109 South College Rd Lafayette, LA 70503
Office # 337-233-2096- Fax # 337-769-9069
Facility/ Hospital/ Location:
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****Please add Location/City for any (AMG, Heritage, Woodlake, or Sage) Facilities***
Shift Worked:
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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
Other
Date of Shift Worked
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Year
Date Picker Icon
Time worked (Clocked in and out)
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Minutes
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PM
AM/PM Option
Until
until
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Minutes
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PM
AM/PM Option
Lunch Break?
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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
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First Name
Last Name
UMS Independent Contractor Position:
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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
*
Facility Employee Approval Name:
*
First Name
Last Name
Facility Approval Employee Position:
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RN
LPN
Manager
Other
Time Slip Approval Signature (FACILITY EMPLOYEE TO SIGN)
*
Submit to Payroll
Should be Empty: