Payroll Adjustment

Name*

First Last

How can we help you?*

Correct my timecard
Add PTO hours to my pay check
Add other type of pay to my paycheck
Other

What do we need to correct?

I forgot to clock in for the start of my shift
I forgot to clock out for lunch
I forgot to clock out at the end of my shift
Other

Date timecard needs corrected:*

Time to clock you in:*

:

Time to clock you out:*

:

Time to clock you out for lunch:*

:

Time to clock you in after lunch:*

:

Comments:

Explain what needs corrected. Be specific about times to clock you in or out.*

How many hours of PTO do you want added to the current payroll?*

Verify available PTO hours*

I have checked my PTO balance in Dayforce to verify that I have enough hours available to cover this request.

Comments:

Please add pay for the following:*

I completed a work task at home or another location
I attended an approved CE event
I am requesting bereavement pay
I am requesting jury duty pay
I am an RVT requesting pay for an after hours emergency surgery
I shopped for the hospital
Other

What task did you complete off-site?*

Where did you complete the task?*

How many minutes or hours did the task take to complete?*

What CE event did you attend?*

How many minutes or hours did you spend in CE?*

Documentation Required. Upload a receipt or CE certificate if you have not already submitted a copy.

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 256 MB.

Bereavement Pay Policy: After a 90-day introductory period, in the event of a death in your immediate family, you will be allowed up to three days off with pay. The immediate family consists of father, mother, sisters, brothers, daughter, son, guardian or spouse. Employees will be allowed one day of absence with pay in the event that a grandparent, granddaughter, grandson, uncle, aunt, or a member of your spouse’s immediate family should pass away. Employees with less than 90 calendar days of employment may receive the above leave without pay. All employees will be covered by this policy.

Select:

I am requesting 3 days of paid leave due to the death of my parent, sibling, child, guardian or spouse.
I am requesting 1 day of paid leave due to the death of my grandparent, grandchild, uncle, aunt, or a member of my spouse’s immediate family.

Documentation Required. Upload a funeral notice, obituary, or other documentation if you have not already submitted a copy.

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 256 MB.

Comment:

Jury Duty Policy: Employees will receive the difference between their regular pay and jury pay if called to serve for a total of up to one work week of pay. Any employee called to serve on jury duty for longer than one week will receive an unpaid leave of absence. Please submit a statement from the court listing the days you served and the amount you were paid.

How many hours did you miss working due to Jury duty.?

Documentation Required. Upload a statement from the court indicating how many days you served and pay received.

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 256 MB.

Please verify:*

I stayed 1 hour beyond the end of my shift or I came in on my day off
The emergency surgery fee was charged to the client

Name and CID of patient who had surgery*

Are you sharing the emergency fee with another technician? Who?*

Select all that apply:*

I shopped for the hospital at Costco, Walmart, or other retail stores
Please add the shopping bonus to my paycheck
I used my vehicle. Please add $10 for gas to my paycheck.

Comments:

Please explain:*

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