Under California law you must:

Be provided with no less than a 30-minute meal period when the work period is more than five hours. Unless you are relieved of all duties during the entire 30-minute meal period and are free to leave the premises, the meal period shall be considered “on duty,” counted as hours worked, and paid for at your regular rate of pay.

In addition, you must be able to take uninterrupted rest periods. The authorized rest period time shall be based on the total hours worked daily at the rate of a minimum of ten minutes net rest time per four hours worked. (Some of our contracts establish fifteen minute breaks.)

If the hospital fails to provide you a meal or break, the hospital shall pay you one hour of pay at your regular rate for each workday that the meal period is not provided, and one hour of pay at your regular rate for each workday that the rest period is not provided (no more than two hours per day).

You are entitled to be compensated for missed lunch and breaks. If you are not able to take your break or lunch, please complete this form.

• Use only one form per shift.
• Maximum penalty payment is two hours per day.

This form is for data collection only.

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* 1. Employee Name

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* 2. Mobile Number*
*By providing my mobile phone number, I understand that SEIU and its locals and affiliates may use automated calling technologies and/or text message me on my mobile phone on a periodic basis. SEIU will never charge for text message alerts. Carrier message and data rates may apply to such alerts. Text STOP to 787753 to stop receiving messages. Text HELP to 787753 for more information.

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* 3. Hospital

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* 4. Department #

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* 5. Title

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* 6. Manager

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* 7. Date of missed break(s)

Date / Time

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* 8. Scheduled hours worked

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* 9. List below the reasons for missing the break

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* 10. Was your missed break/meal scheduled?

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* 11. If yes, when was your missed break/meal scheduled?

Date / Time

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* 12. Did you notify a supervisor prior to the scheduled break time that you would not be able to take the break/meal period?

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* 13. If "no," why not?

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* 14. If "yes," whom did you notify and when?

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* 15. Payment requested for:

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* 16. Time of 1st missed break

Date / Time

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* 17. Explain

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* 18. Payment requested for:

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* 19. Time of 2nd missed break

Date / Time

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* 20. Explain

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* 21. Payment requested for:

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* 22. Time of 3rd missed break

Date / Time

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* 23. Explain

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* 24. Payment requested for:

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* 25. Time of 4th missed break

Date / Time

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* 26. Explain

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* 27. Today's date

Date / Time

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