Annex 4: Sample Worksheet for Trip Times[107]
| Driver Name: | |
| Date: | |
| Total Passenger Count: | |
| Company/Agency Name: | |
| Company/Agency Contact Information: |
| Departure Time | Departure Location | Arrival Time | Shelter Location or Receiving Facility | Passenger Name | Staging Area Location | Additional Pick-up Points (if any) |
Caregiver Name if Traveling Together | List Any Service Animal, Pet, or DME with Passenger | Beginning & Ending Mileage | Other (Add in as necessary) |
|---|---|---|---|---|---|---|---|---|---|---|
[107] This is a sample worksheet; agencies should modify, add, and/or delete categories as necessary.
