DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F-62440 (Rev. 02/09)
STATE OF WISCONSIN
REPORT OF HOURS WORKED OTHER DIRECT CARE NURSE AIDE / DAY
Instructions for this form are available on form F-62022A.
Name - Facility Schedule Dates FROM OTHER DIRECT CARE NURSE AIDE TO SUN MON TUE WED THUR FRI SAT SUN MON City Time Allowed for Meal Break License Number Meal Break (Check one.)
DAY SHIFT
Paid Time
TUE WED
Unpaid Time
THUR FRI SAT
SUB-TOTAL GRAND TOTAL