NURSES DIRECT LLC
** 109 South College Rd ** Lafayette, LA 70503
Office # 337-289-5393 - Fax # 337-769-9069
Facility / Hospital / Location:
*
Acadia General Hospital
Opelousas General Health System
Savoy Medical Center
Iberia Rehabilitation
Acadiana Rehabilitation
New Beginnings Recovery (Opelousas)
New Ways of SW LA (Ville Platte)
Acadia Vermilion Behavioral
LHC LTAC Facility
AMG Specialty Facility
Lake Charles Care Center
The Ellington / Rayne Guest House
Total Wellness / Flu shot clinic
Private Duty
Other
Chose a facility or facility type
Location / City
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Client Name
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Shift worked:
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Type of shift worked
Savoy Medical floor worked:
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ER
ICU
Rehab
MedSurg
Psych
Acadia General Hospital floor worked:
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ER
ICU
MedSurg
Orientation
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
LHC LTAC location worked:
*
Lafayette - Louisiana Ext Care
Opelousas - St Landry Ext Care
New Iberia - Iberia Ext Care
Eunice - Eunice Ext Care
AMG location worked:
*
Lafayette Physical Rehab - Lafayette
Lafayette AMG
Zachery AMG
Covington AMG
Houma AMG
Date of shift worked
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Month
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Day
Year
Date when shift STARTED
Date Picker Icon
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
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PM
AM/PM Option
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
Nurses Direct Employee Name
*
First Name
Last Name
Nurses Direct Employee position:
*
RN
LPN
CNA
Charge Nurse (RN ONLY)
*
YES
NO
ON CALL SHIFT:
*
YES
NO
Employee Personal Email:
*
example@example.com
Nurse Direct employee signature
*
Clear
Facility employee approval name:
*
First Name
Last Name
Shift approval name:
*
First Name
Last Name
Facility approval employee position:
*
RN
LPN
Facility employee approval signature
*
Clear
Shift approval signature
*
Clear
Submit to Payroll
Should be Empty: