Meal and Rest Break Compliance Attestation

Attestation Form

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Meal and Rest Break Compliance Attestation

First Name

Last Name

Division

Date

Over the course of the prior pay period, were you provided and able to take all of your first and, when you worked over 10 hours on a shift, second meal periods?

Over the course of the prior pay period, can you attest that your meal periods provided and taken were all: (a) at least 30 minutes in length, (b) taken on or before the 5th hour of shifts of ten hours or more and less than 12 hours, (c) uninterrupted, and (d) duty free?

Over the course of the prior pay period, were you provided and able to take all of your first and, when you worked more than 6 and 9 hours shifts, respectively, your second and third rest periods, respectively?

During the preceding pay period, please identify the dates and details of any late, missed, or interrupted meal or rest breaks. Please note that employees will be paid the applicable premiums for any dates where a meal period, rest period, or both were missed, taken late, or interrupted.

During the preceding pay period, did you sustain any injury in the course of your employment? If yes, please specify the date, location, and circumstances of the injury.

Attestation Form

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