1. SDHH Break and Expense Report

BREAK & EXPENSE

Tracking Form
First and Last Name*
(DEACTIVATED FIELD) Name

First NameLast Name
(DEACTIVATED FIELD) Employee ID
Your shift's date & start time:*
Team Name?*
(DEACTIVATED FIELD)Your shift's date:
••• BREAKS •••
YESNO
You indicated that you did not take all of your breaks for this shift. Please explain why:*
••• MILEAGE •••
1) TO / FROM MILEAGE: Were you offered paid mileage in this shift's details on Humanity?*
Input the amount of paid mileage offered to and from the shift as specified in Humanity- ONLY if you drove your own vehicle:
2) ROUTE MILEAGE: Did you drive your own vehicle today after the first worksite to additional worksites?*
If you did not drive to multiple locations or if you rode with someone, select "NO".
Input your total mileage from the first worksite to any additional worksites ONLY if you drove your own vehicle during the shift hours.
Do not include mileage to arrive at the first location nor mileage after you depart from the final location. (*Exception: if you are transporting materials for the shift.)
$ AMOUNT DUE for Grand Total Miles (Route + TO/FROM)*
Based on current IRS mileage rate.
Reimburseable mileage must be submitted in the mileage section of this form. Mileage that is omitted or improperly reported may be delayed until corrected and properly documented.
••• EXPENSES •••
YesNo
If an expense was charged to a company credit card, do not submit it on this form.
Instead, submit it here then return to complete this form: Submit company CC receipts.

Complete, itemized receipts showing date, time, vendor, service details, ride route, total, and proof of payment are required for reimbursement. Pending or incomplete receipts will not be accepted.
Expense Amount #1
do not include a dollar sign ($)
Reason for expense #1?*
Take Photo of receipt #1
or attach a receipt #1 photo if applicable.

Browse Files

Cancelof
Expense Amount #2
do not include a dollar sign ($)
Reason for expense #2?*
Take Photo of receipt #2
Attach a receipt #2 photo if applicable.

Browse Files

Cancelof
Expense Amount #3
do not include a dollar sign ($)
Reason for expense #3?*
Take Photo of receipt #3
Attach a receipt #3 photo if applicable.

Browse Files

Cancelof
Expense Amount #4
do not include a dollar sign ($)
Reason for expense #4?*
Take Photo of receipt #4
Attach a receipt #4 photo if applicable.

Browse Files

Cancelof
YesNo
YesNo
Attach receipts

Browse Files or Take Photo

Cancelof
Details, comments, or feedback pertaining only to breaks, mileage, or expenses.
This is ONLY for comments related to breaks, expenses, or mileage and not for anything related to your clock in nor clock out.
For any other feedback about this shift that is not related to breaks, expenses, nor time clocks, please email max@staffableagency.com
Draw a clear signature!!!

No initials. No squiggles. It should look like your I.D.
Signature*

Clear
Signature must be clear and match your I.D.
Internal notes on this entry

BREAK & EXPENSE

••• BREAKS •••

••• MILEAGE •••

••• EXPENSES •••

Draw a clear signature!!!