Casual Hour Record

Genesys Nursing PerDiem Employee Availability
This form is for all Genesys Nursing PerDiem Employees. Please complete the form below to inform us of your availability to work at Genesys.

CONTACT INFORMATION: (Bolded Fields are required.)

First Name:

Last Name:

E-mail Address:

Home Telephone #:

Please enter the Departments that you can work:
[Seperate multiple dept. names with a comma]

Dates and Hours Available to Work:
[If Start Time + # Hours can work is greater than midnight, you must enter seperate entries for hours past midnight]
Example: If an employee was available on 12/01/2005 starting at 3:00 p.m. for 12 hours, they would enter the following:
1) Date Available = 12/01/2005 : Start Work = 3:00 p.m. : #Hours Can work = 9
2) Date Available = 12/02/2005 : Start Work = 12:00 a.m. : #Hours Can work = 3

	1st Available	2nd Available	3rd Available
Date: [mm/dd/yy]
Start Time: [HH:MM a.m. or p.m.]
# Hours Can Work:

	4th Available	5th Available	6th Available
Date: [mm/dd/yy]
Start Time: [HH:MM a.m. or p.m.]
# Hours Can Work:

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