OLD FORM: use
Timesheet Adjustment Request
in Web Forms menu
Time & Attendance Record
Complete the appicable
YELLOW
potions only
Submit a separate form for each Pay Period (1st-15th or 16th-End of Month)
Month/Year:
W#:
Employee Name:
Position #:
Position Title:
Department:
Dates in Pay Period
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Day of the Week
Dates in Pay Period
16
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day of the Week
List Earn Code(s) below
List Number of Hours Worked Each Day Below
TOTAL
Hours Worked Per Day
Overtime
Comp Time Earned
Holiday Premium Pay
Call Back
Holiday Comp Worked
Late Hours
Stand By Pay
Shift Differential Pay
Shift Differential Overtime
Shift Diff Pay-BUD
Shift Diff OVT-BUD
Hours Over Appointment
List Leave Taken below
List Number of Leave Hours Taken or Earned Each Day Below
Vacation Leave
Sick Leave
Comp Time Taken
Personal Holiday
Leave Without Pay
Military Leave
Personal Leave Day
Holiday Comp Time Earned
Holiday Comp Time Taken
Cyclic Leave
Bereavement Leave
Other
TOTAL
I certify that I have verified the hours recorded with the employee and it accurately reflects the hours worked or leave taken.
Date:
Supervisor Signature:
I certify the hours recorded above accurately reflect the hours I've worked or leave taken.
Date:
Employee Signature: