Rx Med Staff, LLC 502 Granberry Humble, Texas 77338 Office: (832) 527-0771 Fax: (281) 596-2714 7214 www.rxmedstaff.com Hospital/Client’s name Employee’s name Social Security # Area date
Dept# time start
Thu Fri Sa
Total hours to nearest ¼ hrs
I certify that the hours shown above are correct and performed satisfactorily. Employee signature:
I certify that the hours shown above are the accurate hours worked and verified by client or by an authorized representative.
Signatue of authorized personnel of Facility ONLY