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Declaration of Extra Hours Worked

This form has been designed to collect pertinent information for the purpose of ascertaining a resolution for reported instances of extended work hours during a Live-in assignment. Please be aware that the data provided herein may be shared with the client and relevant stakeholders for investigative purposes.

*Please note that this form must be completed within 24 hours for proper investigation and resolution.
*When was this first reported and to whom did you report?
On the date that extra hours were worked, describe all of the times worked, tasks performed, and the reason proper break time and rest/sleep time were not received.
If no attempts were made, please describe why.