MEAL BREAK ADJUSTMENT REQUEST

Precision Temperature Inc.

11974 Woodside Ave | Lakeside, CA 92040

619-588-5321 | info@ptempinc.com
MEAL BREAK ADJUSTMENT REQUEST

PER California Labor Code Section 512, meal periods are as follows:

First Meal Period
- I understand that I am entitled to an unpaid meal break of not less than 30 minutes for every five (5) hour period of time worked. However, I understand that I can waive the meal period when my total day’s work will be completed within a work period of not more than six (6) hours.
- Accordingly, I agree to waive the meal period whenever my total day’s work will be completed within a work period of not more than six (6) hours.
Second Meal Period
- I understand that I am entitled to a second unpaid meal break of not less than 30 minutes if I work more than ten (10) hours during a work day. However, I understand that I can waive the second meal period when my total day’s work will be completed within a work period of not more than twelve (12) hours, as long as I did not waive the first meal period.
- Accordingly, I agree to waive the second meal period whenever my total day’s work will be completed within a work period of not more than twelve (12) hours, as long as I did not waive the first meal period.
Select Reason why Meal break was not documented properly

Forgot to time-out for Meal BreakForgot to time-in from Meal BreakForgot to time-in / time-out from Meal BreakOther
Date meal break needs to be adjusted and/or documented correctly *

MonthDayYear
Date
Correct Meal Break OUT-Time

:HourMinutesAM/PM Option
Correct Meal Break IN-Time

:HourMinutesAM/PM Option
Acknowledgment

I am requesting that my meal break be documented as per above. I have submitted this form freely and voluntarily. I acknowledge that the time reported is correct and that I was allowed and have taken all my rest and meal breaks for the above date and that I have not experienced any work related injuries that have not been reported to my manager and/or Human Resources.
Name*

First NameLast Name
Date this form was submitted *

MonthDayYear
Date
Signature*

Clear
Should be Empty:

Acknowledgment