Nurse Incentive Commitment Form
Confirm your understanding of AccuCare’s three shift commitments and sign to acknowledge eligibility requirements.
Nurse Information
Full Name
*
First Name
Last Name
Nurse Email
*
example@example.com
Credential / Title
*
RN
LPN
Other
Assigned Case / Patient
*
Primary Supervisor
*
Effective Date
*
-
Month
-
Day
Year
Date
My Commitments
Arrive On Time — I will arrive at my assigned case at or before my scheduled start time, ready to provide patient care, and clock in promptly through KanTime.
*
I agree
Leave at the Designated Time — I will remain on duty for my full scheduled shift, complete a proper handoff, and depart at my designated end time, not leaving early and not extending hours without prior authorization.
*
I agree
Submit All Notes at End of Shift — I will complete and submit all required clinical notes and documentation by the end of each shift, in accordance with AccuCare policy and applicable regulatory requirements.
*
I agree
Incentive Eligibility
Incentives are earned by consistently meeting all three commitments above and are verified against KanTime schedule, clock-in/clock-out, and documentation records. Incentive amounts and any applicable bonuses are defined in the current AccuCare incentive program. Repeated or unexcused failure to meet these commitments may result in suspension or forfeiture of incentive eligibility for the affected pay period(s), at AccuCare's discretion. This commitment does not alter your base rate of pay or your status as an employee and does not replace any other AccuCare policy.
Applicable Incentive(s)
Acknowledgment & Signature
I have read and understand the commitments described in this form. I agree to meet these standards on each assigned shift in order to qualify for AccuCare incentives.
Nurse Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Submit
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