st and 16th of each month. Logs received late will not be paid until the
following pay period. Logs received more than 45 days after the date of service will not be paid.

Staff Name: (Print)                                                                  Total Number of Hours:


Staff Signature:                                                                     Supervisor’s Signature:

                                                                                                               Date Received:
C:\Docstoc\Working\pdf\6fe716b1-41ba-4313-8289-fcf377932516.doc

								
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