Date of Report being made *

MM

DD

YYYY

Name of Staff Submitting Request *

First Name

Last Name

Name of staff performing transaction? *

First Name

Last Name

Date of business transaction? *

MM

DD

YYYY

Staff Name *

First Name

Last Name

What shift(s) do you normally work? *

Select the shift(s) that are closest to your regular working schedule below.

3:00 PM - 11:30PM or Evening

11:30 PM - 8:00 AM or Overnight

8:00 AM - 8:00 PM Dayside

8:00 PM - 8:00 AM Nightside

ISS (Day Center)

Office

Start of Requested Days Off *

First day expected to be off work.

MM

DD

YYYY

End of Requested Days Off* *

The FIRST day you can be scheduled to work. If traveling, do not request to work on the same day you are to return from your trip.

MM

DD

YYYY

Name *

First Name

Last Name

Date of Error on Timecard *

MM

DD

YYYY

Which Location did you work? *

ISS Center

7951 Charlestown Lane (Womens Home)

7950 Charlestown Lane (Mens Home)

1182 Hathcox Ave (Mens Home)

2936 Hunting Drive

4217 Henderson Street

3941 Ryan Avenue

1178 Hathcox Avenue (Womens Home)

2601 Hunting Drive

Office

4760 Marshall St

6513 Vega Dr

Start Shift Time *

What time did you begin your shift?

Hour

Minute

Second

AM PM

End Shift Time *

What time did you end your shift?

Hour

Minute

Second

AM PM

Check any box that applies to this shift being reported *

Transport hours are 7:30A - 8:30A & 2:30P - 3:30P Monday - Friday.

I transported.

I did not transport.

Check which box applies to your this shift being reported.

Your ADP timecard shows either a missing clock in our out. (If you clocked in and out, there is no need for this form.)

I did not clock in.

I did not clock out.

I understand that as an employee, my timecard is my responsiblity. *

Yes, I am aware that my time card is my responsibility.

No, I do not understand clocking in & out and accurate time keeping is my responsibility.

Staff Name completing report *

First Name

Last Name

Date

MM

DD

YYYY

Name *

First Name

Last Name

Date of Request for Gas *

MM

DD

YYYY