Nurses Direct E-Time Slip

** 109 South College Rd ** Lafayette, LA 70503

Office # 337-289-5393 - Fax # 337-769-9069
Are you on a Contract or Travel assignment at THIS LOCATION? *

YES NO
Alabama - Facility / Hospital: *
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Location of work: *
US States
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Florida - Facility / Hospital: *
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Missouri - Facility / Hospital: *
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New Mexico - Facility / Hospital: *
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Tennessee - Facility / Hospital: *
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Texas - Facility / Hospital: *
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Wyoming - Facility / Hospital: *
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Louisiana - Facility / Hospital: *
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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 *
Client Name *
Savoy Medical floor worked: *

ER ICU Rehab MedSurg Psych
OGHS floor worked: *

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
LHC LTAC location worked: *

Lafayette - Louisiana Ext Care Opelousas - St Landry Ext Care Crowley - Acadia Ext Care West Monroe - Louisiana Ext Care Alexandria - Christus Dubuis Hospital New Orleans - Ocshner Ext Care North Shore - Northshore Ext Care Hot Springs, AR - CHRISTUS Dubuis Fort Smith, AR - CHRISTUS Dubuis Monroe - Specialty Hospital
AMG location worked: *

Lafayette Physical Rehab - Lafayette Lafayette AMG Zachary AMG AMG Physical Rehab Hospital - Covington Houma AMG
CVS Infusion - Patient Name *

First Name Last Name
Total Travel Time (Minutes) *
Total Miles Driven *
Training Time (Minutes) *
*

Month Day Year
Date when shift STARTED
Time worked (Clocked in and out) *

: Hour Minutes AM/PM Option
Until
until : Hour Minutes AM/PM Option
Total Hours Worked (LHC)
Lunch Break? *

YES NO
Total Hours Worked (WITH meal break)
Total Hours Worked (WITHOUT meal break)
Reason for NO LUNCH/MEAL break (VALID reason must be documented) *

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: *

YES NO
Nurses Direct Employee Name *

First Name Last Name
Nurses Direct Employee position: *

RN (Registered Nurse) LPN (Licensed Practical Nurse) CNA (Certified Nurse Assistant) CMA (Certified Medical Assistant) Surgical Tech / OR Tech RT (Respiratory Therapist) EMERGENCY PREPAREDNESS
Charge Nurse (RN ONLY) *

YES NO
Employee Personal Email: *
example@example.com
Nurse Direct employee signature *

Clear
*

Shift times approved and signed by authorized individual NO ONE AVAILABLE TO SIGN/APPROVE OF SHIFT TIMES
Facility employee approval name: *

First Name Last Name
Facility approval employee position: *

RN LPN RT Manager
Time slip approval signature (FACILITY EMPLOYEE TO SIGN) *

Clear
Should be Empty:

** 109 South College Rd ** Lafayette, LA 70503

109 South College Rd Lafayette, LA 70503