AHS Payroll Correction Request

Payroll Correction Request
Submission Date

MonthDayYear
Date
Employee Name

First NameLast Name
Number of Corrections/Shifts
Shift Start Date (1)

MonthDayYear
Date
Shift End Date (1)

MonthDayYear
Date
Shift Start (1)

Hour Minutes

AM/PM Option
Shift End (1)

Hour Minutes

AM/PM Option
Hours Worked (1)
Rate (1)
Department (1)
Shift Start Date (2)

MonthDayYear
Date
Shift End Date (2)

MonthDayYear
Date
Shift Start (2)

Hour Minutes

AM/PM Option
Shift End (2)

Hour Minutes

AM/PM Option
Hours Worked (2)
Rate (2)
Department (2)
Shift Start Date (3)

MonthDayYear
Date
Shift End Date (3)

MonthDayYear
Date
Shift Start (3)

Hour Minutes

AM/PM Option
Shift End (3)

Hour Minutes

AM/PM Option
Hours Worked (3)
Rate (3)
Department (3)
Shift Start Date (4)

MonthDayYear
Date
Shift End Date (4)

MonthDayYear
Date
Shift Start (4)

Hour Minutes

AM/PM Option
Shift End (4)

Hour Minutes

AM/PM Option
Hours Worked (4)
Rate (4)
Department (4)
Shift Start Date (5)

MonthDayYear
Date
Shift End Date (5)

MonthDayYear
Date
Shift Start (5)

Hour Minutes

AM/PM Option
Shift End (5)

Hour Minutes

AM/PM Option
Hours Worked (5)
Rate (5)
Department (5)
Shift Start Date (6)

MonthDayYear
Date
Shift End Date (6)

MonthDayYear
Date
Shift Start (6)

Hour Minutes

AM/PM Option
Shift End (6)

Hour Minutes

AM/PM Option
Hours Worked (6)
Rate (6)
Department (6)
Shift Start Date (7)

MonthDayYear
Date
Shift End Date (7)

MonthDayYear
Date
Shift Start (7)

Hour Minutes

AM/PM Option
Shift End (7)

Hour Minutes

AM/PM Option
Hours Worked (7)
Rate (7)
Department (7)
Shift Start Date (8)

MonthDayYear
Date
Shift End Date (8)

MonthDayYear
Date
Shift Start (8)

Hour Minutes

AM/PM Option
Shift End (8)

Hour Minutes

AM/PM Option
Hours Worked (8)
Rate (8)
Department (8)
Shift Start Date (9)

MonthDayYear
Date
Shift End Date (9)

MonthDayYear
Date
Shift Start (9)

Hour Minutes

AM/PM Option
Shift End (9)

Hour Minutes

AM/PM Option
Hours Worked (9)
Rate (9)
Department (9)
Shift Start Date (10)

MonthDayYear
Date
Shift End Date (10)

MonthDayYear
Date
Shift Start (10)

Hour Minutes

AM/PM Option
Shift End (10)

Hour Minutes

AM/PM Option
Hours Worked (10)
Rate (10)
Department (10)
Shift Start Date (11)

MonthDayYear
Date
Shift End Date (11)

MonthDayYear
Date
Shift Start (11)

Hour Minutes

AM/PM Option
Shift End (11)

Hour Minutes

AM/PM Option
Hours Worked (11)
Rate (11)
Department (11)
Shift Start Date (12)

MonthDayYear
Date
Shift End Date (12)

MonthDayYear
Date
Shift Start (12)

Hour Minutes

AM/PM Option
Shift End (12)

Hour Minutes

AM/PM Option
Hours Worked (12)
Rate (12)
Department (12)
Shift Start Date (13)

MonthDayYear
Date
Shift End Date (13)

MonthDayYear
Date
Shift Start (13)

Hour Minutes

AM/PM Option
Shift End (13)

Hour Minutes

AM/PM Option
Hours Worked (13)
Rate (13)
Department (13)
Shift Start Date (14)

MonthDayYear
Date
Shift End Date (14)

MonthDayYear
Date
Shift Start (14)

Hour Minutes

AM/PM Option
Shift End (14)

Hour Minutes

AM/PM Option
Hours Worked (14)
Rate (14)
Department (14)
Shift Start Date (15)

MonthDayYear
Date
Shift End Date (15)

MonthDayYear
Date
Shift Start (15)

Hour Minutes

AM/PM Option
Shift End (15)

Hour Minutes

AM/PM Option
Hours Worked (15)
Rate (15)
Department (15)
Shift Start Date (16)

MonthDayYear
Date
Shift End Date (16)

MonthDayYear
Date
Shift Start (16)

Hour Minutes

AM/PM Option
Shift End (16)

Hour Minutes

AM/PM Option
Hours Worked (16)
Rate (16)
Department (16)
Shift Start Date (17)

MonthDayYear
Date
Shift End Date (17)

MonthDayYear
Date
Shift Start (17)

Hour Minutes

AM/PM Option
Shift End (17)

Hour Minutes

AM/PM Option
Hours Worked (17)
Rate (17)
Department (17)
Shift Start Date (18)

MonthDayYear
Date
Shift End Date (18)

MonthDayYear
Date
Shift Start (18)

Hour Minutes

AM/PM Option
Shift End (18)

Hour Minutes

AM/PM Option
Hours Worked (18)
Rate (18)
Department (18)
Shift Start Date (19)

MonthDayYear
Date
Shift End Date (19)

MonthDayYear
Date
Shift Start (19)

Hour Minutes

AM/PM Option
Shift End (19)

Hour Minutes

AM/PM Option
Hours Worked (19)
Rate (19)
Department (19)
Shift Start Date (20)

MonthDayYear
Date
Shift End Date (20)

MonthDayYear
Date
Shift Start (20)

Hour Minutes

AM/PM Option
Shift End (20)

Hour Minutes

AM/PM Option
Hours Worked (20)
Rate (20)
Department (20)
Shift Start Date (21)

MonthDayYear
Date
Shift End Date (21)

MonthDayYear
Date
Shift Start (21)

Hour Minutes

AM/PM Option
Shift End (21)

Hour Minutes

AM/PM Option
Hours Worked (21)
Rate (21)
Department (21)
Shift Start Date (22)

MonthDayYear
Date
Shift End Date (22)

MonthDayYear
Date
Shift Start (22)

Hour Minutes

AM/PM Option
Shift End (22)

Hour Minutes

AM/PM Option
Hours Worked (22)
Rate (22)
Department (22)
Shift Start Date (23)

MonthDayYear
Date
Shift End Date (23)

MonthDayYear
Date
Shift Start (23)

Hour Minutes

AM/PM Option
Shift End (23)

Hour Minutes

AM/PM Option
Hours Worked (23)
Rate (23)
Department (23)
Shift Start Date (24)

MonthDayYear
Date
Shift End Date (24)

MonthDayYear
Date
Shift Start (24)

Hour Minutes

AM/PM Option
Shift End (24)

Hour Minutes

AM/PM Option
Hours Worked (24)
Rate (24)
Department (24)
Shift Start Date (25)

MonthDayYear
Date
Shift End Date (25)

MonthDayYear
Date
Shift Start (25)

Hour Minutes

AM/PM Option
Shift End (25)

Hour Minutes

AM/PM Option
Hours Worked (25)
Rate (25)
Department (25)
Shift Start Date (26)

MonthDayYear
Date
Shift End Date (26)

MonthDayYear
Date
Shift Start (26)

Hour Minutes

AM/PM Option
Shift End (26)

Hour Minutes

AM/PM Option
Hours Worked (26)
Rate (26)
Department (26)
Shift Start Date (27)

MonthDayYear
Date
Shift End Date (27)

MonthDayYear
Date
Shift Start (27)

Hour Minutes

AM/PM Option
Shift End (27)

Hour Minutes

AM/PM Option
Hours Worked (27)
Rate (27)
Department (27)
Shift Start Date (28)

MonthDayYear
Date
Shift End Date (28)

MonthDayYear
Date
Shift Start (28)

Hour Minutes

AM/PM Option
Shift End (28)

Hour Minutes

AM/PM Option
Hours Worked (28)
Rate (28)
Department (28)
Shift Start Date (29)

MonthDayYear
Date
Shift End Date (29)

MonthDayYear
Date
Shift Start (29)

Hour Minutes

AM/PM Option
Shift End (29)

Hour Minutes

AM/PM Option
Hours Worked (29)
Rate (29)
Department (29)
Shift Start Date (30)

MonthDayYear
Date
Shift End Date (30)

MonthDayYear
Date
Shift Start (30)

Hour Minutes

AM/PM Option
Shift End (30)

Hour Minutes

AM/PM Option
Hours Worked (30)
Rate (30)
Department (30)
Shift Start Date (31)

MonthDayYear
Date
Shift End Date (31)

MonthDayYear
Date
Shift Start (31)

Hour Minutes

AM/PM Option
Shift End (31)

Hour Minutes

AM/PM Option
Hours Worked (31)
Rate (31)
Department (31)
Total Hours worked
Please note any other hours
Reason for correction
Completed By

First NameLast Name
Email
example@example.com
Should be Empty: