Time Clock Exception Form

    AGENCY NAME:

    Time Clock Exception Form

    Employee Name

    Client Name

    Manager's Name

    This form will be used when an employee fails to clock IN or OUT and/or update the task codes to his/her time clock 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 site's Program Manager

    Date

    Scheduled Time

    IN

    OUT

    Actual Clocked Time

    Reason Code

    Task codes (If out call was missed)

    Submit no later than 24 hrs after missing clock in/out.. I certify that the above information is accurate and complete to the best of my knowledge. I understand that Agency 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:



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