DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F-62165 (Rev. 07/08)
STATE OF WISCONSIN
EVENING SHIFT
REPORT OF HOURS WORKED LICENSED PRACTICAL NURSE / EVENING
Instructions are available for this form on form F-62022A.
Name - Facility City License Number
From
Schedule Dates To SUN MON TUE WED
Time Allowed for Meal Break
MEAL BREAK (Check one.)
Paid Time
THUR FRI SAT SUN MON TUE WED THUR
Unpaid Time
FRI SAT
LPN
SUB-TOTAL GRAND TOTAL