Time Clock Exception Form

    Time Clock Exception Form

    Employee Name

    This form will be used when an employee fails to clock IN or OUT and/or update the task codes to his/her timeclock record. No edits will be done to the employee's time clock record without this form. Failure to submit this form may result in lost wages and/or disciplinary action. Call or text will not be accepted as a replacement for the form. Submit to the Program Manager

    Date

    Scheduled Time

    IN

    OUT

    Actual Clocked Time

    Reason Code

    Task codes (If out call was missed)

    09. Phone in Use by Patient/Family

    10. Phone Disconnected

    11. Client Emergency during the scheduled visit

    14. Staff Family Emergency During Shift

    20. Severe Inclement Weather or Natural Disaster

    22. Other

    23. Phone not Functioning

    24. Check-In Not Functioning; Documentation Provided

    25. Check-Out Not Functioning; Documentation Provided

    Submit no later than 24 hrs after missing clock in/out to. I certify that the above information is accurate and complete to the best of my knowledge. I understand that PC&H may investigate all statements made in this document and that any false or misleading information provided can result in disciplinary action or immediate discharge as appropriate

    Client Signature::

    Employee Signature::

    Date:

    Scroll to Top