Waived Meal Break Report
Name of employee
*
First Name
Middle Name
Last Name
Last 4 of SSN
Shift Started
*
-
Month
-
Day
Year
Date
Shift Start Time Minutes
AM
PM
AM/PM Option
Shift Ended
*
-
Month
-
Day
Year
Date
Shift End Time Minutes Minutes
AM
PM
AM/PM Option
Which of the following statements applies to you: Provide reason or explanation in the text box below.
*
My shift is over 5 hours but less than 6 hours, I am waiving my Meal Break.
My shift is over 10 hours but less than 12 hours, I am waiving my second Meal Break.
Other
By signing below, I certify that the above statement is true.
*
Submit
Should be Empty: