DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F-62026 (Rev. 07/08)
STATE OF WISCONSIN
REPORT OF HOURS WORKED NURSE AIDE / EVENING
Instructions for this form are available on form F-62022A.
Name - Facility Schedule Dates FROM NURSE AIDE TO SUN MON TUE WED THUR FRI SAT SUN MON City Time Allowed for Meal Break
EVENING SHIFT
License Number Meal Break (Check one.)
Paid Time
TUE WED
Unpaid Time
THUR FRI SAT
SUB-TOTAL GRAND TOTAL