Weekly Timesheet Form
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1Weekly
Timesheet Form
Employee Name: _____________________________________
Week Ending Date: ____________________
Full Legal Name
(mm/dd/yy)
___________________
____________________________________________
______________________
Discipline
*Employee Signature
Last four digits of SS#
____________________________________________
_____________________________________
____________________________________
Client Name (Mgmt Comp, Owner, Hospital Sys)
Facility Name
** Authorized Client Signature
*Employee: I certify that the hours shown accurately represent my total hours worked on this assignment during the week and that they were properly verified by
an authorized representative of the client. By signing this timesheet, I verify that I have reported any accident or injuries during this pay period.
**Client: The hours as shown on this timesheet are correct. By signing this client approval, we acknowledge our receipt and acceptance of general conditions of
assignment and the terms of payment.
Total
Guarantee
OT/Min Hrs
Date
***Work Mode
Shift
Day
Dept
In
Out
Lunch
Hours
Min Hrs
Approval
(mm/dd)
R
C
B
O
Day
Eve Night
Sun
Mon
Tue
Wed
Thu
Fri
Sat
*** Work Mode: R=Regular and Overtime, C=On Call, B=Call Back, O=Orientation
Regular Hrs
Overtime Hrs
On Call Hrs
Call Back Hrs
Orientation Hrs
Guarantee Hrs
Total Work
Total
Expense:
Day:
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Total
Mileage (in miles)
Travel Time (in hrs/min)
DUE DATE: Timesheets must be received by 12pm on Mondays or payment will be delayed by one week.
Remit to: SHC Services, Inc. d/b/a Supplemental Health Care
Weekly Timesheet, Revision 4.9-
AG1
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Parent category: Business