201 Rue Iberville - Suite 700- Lafayette, LA 70508
Corporate office: 337-362-4004
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Beacon Behavioral - Luverne
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(Testing)
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Intensive Specialty Location
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Bossier City
North Campus
Pierremont
Shreveport
Shift Worked:
MedSurg
Inpatient Rehab
Emergency Department (ED / ER)
Intensive Care Unit (ICU)
Labor & Delivery
Mother Baby / Nursery
Pediatrics
Surgery Department / Operating Room
Behavioral Unit
Orientation/Training
ON CALL
Location / City
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Client Name
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LARC Home - Baker, LA
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Martin Home
New Castle Home
LARC Home - Jackson, LA
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Briarwood Home
Claridge Home
LARC Home - Zachary, LA
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LARC Home - Lafayette, LA
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Citivan Home
Center Street
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LHC Home Health
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Acadian Home Care - New Iberia
LHC - # of Patients Visits Today
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LHC - Miles Driven Today (Between First and Last Patient)
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Savoy Medical floor worked:
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ER
ICU
Rehab
MedSurg
Psych
Beyond The Horizon unit
Other
OGHS floor worked:
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ER (Main campus)
ER (South campus)
ICU
PCU / 3rd floor
Ortho / 4th floor
MedSurg / 5th floor or South Campus
Rehab / South campus
Post partum (L&D)
Orientation / Training / Education
Other
LHC LTAC location worked:
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Lafayette - Louisiana Ext Care
Crowley - Acadia Ext Care
New Orleans - Ocshner Ext Care
North Shore - Northshore Ext Care
Arc of Acadiana (Rayne Homes)
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Lisa Home
EB North Home
Electa Home
Jackie Home
Arc of Acadiana (New Iberia Homes)
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Kramer
Northside
Central
AMG location worked:
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Lafayette Physical Rehab - Lafayette
AMG LTAC Park Place - Lafayette
AMG LTAC - Zachery
AMG Physical Rehab Hospital - Covington
AMG LTAC - Houma
CVS Infusion - Patient Name
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First Name
Last Name
Total Travel Time (Minutes)
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Total Miles Driven
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start date
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Month
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Day
Year
Date
WeekNum
Training Time (Minutes)
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Date of Shift Worked
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Month
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Day
Year
Date when shift STARTED
Time worked (Clocked in and out)
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Minutes
AM
PM
AM/PM Option
Until
until
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Hour
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Minutes
AM
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AM/PM Option
Total Hours Worked (Meal Required)
Total Hours Worked (*Meal Required*)
Lunch Break?
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YES
NO
Total Hours Worked (WITH meal break)
Total Hours Worked (WITHOUT meal break)
Mileage driven today between patients:
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total miles for today
Reason for NO LUNCH/MEAL break (VALID reason must be documented)
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Short staffed / No relief
Extremely busy
Short shift / Sent home early
Schedule error / sent home
Shift cancelled less than 2 hours prior to shift beginning
**Emergency preparedness stay**
On Call:
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YES
NO
On call hours worked
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Include total number of hours worked while on call if called while on call.
On call Miles Driven
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Include total number of miles driven while on call if called while on call.
Nurses Direct Employee Name
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First Name
Last Name
Nurses Direct Employee position:
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RN (Registered Nurse)
LPN (Licensed Practical Nurse)
CNA (Certified Nurse Assistant)
RT (Respiratory Therapist)
Other
Charge Nurse (RN ONLY)
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YES
NO
Charge Nurse or RN Supervisor: (RN only)
*
Please Select
YES
NO
Employee Personal Email:
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example@example.com
Nurse Direct employee signature
*
*
Shift times approved and signed by authorized individual
NO ONE AVAILABLE TO SIGN/APPROVE OF SHIFT TIMES
Facility employee approval name:
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First Name
Last Name
Facility approval employee position:
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RN
LPN
RT
Manager
Other
Time slip approval signature (FACILITY EMPLOYEE TO SIGN)
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Time of Submission
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Minutes
AM
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AM/PM Option
Timeslip Acknowledgment:
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I understand and acknowledge, that if the information submitted via this timeslip differs from the information provided by the facility, my next paycheck will be adjusted accordingly to match what the facility has on record. If at any reason this time slip is found to be falsified, my employment may be terminated immediately.
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Timeslip response
example@example.com
Should be Empty: