Facility Worked:
*
Unit Worked
*
Medsurg
LTAC
ER
ICU
Labor and Delivery
Nursery
On Call
Failure to Cancel
Nursing Home
Rehabilitation
BHU
Private Duty
Assisted Living
Orientation
PEDS
Observation
COVID Unit
*
No- NOT Directly ASSIGNED to COVID Patients/residents
Yes- ASSIGNED to COVID patients/residents
Date at Start of Shift
*
-
Month
-
Day
Year
Date
Time worked (Clocked in and out)
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
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
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
Minutes
AM
PM
AM/PM Option
Lunch Break?
*
YES
NO
Total Hours Worked (WITH meal break)
Reason for NO LUNCH/MEAL break (VALID reason must be documented)
*
Short Staffed/No Relief
Extremely Busy
Short Shift/Sent home early
Total Hours Worked (WITHOUT meal break)
UMS Contract Nurse Name
*
First Name
Last Name
UMS Contract Nurse Personal Email
*
example@example.com
UMS Contract Nurse Position:
*
RN
LPN
CNA
UMS Contract Charge Nurse (RN ONLY)
*
YES
NO
UMS Contract Nurse signature
*
Clear
Facility Representative Approval Name:
*
First Name
Last Name
Facility Representative Approval Position:
*
RN
LPN
Facility Representative Approval Signature
*
Clear
Save
Submit to Payroll
Should be Empty: