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

MM

DD

YYYY

Start Punch

: HH

MM

Stop Punch

: HH

MM

ENTER REVISED TIME(S) FOR MONDAY

MM

DD

YYYY

Start Punch

: HH

MM

Stop Punch

: HH

MM

ENTER REVISED TIME(S) FOR TUESDAY

MM

DD

YYYY

Start Punch

: HH

MM

Stop Punch

: HH

MM

ENTER REVISED TIME(S) FOR WEDNESDAY

MM

DD

YYYY

Start Punch

: HH

MM

Stop Punch

: HH

MM

ENTER REVISED TIME(S) FOR THURSDAY

MM

DD

YYYY

Start Punch

: HH

MM

Stop Punch

: HH

MM

ENTER REVISED TIME(S) FOR FRIDAY

MM

DD

YYYY

Start Punch

: HH

MM

Stop Punch

: HH

MM

ENTER REVISED TIME(S) FOR SATURDAY

MM

DD

YYYY

Start Punch

: HH

MM

Stop Punch

: HH

MM

PAY PERIOD WEEK 2

SUNDAY
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY

ENTER REVISED TIME(S) FOR SUNDAY

MM

DD

YYYY

Start Punch

: HH

MM

Stop Punch

: HH

MM

ENTER REVISED TIME(S) FOR MONDAY

MM

DD

YYYY

Start Punch

: HH

MM

Stop Punch

: HH

MM

ENTER REVISED TIME(S) FOR TUESDAY

MM

DD

YYYY

Start Punch

: HH

MM

Stop Punch

: HH

MM

ENTER REVISED TIME(S) FOR WEDNESDAY

MM

DD

YYYY

Start Punch

: HH

MM

Stop Punch

: HH

MM

ENTER REVISED TIME(S) FOR THURSDAY

MM

DD

YYYY

Start Punch

: HH

MM

Stop Punch

: HH

MM

ENTER REVISED TIME(S) FOR FRIDAY

MM

DD

YYYY

Start Punch

: HH

MM

Stop Punch

: HH

MM

ENTER REVISED TIME(S) FOR SATURDAY

MM

DD

YYYY

Start Punch

: HH

MM

Stop Punch

: HH

MM

Signature*

Comments

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