Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F-62442 (Rev. 02/09)

STATE OF WISCONSIN

NIGHT SHIFT REPORT OF HOURS WORKED ­ OTHER DIRECT CARE NURSE AIDE / NIGHT
Instructions for this form are available on form F-62022A.
Name - Facility City License Number

Schedule Dates FROM OTHER DIRECT CARE NURSE AIDE TO SUN MON TUE WED THUR

Time Allowed for Meal Break

Meal Break (Check one.)

Paid Time
FRI SAT SUN MON TUE WED

Unpaid Time
THUR FRI SAT

SUB-TOTAL GRAND TOTAL