Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F-62165 (Rev. 07/08)

STATE OF WISCONSIN

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

From

Schedule Dates To SUN MON TUE WED

Time Allowed for Meal Break

MEAL BREAK (Check one.)

Paid Time
THUR FRI SAT SUN MON TUE WED THUR

Unpaid Time
FRI SAT

LPN

SUB-TOTAL GRAND TOTAL