United Medical Staffing, Inc.
109 South College Rd - Lafayette, LA
Patient's Name
*
First Name
Last Name
Date at Start of Shift #1
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Time in and Out of Shift #1
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AM/PM Option
Date at Start of Shift #3
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Minutes
AM
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AM/PM Option
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until
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Hour
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AM/PM Option
Date at Start of Shift #4
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Date
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Minutes
AM
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AM/PM Option
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until
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Hour
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Minutes
AM
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AM/PM Option
Date at Start of Shift #5
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Month
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Year
Date
Time in and Out of Shift #5
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Minutes
AM
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AM/PM Option
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until
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Hour
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AM
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AM/PM Option
Date at Start of Shift #6
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Year
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Time in and Out of Shift #6
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Minutes
AM
PM
AM/PM Option
Until
until
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Hour
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Minutes
AM
PM
AM/PM Option
Date at Start of Shift #7
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Month
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Year
Date
Time in and Out of Shift #7
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Hour
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Minutes
AM
PM
AM/PM Option
Until
until
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Hour
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Minutes
AM
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AM/PM Option
TOTAL HOURS WORKED
Additional Comments (explanation of overtime)
*
Nurse Name
*
First Name
Last Name
Nurse Personal Email:
*
example@example.com
Nurse Signature
*
Clear
Patient / Authorization Name
*
First Name
Last Name
Relationship to Patient
*
Self / Patient
Spouse
Parent
Guardian / POA
Child
PATIENT PHYSICALLY UNABLE TO SIGN
Patient Signature
Clear
Submit
Should be Empty: