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Map to Focus, Inc.

2809 Forest Home Rd, Jonesboro, AR 72401

 

 

 

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Disclaimer

 

In accordance with the Civil Rights Act of 1964, Focus, Inc., accepts participants without regard to race, color, gender, age, or national origin, and is an equal opportunity employer.

 
 

 
 

FORMS FOR IMPLEMENTERS

The following Implementer Forms are examples, a link to each printable form is located at the bottom of each sample page. If you have any questions on the proper way to fill out these forms contact your Case Manager of any of the WAIVER personnel.

NOTE

You Must Have Adobe Reader to view and print these forms.

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FOCUS INC.

IMPLEMENTERS TRAVEL EXPENSE REIMBURSEMENT FORM

 

EMPLOYEE NAME:__your name_____CONSUMER NAME:___________________________MONTH:___12____YEAR: 20 _05_
MONTH DAY TRAVEL FROM TRAVEL TO Reason For Travel(Consumer's Goal or Task the Travel is Related to) Miles Driven Amount Claimed ($0.30 per mile)
12 6 home grocery store (round trip) buy food stuff  20 $          6  .00
12 7 home library (round trip) books  26 $         7   .80
12 7 home pharmacy pickup medications 3 $            0 .90
12 7 pharmacy park recreation 4 $           1  .20
12 7 park home return home 11 $           3  .30
            $             .
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            $             .
            $             .
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      Totals 64 $         19  .60
*Travel must take place in employee's privately owned vehicle.        
*Consumer must be in the vehicle. Subtotal This Page:____19.60__________    
*Travel must be for Consumer's goal-related purposes. Subtotal Previous Pages:________________    
      Travel Grand Total:____19.60___________    
  _____your signature_____________________ Other Expenses:_____________________    
  Employee Signature (Must be Pre-Approved by Supervisor and you must attach Receipt)
For Office Use Only          
Check Number:_________________ Code____________ ___________________________ Amount Approved:___________
      Approved By      

LINK TO PRINTABLE FORM

 

 

 

IMPLEMENTERS TIME SHEET

IMPLEMENTER NAME: ___________YOUR NAME____________      PAY PERIOD _END DATE__
 
CONSUMER NAME: _PERSON YOU ARE WORKING WITH_________    
             
DATE TIME FROM TIME TO SL R