Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F-62164 (Rev. 07/08)

STATE OF WISCONSIN

REPORT OF HOURS WORKED - LICENSED PRACTICAL NURSE / DAY
Instructions for this form are available on form F-62022A.
Name - Facility City License Number

DAY SHIFT

From

Schedule Dates To

Time Allowed for Meal Break

MEAL BREAK (Check one.)

Paid Time
MON TUE WED THUR FRI SAT SUN MON TUE WED THUR

Unpaid Time
FRI SAT

LPN

SUN

SUB-TOTAL GRAND TOTAL