OFFICE: 904-823-1458
 TOLL-FREE 1-800-381-1458
 TOLL-FREE FAX 1-866-655-4347
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Please select which day you worked
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Date worked

Employee Name

Start time A.M. P.M.

End time   A.M. P.M.

30 minute lunch
30 minute lunch, not taken. Must be approved by Supervisor, and initialed by Supervisor:

Total hours worked Overtime hours

Name of Client Select FL Hosp Deland FL Hosp Fish FL Hosp Flagler FL Hosp Ormond FL Hosp Oceanside FL Hosp Waterman Southlake

Per Diem unit assigned Floated to

Traveler Select Unit Travel SDS Travel ICU Travel PCU Travel PACU Travel ED

Pay Card   or   Direct deposit

Classification Select RN LPN CNA

I certify that the hours shown above represent my total hours worked and that they were properly verified by the client or by an authorized representative. I understand I must report for reassignment upon conclusion of each assignment, and that unemployment benefits may be denied for failure to report.

Additional Notes

Georgia's Medical Fund $5 per pay check $10 per pay check $15 per pay check $20 per pay check $25 per pay check $5 One time donation $10 One time donation $15 One time donation $20 One time donation $25 One time donation Other. Add specific amount or note in the box above. Sorry, Im not able to help at this time or Ive already donated.
We appreciate your help.

Employee Signature

Email Address*