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Family Respite Program Respite Service Report (RSR)

RSRs must be received by noon on the Friday the payroll period ends (see Payroll Schedule) 

  • Providers will not be paid unless this form is completely filled out.
  • Providers cannot work more than 29 hours per week (58 hours per pay period). Exceptions are limited and require prior approval from the provider’s regional director/coordinator.
  • Hours worked over 29 that do not have prior approval will not be paid.
  • Overtime (more than 40 hours per week) is not permitted.
  • Providers cannot call in to a supervision while providing respite.

Dates must be MM/DD/YYYY format.

Enter the ID numbers of any children who received respite.


Providers must be 21 years or older and provide a minimum of 4 hours of respite per service report. Mileage is reimbursable for one round trip from provider home to point of service and point of service to provider home only. Please record your TOTAL MILES below. Providers are NOT reimbursed for the first 20 miles and will not be reimbursed for more than 100 miles.

Respite providers are required to follow all NAMI Maine policies and all Respite Services Handbook procedures.Violations of policies and procedures will result in disciplinary action.