Start Finish Pay date Participant Worksite Time
(hours)
Paid absence
d(days) h(hours) m(minutes)
Unpaid absence
d(days) h(hours) m(minutes)
Committed Approved by
worksite supervisor
Approved by
payroll
Date Absence reason Time out Start Finish Less lunch / break Total hours
  Total hours for first week
Date Absence reason Time out Start Finish Less lunch / break Total hours
* Job search (4 hrs/week) Final 3 months—PWE ONLY
* WC—Worker's Comp: day of injury
Total hours for second week
Total hours NOT to exceed 80.00
Did you experience a work-related injury during this pay cycle?
Did you work on a holiday during this pay cycle?