1. SDHH Break and Expense Report

BREAK & EXPENSE FORM

This form must be completed immediately at the end of each shift and prior to clocking out.

First and Last Name

Your shift's date & scheduled START TIME (Not the onsite time):

Team Name?

Did you take all required rest break(s) and meal break(s) based on your continuous work time today? (If a break was required, it must be taken.)

You indicated that you did not take all required breaks. Please explain, including any additional work performed before or after this shift and whether it was continuous.

Did you operate or ride in a company vehicle at any time today?

ROUTE MILEAGE: Did you drive your own vehicle after arriving at your first worksite as part of your work duties during this shift?

Enter miles driven while performing work (e.g., between worksites or required logistics tasks).

Do not include mileage to arrive at the first location nor mileage after you depart from the final location. (*Exception: if you were required to transport materials for the shift.)

TO / FROM MILEAGE: Was mileage reimbursement offered TO and FROM work in the shift's details on Humanity?

Enter the pre-set mileage amount listed in the shift details (if applicable):

This is a fixed amount assigned to the shift and is not based on actual miles driven.

Reimburseable mileage must be submitted in the mileage section of this form. Mileage that is omitted or improperly reported may be delayed until corrected and properly documented.

Do you have any pre-approved expenses you paid for personally that need to be reimbursed to you?

If an expense was charged to a company credit card, do not submit it on this form.
Instead, submit it with this link then return to complete this form: Submit company CC receipts.

Complete, itemized receipts showing date, time, vendor, service details, ride route, total, and proof of payment are required for reimbursement. Pending or incomplete receipts will not be accepted.

Expense Amount #1

do not include a dollar sign ($)

Reason for expense #1?

Take Photo of receipt #1

or attach a receipt #1 photo if applicable.

Browse Files

Expense Amount #2

do not include a dollar sign ($)

Reason for expense #2?

Take Photo of receipt #2

Attach a receipt #2 photo if applicable.

Browse Files

Expense Amount #3

do not include a dollar sign ($)

Reason for expense #3?

Take Photo of receipt #3

Attach a receipt #3 photo if applicable.

Browse Files

Expense Amount #4

do not include a dollar sign ($)

Reason for expense #4?

Take Photo of receipt #4

Attach a receipt #4 photo if applicable.

Browse Files

Were you the Team Lead on this shift?

Do you have any receipts for charges to a Remarq credit card?

Attach receipts

Browse Files or Take Photo

Details, comments, or feedback pertaining only to breaks, mileage, or expenses.

This is ONLY for comments related to breaks, expenses, or mileage and not for anything related to your clock in nor clock out.

For any other feedback about this shift that is not related to breaks, expenses, nor time clocks, please email max@staffableagency.com

Signature

Signature must be clear and match your I.D.

Internal notes on this entry

••• BREAKS •••

••• MILEAGE •••

••• EXPENSES •••

Draw a clear signature!!!

BREAK & EXPENSE