Timekeeping Correction Form

• 1.) This form should be submitted within 48 hours of occurrence 2.) Please fill out the following information. Do not leave any spaces blank. 3.) A 15 minute administration fee may be assessed. Only GHPM employees are authorized to submit a correction form. Forms submitted by anyone other than the employee will be rejected and considered invalid.
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• Required Information
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• Employee PIN #*
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• First Name*
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• Last Name:*
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• Address:*
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• City*
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• State*

  TexasAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
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• Zip Code*
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• Home Phone*(xxx-xxx-xxxx)
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• Cell Phone*(xxx-xxx-xxxx)
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• Email*(must be filled out to send form)
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• Name of pool where shift was worked:*
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• Date shift was worked*MM/DD/YYYY
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• Times you worked:*(ex: 8-2p)
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• Winess Name*(First and Last) Witness must be the Manager on Duty (MOD) during the date and time listed above:
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• Reason For Time Adjustment
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• Reason for not clocking in/out: (Provide all details for your case)*
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• I agree to the 15 minute administration fee. (Please note, if the clock in/out system is down/unavailable, you will not be charged the administration fee.) By clicking submit, you agree to the 15 minute administration fee.*

  I Agree
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• Security Validationcopy the characters
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• Submit Form
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