Janitorial Break Report Form
Please complete this form to accurately record your break details for compliance and tracking purposes.
Full Name
*
First Name
Last Name
Employee ID
*
Date of Break
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Break Start Time
*
Hour Minutes
AM
PM
AM/PM Option
Break End Time
*
Hour Minutes
AM
PM
AM/PM Option
Break Location
*
Please Select
Main Lobby
Restroom
Break Room
Storage Area
Other
Type of Break
*
Meal Break
Rest Break
Personal
Other
Supervisor on Duty
*
Were there any incidents or issues during your break?
*
No incidents
Yes, see notes below
Additional Notes (optional)
Supervisor Comments
Employee Signature
*
Submit Report
Submit Report
Should be Empty: