NURSES DIRECT LLC
** 109 South College Rd ** Lafayette, LA 70503
Office # 337-289-5393 - Fax # 337-769-9069
Facility / Hospital / Location:
*
Accord Rehab - Plaquemine
Acadiana Rehabilitation
Acadia Vermilion Behavioral
AMG Specialty Facility
Aventi Senior Living
Assumption HealthCare & Rehab
Carpenter House - New Orleans
Carpenter House - Baton Rouge
Carrington Place of Baton Rouge
Chateau D'ville Nursing/Rehab
Chateau St. James Nursing/Rehab
Covington Behavioral
Heart of Hospice - NOLA
Iberia Rehabilitation
LHC LTAC Facility
Lake Charles Care Center
Legacy Nursing & Rehab
New Beginnings Recovery (Opelousas)
New Ways of SW LA (Ville Platte)
Opelousas General Health System
Promise Hospital - Baton Rouge
Resthaven Living Center
Savoy Medical Center
Sage LTAC - Denham Springs
Sage LTAC - Baton Rouge
Southeast Regional Medical Center
The Ellington / Rayne Guest House
The Woodlands Healthcare Center
Total Wellness / Flu shot clinic
United Medical Rehab
Vermilion Health Care
Private Duty
Blood Bank / Blood drive
Chose a facility or facility type
Legacy Location:
*
Franklin
Morgan City
Location / City
*
Client Name
*
Shift worked:
*
Type of shift worked
Savoy Medical floor worked:
*
ER
ICU
Rehab
MedSurg
Psych
Other
United Medical Rehab (Locations)
*
Gonzales
Hammond
New Orleans
Acadia General Hospital floor worked:
*
ER
ICU
MedSurg
Orientation
OGHS floor worked:
*
ER (Main campus)
ER (South campus)
ICU
PCU / 3rd floor
Ortho / 4th floor
MedSurg / 5th floor or South Campus
Rehab / South campus
Post partum (L&D)
Orientation / Training / Education
Other
LHC LTAC location worked:
*
Lafayette - Louisiana Ext Care
Opelousas - St Landry Ext Care
New Iberia - Iberia Ext Care
Crowley - Acadia Ext Care
AMG location worked:
*
Lafayette Physical Rehab - Lafayette
Lafayette AMG
Zachary AMG
Covington AMG
Houma AMG
Acadia Vermilion Location:
*
Main Campus
South Campus
Date of shift worked
*
/
Month
/
Day
Year
Date when shift STARTED
Time worked (Clocked in and out)
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
01
02
03
04
05
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45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
Minutes
AM
PM
AM/PM Option
Until
until
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
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18
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20
21
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33
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35
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38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
Minutes
AM
PM
AM/PM Option
Lunch Break?
*
YES
NO
Total Hours Worked (WITH meal break)
Total Hours Worked (WITHOUT meal break)
Reason for NO LUNCH/MEAL break (VALID reason must be documented)
*
No oncoming shift available to sign/approve
Short staffed / No relief
Extremely busy
Short shift / Sent home early
Schedule error / sent home
Shift cancelled less than 2 hours prior to shift beginning
Nurses Direct Employee Name
*
First Name
Last Name
Nurses Direct Employee position:
*
RN
LPN
CNA
Charge Nurse (RN ONLY)
*
YES
NO
Employee Personal Email:
*
example@example.com
Nurse Direct employee signature
*
*
Shift times approved and signed by authorized individual
NO ONE AVAILABLE TO SIGN/APPROVE OF SHIFT TIMES
Facility employee approval name:
*
First Name
Last Name
Facility approval employee position:
*
RN
LPN
Other
Facility employee approval signature
*
Submit to Payroll
Should be Empty: