Meal Break Report
This report is for use when reporting meal break issues. This report should be used for your Meal Break start and Meal Break end timekeeping corrections and / or reporting missed Meal Break periods. Please call 818-686-2102 if you are uncertain about how to fill the report out.
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.
*
I DID take a compliant Meal Break, but did not clock it. (LIST CORRECT TIMES BELOW)
I did not take my Meal Break
I did not take my second Meal Break
My Meal Break was interrupted by duty
My second meal Break was interrupted by duty
I forgot to take my Meal Break
I forgot to take my second Meal Break
Other
Please describe in detail why you did not take OR clock your meal break and list the correct times if you did take one.
*
Did you notify operations that you could not complete your meal break?
*
Yes
No
NA
Are you aware that you must clock in or out for Meal Breaks via the timekeeping system application?
*
Yes
No
NA
Was your meal break interrupted by an emergency?
*
Yes
No
NA
If interrupted, did you attempt to retake your meal break?
*
Yes
No
N/A
Are you aware that meal break time management is the employee's responsibility?
*
Yes
No
Was your post supposed to be an "On Duty" or "Off Duty" meal break?
*
OFF DUTY MEAL BREAK
ON DUTY MEAL BREAK
Are you aware that per company policy, for any 5 - 8 hour shifts, meal breaks must be taken by the start of the 4th working hour?
*
Yes
No
Are you aware that per company policy, for any 10 to 12 hour shifts, your first meal break must be taken by the start of the 4th working hour, and the second meal break must be taken by the start of the 8th working hour?
*
Yes
No
Are you aware, per company policy, your meal break must be no less than 30 minutes?
*
Yes
No
Are you aware, per company policy, you must notify a supervisor prior to waiving any meal breaks?
*
Yes
No
NA
Are you aware, per company policy, you have a 5 min window, after you completed your 30-minute meal break to clock back in?
*
Yes
No
By signing below, I certify that the above statement is true.
*
Submit
Should be Empty: