** 109 South College Rd ** Lafayette, LA 70503
Office # 337-289-5393 - Fax # 337-769-9069
Facility / Hospital / Location:
*
Acadiana Rehabilitation
Acadia Vermilion Behavioral
Acadia St. Landry Guest Home
Allen Parish Hospital
AMG Specialty Facility
Aventi Senior Living
Avoyelles Hospital
Assumption Healthcare & Rehab
Baylor Genetics - COVID swabs
Bliant Specialty Hospital
Carpenter House - New Orleans
Carpenter House - Baton Rouge
Carpenter House - Lafayette
Carpenter House - Shreveport
Center point Healthcare
Chateau D'ville Nursing/Rehab
Chateau St. James Nursing/Rehab
Chateau Terrebonne
Compass Behavioral - Alexandria
Compass Behavioral - Marksville
Cornerstone At the Ranch
Covington Behavioral
Eastridge Nursing and Rehab
Encore Healthcare & Rehab
Ferncrest Manor
Greenbriar Community Care Center
Heart of Hospice - NOLA
Heritage Manor Ville Platte
Iberia Rehabilitation
Jo Ellen Smith Living Center
Kaplan HealthCare Center
Lafourche Home For The Aged
Lake Charles Care Center
Legacy Nursing & Rehab
LHC LTAC Facility
Mary Anna Nursing Home
New Beginnings Recovery (Opelousas)
New Ways of SW LA (Ville Platte)
Old Brownlee Community Care Center
Opelousas General Health System
Our Lady of Wisdom (NOLA)
Pelican Pointe Healthcare & Rehab
Pelican Bay Assisted Living
Promise Hospital - Baton Rouge
Resthaven Living Center
Ridgecrest Community Care Center
Riverbend Rehab Hospital
Rosewood Assisted Living
Savoy Medical Center
Sage LTAC- Denham Springs
Sage LTAC- Baton Rouge
Sage REHAB - Baton Rouge
Southeast Regional Medical Center
Southwind Healthcare & Rehab
St. Landry Parish Jail
The Ellington / Rayne Guest House
The Woodlands Healthcare Center
Total Wellness / Flu shot clinic
United Medical Rehab
Vermilion Health Care
Private Duty
Vitalant / Blood Bank / Blood drive
Waverly Community Home
Woman’s Hospital
Chose a facility or location:
Sample collection type:
*
Routine COVID swabs
LSU - Sentinel swabs
Waste Water COVID swabs
Unit Worked:
MedSurg
Emergency Department (ED / ER)
Intensive Care Unit (ICU)
Labor & Delivery
Mother Baby / Nursery
Pediatrics
Legacy Location:
*
Franklin
Morgan City
Location / City
*
Client Name
*
Savoy Medical floor worked:
*
ER
ICU
Rehab
MedSurg
Psych
United Medical Rehab (Locations)
*
Gonzales
Hammond
New Orleans (NOLA)
Acadia General Hospital floor worked:
*
ER
ICU
MedSurg
Orientation
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
Monroe
Kenner
Alexandria
New Orleans - Ocshner Ext Care
North Shore
AMG location worked:
*
Lafayette Physical Rehab - Lafayette
Lafayette AMG
Zachary AMG
Covington AMG
Houma AMG
Acadia Vermilion Location:
*
Main Campus
South Campus
Covid unit:
*
YES - ASSIGNED to COVID patients/residents
No - NOT Directly ASSIGNED to COVID patients/residents
Date of shift worked
*
/
Month
/
Day
Year
Date when shift STARTED
Time worked (Clocked in and out)
*
1
2
3
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5
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Hour
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46
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59
Minutes
AM
PM
AM/PM Option
Until
until
1
2
3
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5
6
7
8
9
10
11
12
:
Hour
00
01
02
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Minutes
AM
PM
AM/PM Option
Lunch Break? (Facility)
*
YES
NO
Lunch Break? (Sample collections)
*
YES
NO
Total Hours Worked (WITH meal break)
Total Hours Worked (Sample Collections)
Total Hours Worked (WITHOUT meal break)
Reason for NO LUNCH/MEAL break (VALID reason must be documented)
*
No oncoming shift available to sign/approve
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**
*
30 min meal break taken
Short shift / Sent home early
Schedule error / sent home
Shift cancelled less than 2 hours prior to shift beginning
**Emergency preparedness stay**
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)
RT (Respiratory Therapist)
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
Facility employee approval signature
*
Clear
Submit to Payroll
Should be Empty: