Date
Time & lunch
Work blocks
Add one block per work type. Total should match your clock hours.
Safety
Acknowledgment
I hereby acknowledge, certify, and affirm that the hours listed above are true, accurate, and correct. I further affirm that I have received all required duty-free meal and rest periods during this payroll period. On shifts that I worked six hours or less without taking a duty-free meal period I voluntarily waived my right to a duty-free meal period. I acknowledge that I have not suffered a work-related injury or illness during this payroll period (unless noted above).