Payroll Adjustment Form

Payroll Adjustment Form

Submit corrections to your timecard, request PTO to be paid on this payroll, or request other adjustments to your timecard or pay.
Name*

First NameLast Name
How can we help you?*

Correct my timecardAdd PTO and/or Sick Leave hours to my pay checkAdd other type of pay to my paycheckOther

Correct my timecard
What do we need to correct?

I forgot to clock in for the start of my shiftI forgot to clock out for lunchI forgot to clock out at the end of my shiftOther
Date timecard needs corrected:

MonthDayYear
Date

Add PTO/Sick leave hours to my paycheck
How many hours of PTO Leave do you want added to the current payroll?
How many hours of Sick Leave do you want added to the current payroll?
Verify available PTO/Sick leave hours

I have checked my PTO/Sick Leave balance in Dayforce to verify that I have enough hours available to cover this request.
Comments:

Add other type of pay to my paycheck
Please add pay for the following

I completed a work task at home or another locationI attended an approved CE eventI am requesting bereavement payI am requesting jury duty payI am an RVT requesting pay for an after hours emergency surgeryI shopped for the hospitalOther

I attended an approved CE event
What CE event did you attend?
How many minutes or hours did you spend in CE?
Documentation Required. Upload a receipt or CE certificate if you have not already submitted a copy.

Cancelof

I am requesting bereavement pay
Bereavement Pay Policy: In the event of a death in your immediate family, you will be allowed up to three days off with pay. The immediate family consists of father, mother, sisters, brothers, daughter, son, guardian or spouse. Employees will be allowed one day of absence with pay in the event that a grandparent, granddaughter, grandson, uncle, aunt, or a member of your spouse’s immediate family should pass away. Employees will be allowed 1 day of absence with pay if a pet who is listed on their employee account in AVImark passes away. All employees are covered by this policy. A "day" of pay will be defined as the number of hours you were scheduled to work on the day(s) that you missed.
Select:

I am requesting 3 days of paid leave due to the death of my parent, sibling, child, guardian or spouse.I am requesting 1 day of paid leave due to the death of my grandparent, grandchild, uncle, aunt, or a member of my spouse’s immediate family.I am requesting 1 day of paid leave due to the death of my pet.
Documentation Required. Upload a funeral notice, obituary, or other documentation if you have not already submitted a copy.

Cancelof
Comment:

I am requesting jury duty pay
Jury Duty Policy: Employees will receive the difference between their regular pay and jury pay if called to serve for a total of up to one work week of pay. Any employee called to serve on jury duty for longer than one week will receive an unpaid leave of absence. Please submit a statement from the court listing the days you served and the amount you were paid.
How many hours did you miss working due to Jury duty.?
Documentation Required. Upload a statement from the court indicating how many days you served and pay received.

Cancelof

I am an RVT requesting pay for an after hours emergency surgery
Please verify (MUST select both options to qualify for the pay requested.)*

I stayed 1 hour beyond the end of my shift or I came in on my day offThe emergency surgery fee was charged to the client
Name and CID of patient who had surgery
Are you sharing the emergency fee with another technician? Who?

I shopped for the hospital
Select all that apply

I shopped for the hospital at Costco, Walmart, or other retail storesPlease add the shopping bonus to my paycheckI used my vehicle. Please add $10 for gas to my paycheck
Comments