DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F-62024 (Rev. 07/08)
STATE OF WISCONSIN
REPORT OF HOURS WORKED NURSE AIDE / DAY
Instructions for this form are available on form F-62022A.
Name - Facility City License Number
DAY SHIFT
Schedule Dates FROM NURSE AIDE TO SUN MON TUE WED THUR
Time Allowed for Meal Break
Meal Break (Check one.)
Paid Time
FRI SAT SUN MON TUE WED
Unpaid Time
THUR FRI SAT
SUB-TOTAL GRAND TOTAL