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: