Missed Meal Authorization Form

Division*
Name*
First Last
Pay Period
Date of Shift*
Missed
- Missed meal period
- Missed rest break
Detailed reason for missed meal period/rest break*
Authorizing Supervisor or Manager
Supervisor Approval
- All available supervisors/managers failed or refused to sign
Refusing supervisor(s) name(s), date and time of request*
Certification*
- I certify that the information entered into this form is accurate.

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The Joint Commission is the nation's oldest and largest standards-setting and accrediting body in health care.