DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F-62164 (Rev. 07/08)
STATE OF WISCONSIN
REPORT OF HOURS WORKED - LICENSED PRACTICAL NURSE / DAY
Instructions for this form are available on form F-62022A.
Name - Facility City License Number
DAY SHIFT
From
Schedule Dates To
Time Allowed for Meal Break
MEAL BREAK (Check one.)
Paid Time
MON TUE WED THUR FRI SAT SUN MON TUE WED THUR
Unpaid Time
FRI SAT
LPN
SUN
SUB-TOTAL GRAND TOTAL