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
LHC Facility
AMG Facility
Psych / Behavioral
Nursing Home
Total Wellness / Flu shot clinic
Specialty Hospital Winnfield
Private Duty
Other
Chose a facility or facility type
Location / City
*
Client Name
*
Shift worked:
*
Type of shift worked
Savoy Medical floor worked:
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ER
ICU
Rehab
MedSurg
Acadia General Hospital floor worked:
*
ER
ICU
MedSurg
Orientation
OGHS floor worked:
*
ER
ICU
PCU / 3rd floor
Ortho / 4th floor
MedSurg / 5th floor or South Campus
Rehab / South campus
Post partum (L&D)
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
Psych location worked:
*
Vermilion Behavioral
Optima Specialty (Vermilion South)
New Beginnings
New Ways of SW LA
Nursing Home worked:
*
Lake Charles Care Center
The Ellington / Rayne Guest Home
Maison De Lafayette
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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Minutes
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PM
AM/PM Range 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
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: