• This form is used to:

    1. Request a correction of an existing time clock entry or submit a missing time entry for time worked (including missed, incomplete, or incorrect clock-ins/outs), or

    2. Report time worked outside of a scheduled shift (only for employees who do not have the ability to create their own shifts in the scheduling system; employees with that ability must record time directly in the system).

  • Choose Your Request Type:*

  • Times should be reported as accurately as possible based on the employee’s best recollection. When exact times are not known, reasonable estimates may be provided.

    Falsification of a time card is grounds for disciplinary action and/ or termination.

  • REQUEST FOR: Time clock adjustment

    If you have any missing or incorrect time clock entries (including missed clock-ins or outs), you are required to complete this form independently as soon as the issue is identified.
  • Date and start time of the shift or work period associated with this time entry (for scheduled shifts, use the scheduled start time—not the onsite time; for unscheduled work, use the actual start time worked).*
     - -
    2 digit month, 2 digit day, 4 digit year
  • CLOCK IN: Enter the actual time you were ready to immediately begin work (onsite and prepared). This may match the scheduled start time or "Onsite Time", but only if that reflects when you were actually ready to begin work.*
  • CLOCK OUT: Enter the actual time you completed all work duties and were ready to clock out. This may match the scheduled end time or the Departure Time, but only if it reflects when work was actually completed.*
  • What times do you want your clock in and/ or clock out times to be adjusted to?
    Until

  • If you took any breaks during this timeframe, specify them:

  • Did you take all of your rest break(s) and meal break(s) today?*
  • Break #1
    Until
  • Break #2
    Until
  • Break #3
    Until
  • Break #4
    Until

  • REQUEST TO: Report Time Worked Outside a Scheduled Shift

    For employees who do not have the ability to create a shift in the scheduling system.
  • Date work was performed:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Start and End Time of Work.*
    Until

  • Submission of this form is for timekeeping and payroll purposes. All reported compensable time will be recorded and paid in accordance with applicable law. Any questions regarding authorization or procedure will be addressed separately.

  • Date of request*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Time of request*
  • Should be Empty: