Payroll Grievance Form

Employee Name*

Employee Email Address*

Home Worked:*

Shift:

Reason for Grievance*

If you are missing a shift worked, was your Therap documentation completed?*

Yes
No

If you are missing a shift worked, why was there no Clock In/Clock Out reported?*

Was this grievance previously reported? If so, to whom and on what date?*

Request for Time Punch Adjustment

PAY PERIOD WEEK 1

SUNDAY
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY

ENTER REVISED TIME(S) FOR SUNDAY

Start Punch

:

Stop Punch

:

ENTER REVISED TIME(S) FOR MONDAY

Start Punch

:

Stop Punch

:

ENTER REVISED TIME(S) FOR TUESDAY

Start Punch

:

Stop Punch

:

ENTER REVISED TIME(S) FOR WEDNESDAY

Start Punch

:

Stop Punch

:

ENTER REVISED TIME(S) FOR THURSDAY

Start Punch

:

Stop Punch

:

ENTER REVISED TIME(S) FOR FRIDAY

Start Punch

:

Stop Punch

:

ENTER REVISED TIME(S) FOR SATURDAY

Start Punch

:

Stop Punch

:

PAY PERIOD WEEK 2

SUNDAY
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY

ENTER REVISED TIME(S) FOR SUNDAY

Start Punch

:

Stop Punch

:

ENTER REVISED TIME(S) FOR MONDAY

Start Punch

:

Stop Punch

:

ENTER REVISED TIME(S) FOR TUESDAY

Start Punch

:

Stop Punch

:

ENTER REVISED TIME(S) FOR WEDNESDAY

Start Punch

:

Stop Punch

:

ENTER REVISED TIME(S) FOR THURSDAY

Start Punch

:

Stop Punch

:

ENTER REVISED TIME(S) FOR FRIDAY

Start Punch

:

Stop Punch

:

ENTER REVISED TIME(S) FOR SATURDAY

Start Punch

:

Stop Punch

:

Signature*

Name

This field is for validation purposes and should be left unchanged.

employment opportunities

Forms

Payroll Grievance Form

Payroll Grievance Form

Request for Time Punch Adjustment