Declaration of Extra Hours Worked

This form has been designed to collect pertinent information for the purpose of ascertaining a resolution for reported instances of extended work hours during a Live-in assignment. Please be aware that the data provided herein may be shared with the client and relevant stakeholders for investigative purposes.

This form has been designed to collect information to find a resolution for unexpected extended hours worked during a "Live-in" or "Extended Shift" assignment. Please be aware that the information provided herein may be shared with the Client and relevant stakeholders for investigative purposes. *

• By checking this box, I acknowledge and accept that this information will be shared with the Client and relevant stakeholders for investigative purposes.

In accordance with our company policy, it is necessary to promptly report any additional hours worked by completing the provided form within 24 hours of the occurrence. Failure to provide complete and accurate information within 24 hours of the occurance, may result in a potential forfeiture of additional compensation. *

• I acknowledge and accept that I need to report extra hours worked with complete and accurate information within 24 hours of the event occuring.

Date that the event occurred: *

*Please note that this form must be completed within 24 hours for proper investigation and resolution.

Date and Person the event was first reported to: *

*When was this first reported and to whom did you report?

Provide details of the event including what happened, all hours worked, and tasks performed: *

On the date that extra hours were worked, describe all of the times worked, tasks performed, and the reason proper break time and rest/sleep time were not received.

Was there a specific incident that caused the need for additional work to be performed? If yes, please add details. *

Please describe any attempt(s) you made to prevent additional hours worked. *

If no attempts were made, please describe why.

Was the Responsible Party made aware of the additional work needed on this day? If so, who and in what manner were they notified? *

What would you suggest as a possible solution? *

I, the undersigned, confirm the accuracy of the information provided in this form and acknowledge that the compensation for unexpected additional hours worked will be processed in accordance with the organization's policies and applicable labor laws. *

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