EMPLOYEE: / POSITION: NURSE CONSULTANT
(Please print full name) / POSITION: FLOATER (AWAKE)
POSITION: FLOATER (SLEEP)
EMPLOYEE ID#:
SCHEDULED HOURS: WEEK 1
PAY PERIOD: / TO / SCHEDULED HOURS: WEEK 2
PROGRAM CODE
DATE / DAY / TIME
IN OUT / NUMBER OF HOURS WORKED / CUM HRS
HRS WORKED
OVERTIME
HOLIDAY
TOTAL HRS ACTUALLY WORKED
FULL TIME STAFF ONLY
PTO
PAID HOLIDAY
LOA PAY
WK 1 TOTAL PER PROG / COMPLETED BY:
PROGRAM CODE
DATE / DAY / TIME
IN OUT / NUMBER OF HOURS WORKED / CUM HRS / employee full signature
REVIEWED BY:
supervisor full signature
Identify other program
worked in pay period:
Program
Hrs. Worked /

Wk1

/

Wk2

SUPERVISOR’S
COMMENTS TO
PAYROLL:
WK 2 TOTAL PER PROG

DO NOT WRITE BELOW THIS LINE – FOR OFFICE USE ONLY

PROGRAM CODES
2 WEEK TOTAL = REG
OVERTIME
HOLIDAY

PER/36.2-1217

PAY
PERIOD / TIMESHEETS TO
SUPERVISOR PAYROLL
10 AM 4 PM / CHECKS ISSUED /

INSTRUCTIONS FOR TIME SHEET COMPLETION

12/10/2017-12/23/2017 / 12/26/2017 / 12/27/2017* / 12/29/2017 / PROGRAM CODES
12/24/2017-01/06/2018 / 01/08/2018 / 01/09/2018 / 01/12/2018 / 31 - Apple View
12 - Arbor / 32 – Emerson
13 - 14th Avneue / 35 - Parkwood
27 - Shadyview
01/07/2018-01/20/2018 / 01/22/2018 / 01/23/2018 / 01/26/2018 / 33 - Bassett Creek
10 - BirchLake / 23 – Gardenview
29 - Highland / 19 - Silver Oaks
38 - Skyline
01/21/2018-02/03/2018 / 02/05/2018 / 02/06/2018 / 02/09/2018 / 14 – Burnhaven
28 - Cedar Crest / 26 - Huntington
17 – Jefferson / 07 - South St. Paul Sites
34 - Southview
02/04/2018-02/17/2018 / 02/19/2018 / 02/20/2018 / 02/23/2018 / 39 - Coachman
08 - Cornell Trail / 15 - Lakeview
37 – Midland / 42 - Swift Lane
43 - Third Avenue
02/18/2018-03/03/2018 / 03/05/2018 / 03/06/2018 / 03/09/2018 / 44 - Corner Place
24 - Creekside / 21 - Northview
18 - Oak Hills / 16 - Westwood
20 - Woodlake
03/04/2018-03/17/2018 / 03/19/2018 / 03/20/2018 / 03/23/2018 / 48 – Deerview
22 - EchoPark / 47 – Oxbury
25 - Parkside / 11 - Woodridge
03/18/2018-3/31/2018 / 04/02/2018 / 04/03/2018 / 04/06/2018 / INSTRUCTIONS FOR TIME SHEET COMPLETION
04/01/2018-04/14/2018 / 04/16/2018 / 04/17/2018 / 04/20/2018 / EMPLOYEE: Complete name (please print)
EMPLOYEE ID#: This number can be found on your paycheck.
PAY PERIOD: Reference payroll schedule
PROGRAM CODE: Use site code to indicate place worked (see above) Use the same column for each separate program
Worked in the two week time period.
------
DATE: Date worked
DAY: I.e., Su, M, T, etc.
TIME IN: Time you began work. Include AM or PM.
TIME OUT: Time you finished work. Include AM or PM. Separate days at Midnight (12AM).
# HOURS: Total hours worked that day
CUM HRS: Add cumulative, total hours worked. Record actual hours worked only.
------
EACH WEEK RUNS FROM SUNDAY THROUGH SATURDAY.
WEEK 1 TOTAL: Add all hours for the week in each column vertically.
The total of all columns will equal the total for
CUM HRS.
FOLLOW THE ABOVE PROCEDURE FOR COMPLETING WEEK 2
* If there is not adequate space to record your hours, use additional timesheets.
------
IMPORTANT: Do not write below the line stating: “Do not write below this line.” The temp supervisor will complete this section.
------
Identify other program worked in time period: If you worked at another program or divisions in this time period, identify the program and put the number of hours worked each week.
PLEASE SIGN YOUR TIME CARD VERIFYING THE RECORDED HOURS.
(This is required in all ICF/MR sites.)
*Timecards are due to Payroll at 10:00a.m. on listed date due to holiday during week.
04/15/2018-04/28/2018 / 04/30/2018 / 05/01/2018 / 05/04/2018
04/29/2018-05/12/2018 / 05/14/2018 / 05/15/2018 / 05/18/2018
05/13/2018-05/26/2018 / 05/29/2018 / 05/30/2018 / 06/04/2018**
05/27/2018-06/09/2018 / 06/11/2018 / 06/12/2018 / 06/15/2018
06/10/2018-06/23/2018 / 06/25/2018 / 06/26/2018 / 06/29/2018
06/24/2018-07/07/2018 / 07/09/2018 / 07/10/2018 / 07/13/2018
07/08/2018-07/21/2018 / 07/23//2018 / 07/24/2018 / 07/27/2018
07/22/2018-08/04/2018 / 08/06/2018 / 08/07/2018 / 08/10/2018
08/05/2018-08/18/2018 / 08/20/2018 / 08/21/2018 / 08/24/2018
08/19/2018-09/01/2018 / 09/04/2018 / 09/05/2018 / 09/10/2018**
09/02/2018-09/15/2018 / 09/17/2018 / 09/18/2018 / 09/21/2018
09/16/2018-09/29/2018 / 10/01/2018 / 10/02/2018 / 10/05/2018
09/30//2018-10/13/2018 / 10/15/2018 / 10/16/2018 / 10/19/2018
10/14/2018-10/27/2018 / 10/29/2018 / 10/30/2018 / 11/02/2018
10/28/2018-11/10/2018 / 11/12/2018 / 11/13/2018 / 11/16/2018
11/11/2018-11/24/2018 / 11/26/2018 / 11/27/2018 / 11/30/2018
11/25/2018-12/08/2018 / 12/10/2018 / 12/11/2018 / 12/14/2018
12/09/2018-12/22/2018 / 12/24/2018 / 12/26/2018 / 12/31/2018** / **Pay date is on Monday due to bank holidays affecting deadlines
No benefit deductions: 12/29/17, 6/29/18, & 11/30/18

PER/36.2-1217