Nurses Direct E-Time Slip

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

Office # 337-289-5393 - Fax # 337-769-9069
Facility / Hospital / Location: *
Chose a facility or location:
Sample collection type: *

Routine COVID swabs LSU - Sentinel swabs Waste Water COVID swabs LSU - COVID Vaccines
Shift Worked:

MedSurg Emergency Department (ED / ER) Intensive Care Unit (ICU) Labor & Delivery Mother Baby / Nursery Pediatrics Surgery Department / Operating Room Orientation/Training ON CALL
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 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 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) *

: 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) *

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**
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) 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
Facility employee approval signature *

Clear
Should be Empty:

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

109 South College Rd Lafayette, LA 70503