Time Clock Exception Form

Employee Name

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

Date	Clock Time	IN	OUT	Adjusted Time	Reason Code	Task codes (If out call was missed)

09. Phone in Use by Patient/Family

10. Phone Disconnected

11. Client Emergency during the scheduled visit

14. Staff Family Emergency During Shift

20. Severe Inclement Weather or Natural Disaster

22. Other

23. Phone not Functioning

24. Check-In Not Functioning; Documentation Provided

25. Check-Out Not Functioning; Documentation Provided

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

Time Clock Exception Form

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