PURPOSE

• To serve as the primary document to record an employee's daily work schedule and assigned tasks.
• To document changes to the employee's work schedule or to the employee's assigned tasks, or to both.

PROCEDURE

When to Prepare

The employer completes this form on the hire date and any time one or more changes are made to either the employee's work schedule or assigned tasks. This form is not required when a program-specific form or other documentation is provided.

Number of Copies

Original and two copies for Initial and for any Change to the employee's work schedule or to the tasks to be performed by the employee.

Transmittal

The employer keeps the original form and gives one copy to the employee and one copy to the Consumer Directed Services Agency (CDSA) for the employee's Initial schedule and for any Change to the schedule. For any change to the assigned tasks, the employer keeps the original form and gives a copy to the employee; if a change does not affect the employee's work schedule, a copy is not sent to the CDSA.

Supply Source

This form must be printed or downloaded from the Consumer Directed Services Handbook at: http://www.dads.state.tx.us/handbooks/cds/forms/index.asp

Form Retention

The employer and the CDSA must keep this form for five years after termination of the employee or until all outstanding litigation, claims and audits are resolved.

DETAILED INSTRUCTIONS

Employee Name —  Enter the name of the employee.

Effective Date —  Enter the date that the schedule and/or list of tasks is effective.

Schedule

Space is provided for three schedules to be documented. An example of using two schedules may apply to an individual who attends school. The first schedule may be for "School" while the second schedule may be for "Summer Months and Holidays." Use "AM" and "PM" to distinguish the time of day, or record in military time, for each 'Time In' and 'Time Out.'

Schedule I — The employer enters a description of the schedule if there is more than one schedule.

Time In —  Enter the time the employee is scheduled to start working. Space is available for six 'Time In' entries per day. The first line may be used for the morning work schedule; the second line may be used for the afternoon or evening work schedule.

Time Out —  Enter the time the employee is scheduled to stop working. Space is available for six 'Time Out' entries per day.

Total Daily Hours —  Enter the total daily hours the employee is scheduled to work. Space is available for two 'Total Hours' entries per day.

Weekly Total Hours —  Enter the total number of hours the employee is scheduled to work in the week for Schedule I.

Schedule II — If there is more than one schedule the employer completes the second schedule as for Schedule I.

Tasks

A section is provided for listing the Tasks for Schedule I and for Schedule II (if needed). The tasks may be different depending on the schedule.

Tasks —  Enter the tasks the employee will be delivering during the work hours. If needed, tasks may be continued on an additional sheet of paper attached to this form.

Acknowledgement

The employee and the employer each sign and date this form to acknowledge the employee's work schedule(s) and the assigned tasks for each schedule.