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COMPLETE PROMPTLY; MUST BE SINGED BY EMPLOYEE AND HIS OR HER SUPERVISOR
~ Please Complete One Form for Each Missed, Short, or Late Break ~
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Name of Employee
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Please Select One
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Please Select One
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Date
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Start of Work
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Start of First Break
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End of First Break
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Second Break?
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Start of Second Break
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End of Second Break
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End of Work
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Reason for Missed, Short or Late or Rest Break (Check One)
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Is this Entry a Previous Entry Correction?
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I understand that I must accurately record all hours that I work. I understand that the Company provides me with a 30-minute paid meal break before the end of fifth work hour, a second unpaid meal break if I work over 10 hours, and a 10-minute paid rest break for every 4 hours of work or major fraction thereof, pursuant to policy. I also understand that recording my time incorrectly or working off the clock may result in disciplinary action up to and including termination.
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Employee's Signature:
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Date
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Supervisor's Signature:
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Date
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Missed Break means no meal break or rest break taken. Short Break, with regard to a rest break, means less than 10 minutes; and with regard to a meal break, means less than 30 minutes. Late Break means (1) rest break was taken after 3.5 hours of work; (2) first meal break was taken after the end of your 5th work hour; (3) second meal break was taken after the end of your 10th work hour; or (4) third meal break was taken after the end of your 15th work hour.
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