Provider Wage Supplement Monthly Staff Roster Hours

Reporting Information
Employment Month*
Employment Year*
Please select all of the types of hours you would like to report*
- Hours Worked
- Leave or Paid Time Off (NON-COVID Related)
- Leave or Time off for COVID-19

Hours Worked
Employees with Hours Worked*
Please provide information regarding each of your staff for this last month. Be sure to include their name, title, hire date, date of birth, last 4 of SSN, and number of hours worked each week of this month.
First Name Last Name Hire Date Birth Date Last 4 of SSN Hours Week1 Hours Week2 Hours Week3 Hours Week4 Hours Week5
Note: If no hours were worked for a week or the month only has 4 weeks, please enter 0 (zero) for the hours on that week. Please only enter numbers for the Hours.
Additional Comments or Notes reguarding Working Staff

Leave or PTO
Employees on Leave (NON-COVID Related)*
Please provide information regarding each of your staff for this last month. Be sure to include their name, title, hire date, date of birth, last 4 of SSN, and number of hours on leave each week of this month.
First Name Last Name Hire Date Birth Date Last 4 of SSN Hours Week1 Hours Week2 Hours Week3 Hours Week4 Hours Week5
Note: If an employee did not take leave, do not list them here. And if no Leave/PTO hours were taken for a week or the month only has 4 weeks, please enter 0 (zero) for the hours on that week. Please only enter numbers for the Hours.
Additional Comments or Notes reguarding Staff on Leave

COVID-19
Employees on leave from COVID-19*
Please provide information regarding each of your staff for this last month. Be sure to include their name, title, hire date, date of birth, last 4 of SSN, and number of hours on leave each week of this month from COVID-19.
First Name Last Name Hire Date Birth Date Last 4 of SSN Hours Week1 Hours Week2 Hours Week3 Hours Week4 Hours Week5
Note: If an employee did not take leave on account of COVID-19, do not list them here. And if no COVID Leave hours were taken for a week or the month only has 4 weeks, please enter 0 (zero) for the hours on that week. Please only enter numbers for the Hours.
Additional Comments or Notes reguarding COVID-Staff

Summary

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05/09/2025
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I certify that all information provided on this form is true and accurate. I understand that giving false information may constitute fraud and could result in prosecution.
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Basic Information