Language
English (US)
** 109 South College Rd ** Lafayette, LA 70503
Office # 337-233-2096- Fax # 337-769-9069
Facility/ Hospital/ Location:
*
****Please add Location/City for any (AMG, Heritage, Woodlake, or Sage) Facilities***
Shift Worked:
*
Medsurg
LTAC
Emergency Department (ED/ ER)
Intensive Care Unit (ICU)
Labor and Delivery (L&D)
Nursery
Nursing Home
Rehabilitation
Behavioral Health Unit (BHU)
Assisted Living
Hospice
On Call
Observation
Failure to Cancel
Pediatrics
Addiction Recovery
Date of Shift Worked
*
/
Month
/
Day
Year
Date when shift STARTED
Time worked (Clocked in and out)
*
1
2
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5
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7
8
9
10
11
12
:
Hour
00
01
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58
59
Minutes
AM
PM
AM/PM Option
Until
until
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
01
02
03
04
05
06
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49
50
51
52
53
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58
59
Minutes
AM
PM
AM/PM Option
Lunch Break?
*
YES
NO
Total Hours Worked (WITH meal break)
Total Hours Worked (WITHOUT meal break)
Reason for NO LUNCH/MEAL break (VALID reason must be documented)
*
Short Staffed/No Relief
Extremely Busy
Short Shift/Sent home early
Schedule error/ Sent home
UMS Independent Contractor Nurse/ CNA Name
*
First Name
Last Name
UMS Independent Contractor Position:
*
RN (Registered Nurse)
LPN (Licensed Practical Nurse)
CNA (Certified Nursing Assistant)
UMS Charge Nurse (RN ONLY)
*
YES
NO
UMS Nurse/ CNA Personal Email
*
example@example.com
UMS Contract Nurse/ CNA Signature
*
Clear
Facility Employee Approval Name:
*
First Name
Last Name
Facility Approval Employee Position:
*
RN
LPN
Manager
Time Slip Approval Signature (FACILITY EMPLOYEE TO SIGN)
*
Clear
Submit to Payroll
Should be Empty: