COMMUNITY HEALTH CENTER

EMERGENCY
PLANNING GUIDELINES
In Relation to Community Disaster Plan

“An Action Plan of having an Active Community Health Center and its emergency plan
for the betterment of the Cebuanos and Future Generations”

Submitted by:

Earohn Tracy N. Aguilar

Grade 12 – Loyalty

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COMMUNITY HEALTH CENTER EMERGENCY PLANNING GUIDELINES

TABLE OF CONTENTS

INTRODUCTION........................................................................................ 1

A) PREPAREDNESS.............………………............................................... 3
Getting Organized
Supplies and Equipment
Establishing Emergency Communications Systems
Planning Ahead for Evacuations
Reducing Exposure to Risks and Hazards

B) RESPONSE .........…………………………........................................... 15
Overview
Emergency Response Actions
To Implement an Evacuation
How to Assist People with Disabilities During and Evacuation

C) RECOVERY ……………………………................................................ 24
Support Services and Assistance
Documenting Emergency Outcomes

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COMMUNITY HEALTH CENTER EMERGENCY PLANNING GUIDELINES

INTRODUCTION

Emergencies and disasters can happen at any moment - and, they usually occur without warning. When
an emergency strikes, our immediate safety and prompt recovery will depend on the existing levels of
preparedness among faculty, staff, and students.

Each Community Health Center has an important role to play in maintaining the facility’s emergency
preparedness and safety. We are an interdependent community.

Community Health Center Emergency Plans are written to provide fundamental support for the general
medical school Emergency Plan. During a major emergency or disaster, the medical school Emergency
Management Team (EMT) will rely on effective communication between the “Emergency Operations
Center (EOC)”, corresponding “Community Health Center Operations Centers (DOCs)” in individual
campus Community Health Centers.

Clearly, Community Health Center Emergency Plans are an essential building block of the University’s
emergency response. They are also part of every unit’s basic health and safety responsibilities and
business continuity planning. Community Health Center Emergency Plans outline how an organization
will:

 Protect the safety of students, faculty, staff and visitors in the Community Health Center,
 Safeguard vital records and resources related to the Community Health Center’s mission,
and
 Coordinate with the University’s emergency response and recovery procedures

The “Emergency Handbook” is distributed to every Community Health Center to provide a current copy of
the Emergency Plan, and to offer a model for developing local area contingency plans. The guidelines for
Community Health Center Emergency Plans will produce comprehensive, yet simple and flexible,
procedures that units can apply to a variety of emergency incidents that may occur, including

 Earthquakes
 Fires or Explosions
 Hazardous Materials Releases
 Extended Power or Utility Outages
 Floods
 Mass Casualty Events

Emergencies are classified as minor or major, according to their severity and potential program impact.

Materials in this Handbook provide guidance for any emergency level. The guidelines will help
Community Health Center Officials to identify key emergency roles and responsibilities, plan ahead for
safe building evacuations and effective emergency communications, and develop strategies for resuming
normal functions after emergency conditions subside.

The manual is divided into three sections:

A. PREPAREDNESS
B. RESPONSE
C. RECOVERY

The materials can serve as templates to create a new Community Health Center Emergency Plan, or they

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COMMUNITY HEALTH CENTER EMERGENCY PLANNING GUIDELINES

can be incorporated directly into existing Community Health Center documents. By keeping emergency
preparedness plans in a loose-leaf binder, Community Health Centers can easily customize or update the
contents

The enclosed forms should be adapted or augmented to fit an organization’s mission, staffing, relative
location(s), or other unique circumstances. For example, an emergency plan in a laboratory science
Community Health Center will address hazardous materials concerns; while an administrative service unit
will address client issues.

Whatever form a Community Health Center Emergency Plan takes, it should include the unit’s policies
relating to the emergency “chain of command,” a definition of essential personnel and mission-critical
functions, staff release-time policies, and internal emergency communications procedures.

The Emergency Plan must be known and understood before an emergency occurs. Community Health
Center heads should take immediate steps to:

 Share this important safety information with all faculty, staff, researchers and students annually
 Brief all new personnel as they join the Community Health Center
 Keep multiple copies of the Plan in accessible locations throughout the organization
 Ensure that managers keep a copy of the Community Health Center Plan at home

A) PREPAREDNESS
GETTING ORGANIZED
The first step in building Community Health Center preparedness is to assemble appropriate human and
physical resources to do the job.

Every Community Health Center should have an “Emergency Coordinator” to help develop and implement
their Community Health Center Emergency Plan. An Emergency Coordinator must be familiar with the
Community Health Center’s programs and physical facilities, and should be a person with the
management experience and financial authority to:

 Collaborate with the Community Health Center head to develop and maintain
the information in the Community Health Center Emergency Plan
 Recruit a core “Emergency Preparedness Committee” that represents staff,
faculty, and principal investigators from the Community Health Center’s
major divisions or locations
 Arrange related staff safety education and training
 Purchase Community Health Center emergency supplies and equipment
 Be ready to support the Community Health Center head and business
manager during an emergency incident (and be called back to campus if
necessary).
 Be ready to help prepare post-disaster impact summaries and insurance
claims
 Emergency Coordinators whose supervisors serve at the University
Emergency Operations Center will also interface with the Medical Public
Affairs as “Information Coordinator” for their area

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COMMUNITY HEALTH CENTER EMERGENCY PLANNING GUIDELINES

Some Community Health Centers already have individuals assigned to coordinate safety functions (for
example, areas with active “Community Health Centeral Safety Coordinators”), and may already have
broad-based Safety Committees. These units can easily incorporate emergency preparedness planning
into their programs.

Both existing and newly formed Emergency Preparedness Committees should consider dividing their
members into an Emergency Response Team and an Emergency Recovery Group to handle those
specialized activities.

 The “Emergency Response Team” should be trained to help disseminate emergency instructions,
assist evacuations and security, and provide first aid if necessary.
 The “Emergency Recovery Team” should be prepared to document the effects of the emergency
and coordinate facility and program restoration, according to priorities identified by the
Community Health Center executive.

SUPPLIES AND EQUIPMENT

Community Health Centers will need basic emergency supplies and equipment to be as self-sufficient as
possible after an emergency. Community Health Center emergency kits will vary in size and composition
according to an organization’s structure and function, but all Community Health Centers should have the
following essentials in an accessible location:

 First aid supplies, with instructions

 Flashlights/batteries, approved power strips and extension cords
 Portable AM/FM radios/batteries
 Laboratory spill kits
 Portable emergency water
 Employee rosters

Other resources Community Health Centers may consider to add to their emergency supplies include
such items as megaphones, two-way radios, rescue tools, stretchers, cots, and packaged emergency
rations.

Every manager should encourage employees to keep a personal emergency kit in their work area. These
kits should contain the employee’s flashlight, back-up eyeglasses and medications, sturdy shoes, a
sweater, a wrapped snack and water packet, and personal emergency contact numbers.

ESTABLISHING EMERGENCY COMMUNICATIONS SYSTEMS

The Emergency Plan explains that, during an emergency, Community Health Center heads

 Ensure that life-safety emergencies are reported to Protective Services

 Account for the safety of personnel
 Deliver critical information and instructions to the appropriate personnel
 Forward disaster impact reports to the Emergency Operations Center (EOC) and disseminate
EOC disaster instructions

Be certain that your Emergency Plan includes procedures for making critical notifications during business
hours and during after hours emergencies.

 Establish “telephone trees” and “distribution” voicemail and email lists to initiate rapid emergency

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COMMUNITY HEALTH CENTER EMERGENCY PLANNING GUIDELINES

notifications. (Be ready to use your web page for making updates during extended incidents).
 Create a Community Health Center “Emergency Hotline” so that faculty, staff, and students can
call into your Community Health Center to hear recorded announcements and instructions about
emergency effects on your program
 Keep the Emergency Operations Center number at-hand.

DISASTER COMMUNICATIONS

During a disaster, Community Health Centers with large divisions should have their divisions send
emergency impact reports to their Community Health Centeral Community Health Center Operations
Center (DOC). Community Health Center Emergency Coordinators will then send prioritized emergency
impact reports to the Emergency Operations Center (EOC). The EOC serves as a central coordination
point for deploying resources and information to campus locations.

The flow of information in a disaster is shown below:

Division A
Emergency
Community Management
Division B Health Center Team at the
Operations Center central “EOC”
“DOC”
Division C

PLANNING AHEAD FOR EVACUATIONS

A building evacuation is mandatory whenever a fire alarm sounds, and building occupants should exit
immediately. Building evacuations also follow severe earthquakes, after the shaking stops. After a
building has been evacuated, occupants must wait for a safety inspection before re-entry.

If a complete campus evacuation and closure is necessary during a disaster, it will be announced and
coordinated by the Emergency Management Team from the Emergency Operations Center. Facility
evacuations will be sequential to maintain safety and avoid traffic gridlock.

Note that it may or may not be necessary to vacate the building during minor Level 1 emergency
incidents, or even during some major Level 2 events. Occupants in the area may simply be directed
remain on-site and shut down systems, or they may be asked to move to other sectors of their floor or
building. In some events (such as extended power outages), evacuations are not necessary unless the
incident has generated a hazardous materials incident or immediate health and safety risk. In limited
emergencies, wait for evacuation instructions and engage your Emergency Response Team to
communicate the information throughout the Community Health Center.

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COMMUNITY HEALTH CENTER EMERGENCY PLANNING GUIDELINES

PREPAREDNESS FOR BUILDING EVACUATIONS

Review evacuation information and responsibilities with faculty, PIs, staff and students.
Conduct evacuation drills annually. Plan evacuation needs with disabled personnel.

Plan where to go during an evacuation, and know the routes to get there
Building evacuees go to your Community Health Center’s designated Emergency Assembly Point (EAP).

EAPs are safe outdoor destinations where personnel meet to notify managers of their safety and get
emergency information and assistance.

Contact the General Safety Manager for EAP site selection.

Know how to announce and implement evacuation

A sample script is: We have a ___________________ emergency.
Evacuate to (the EAP)
Take your belongings, do not use the elevators.

Use your Emergency Response Team to assist the evacuation.

Know what to do next

 Be prepared to account for your personnel.

 Know how to obtain and disseminate emergency information and instructions.

REDUCING EXPOSURE TO RISKS AND HAZARDS

The following tips can prevent emergencies from happening in your Community Health Center, and will
certainly mitigate their effects when they do occur.

FIRE PREVENTION
Know the location of alarm stations and extinguishers. Know how to use them
Leave fire doors closed at all times
Clear obstructed corridors, aisles and room exits
Use only grounded electrical plugs
Limit use of extension cords and multiple outlets
Do not use mechanical rooms or utility rooms for storage
Do not smoke in facility

LABORATORY SAFETY & PREPAREDNESS

Maintain a clean work environment
Post lab safety work rules, train all personnel

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COMMUNITY HEALTH CENTER EMERGENCY PLANNING GUIDELINES

Inventory and label chemicals. Do not purchase excess quantities of chemicals

Segregate incompatible chemicals. Keep flammables in flammable storage cabinets
Keep copies of Material Safety Data Sheets
Back up cultures and data off-site
Investigate emergency power options
Install seismic restraints on chemical storage shelves. Latch cabinet doors
Anchor equipment, animal containers, and furniture. Avoid high storage of heavy items
Chain compressed gas cylinders at 1/3 and 2/3 points
Do not store hazardous materials on mobile carts
Dispose of chemical waste properly

BEFORE A POWER EMERGENCY

Identify and prioritize vital power-dependent functions, operations, and equipment
Determine whether you have emergency power outlets in your area. Plan to use them for priority
functions only
Determine if there is emergency lighting in your area. Keep flashlights available in all work areas
Do not overload power strips. Extension cords are for emergency use only
Keep offsite duplicates of critical data and cultures

EARTHQUAKE PREPAREDNESS
Know how and where to take cover during a quake
Anchor bookcases, cabinets, and files over 42 inches. Do not stack furniture
Move tall furniture away from exits. Do not use tall furniture as room dividers
Secure computers, equipment, and display cases. Store heavy items at floor level
Back-up data and sensitive information, store duplicates off-site

Communicate these important preparedness measures to your students, faculty, researchers and staff.
Your Community Health Center’s level of readiness for an emergency situation depends not only on
having an up-to-date plan document, but also on keeping your constituents aware of their personal
responsibility for safety.

EMERGENCY PREPAREDNESS PLANNING TEMPLATES FOLLOW…

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COMMUNITY HEALTH CENTER EMERGENCY PLANNING GUIDELINES

CEBU CITY COMMUNITY HEALTH CENTER

EMERGENCY ORGANIZATION:
(SEND A COPY TO YOUR COMMUNITY HEALTH CENTER EMERGENCY COORDINATOR AND THE
DIRECTOR OF HEALTH AND SAFETY, PHONE #)
EMERGENCY RESPONSE TEAMECEEJLSKDFJK
EMEEE
EMERGENCY RESPONSE TEAM
Room & Building Office Phone Home Phone

Emergency Coordinator

Team Members

EMERGENCY RECOVERY TEAM

Room & Building Office Phone Home Phone

Community Health Center Director

Emergency Coordinator

Team Members

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COMMUNITY HEALTH CENTER EMERGENCY PLANNING GUIDELINES

B) RESPONSE
OVERVIEW

Everyone in a facility - staff, and visitors - must take appropriate and deliberate action when an
emergency strikes a building, a portion of the campus, or entire campus community. Decisive leadership
is essential. Follow these important steps when there is an emergency:

Confirm and evaluate conditions

Report the incident immediately
Follow instructions from emergency personnel precisely
Depending on the nature and severity of the event, activate the

Community Health Center Emergency Response Team

Community Health Center Emergency Recovery Team
Division Managers
All area staff and occupants

Issue clear and consistent emergency notifications. Use all available communications tools
If there is no power or telephone systems are not functioning, emergency
communications will be profoundly restricted
will use messengers, radios, cellular phones, fax and email

Coordinate with your Community Health Center Director at the DOC during major
emergencies or disasters

When an emergency strikes the facility after normal business hours, or on weekends or holidays - or, if
you are off-site during a major emergency, obtain instructions from your Community Health Center
Director and monitor the Emergency Information Hotline and media reports.

If you are recalled to campus, be certain that your household safety is assured and that your route to
campus is safe and functional. Bring your personal emergency kit and a copy of the Community Health
Center plan to campus.

EMERGENCY RESPONSE ACTIONS

The following are basic instructions for various emergency incidents:

ACCIDENT Call ####### for emergencies

 Administer first aid if you are trained to do so
 Do not attempt to move a seriously injured person

FIRE Call ####### for emergencies

 Activate nearest alarm
 Notify Supervisor and staff
 Feel doors for heat
 If cool, exit carefully
 If hot, do not open the door. Stay where you are
 If you see smoke, crouch near floor as you exit
 If you see fire, confine it by closing doors and windows
 Use extinguishers on small fires only if safe to do so
 Pull the pin in the handle
 Aim at the base of the fire
 Squeeze nozzle, sweep back and forth

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COMMUNITY HEALTH CENTER EMERGENCY PLANNING GUIDELINES

 Evacuate DOWNstairs, go upstairs or to roof as last resort only

 Never use an elevator during a fire evacuation
 Go to the Emergency Assembly Point (EAP)

HAZMAT SPILL
MINOR release in the lab
 Follow lab eyewash, rinse or shower procedures
 Flush affected area continuously for 15 minutes
 Vacate persons in immediate area if necessary
 Clean spill if you have suitable training or call ####### for emergency assistance
 Wear protective equipment
 Use appropriate kit to contain, neutralize and absorb
 Collect, containerize, and label waste
 Call ####### for chemical waste pick-up

MAJOR release in the Community Health Center

 Call ####### for emergencies
 Report your name, location, phone number, the material spilled, possible injuries
 Assist injured persons.
 Isolate contaminated persons
 Avoid contamination or chemical exposure
 Close doors or control access to spill site
 Alert Supervisor, Community Health Center Chair
 Communicate critical spill information to responders
 Follow evacuation instructions precisely

POWER OUTAGE
 Assess the extent of the outage in your area
 Report the outage to Facilities ##########
 To obtain information about a prolonged outage, call the Emergency Operations Command
Center at XXX-XXX-XXXX
 Help co-workers in darkened work areas move to safe locations
 If practical, secure current experimental work, then move it to a safe location.
 If you move chemicals on carts between floors, get assistance.
 Hazardous spills are a significant risk during transport
 Keep lab refrigerators or freezers closed throughout the outage
 Unplug personal computers, non-essential electrical equipment and appliances
 Open windows for additional light and ventilation
 If you are asked to evacuate, secure any hazardous materials and leave the building
 Release of personnel after an extended outage is determined by the Community Health
Center chair

EARTHQUAKE
 Take cover immediately, direct others around you
 Under a desk, table, or chair
 Between seating rows in lecture halls
 Against a corridor wall (cover head and neck)
 Outdoors--in open area, away from buildings
 Be alert for aftershocks, avoid potential falling hazards

MINOR QUAKE (brief rolling motion)

 Restore calm. Examine your area for damage
 Report damage/hazardous materials releases
 Review safety procedures and kits
 Await instructions, evacuations are unlikely

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COMMUNITY HEALTH CENTER EMERGENCY PLANNING GUIDELINES

MAJOR QUAKE (violent shaking)

 Restore calm. Assist others
 Report injuries to #############
 Report damage to Community Health Center Director
 Evacuate carefully, be alert for aftershocks
 Take emergency supplies
 Do not use elevators
 Meet at Emergency Assembly Point (EAP)
 Do not enter buildings until they are examined
 Report status to Emergency Operations Center
 Await instructions, be patient, help others

TO IMPLEMENT AN EVACUATION
These directions will help to make the process effective and safe for you and your staff.

Keep calm. Evaluate the situation carefully.

Alert Community Health Center Emergency Response Team to assist

Protective Services in the evacuation

Use communications tools that are appropriate for the type of incident
and the time of occurrence:
Alarms
Phone trees or voicemail broadcast
Messengers

Communicate clearly and succinctly

“We have a____________emergency.
Evacuate to (the EAP)
Take your belongings, do not use the elevators.”

Check offices, classrooms, laboratories, restrooms

Turn equipment off, if possible

Take emergency supplies and staff rosters, if possible

Keep exiting groups together

Account for personnel

WAIT AT THE EAP FOR FURTHER INSTRUCTIONS

HOW TO ASSIST PEOPLE WITH DISABILITIES

DURING AN EVACUATION

TO ALERT VISUALLY IMPAIRED PERSONS

Announce the type of emergency
Offer your arm for guidance
Tell person where you are going, obstacles you encounter

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COMMUNITY HEALTH CENTER EMERGENCY PLANNING GUIDELINES

When you reach safety, ask if further help is needed

TO ALERT PEOPLE WITH HEARING LIMITATIONS

Turn lights on/off to gain person's attention, or
Indicate directions with gestures, or
Write a note with evacuation directions

TO EVACUATE PEOPLE USING CRUTCHES, CANES, OR WALKERS

Evacuate these individuals as injured persons
Assist and accompany to evacuation site if possible, or
Use a sturdy chair (or one with wheels) to move person, or
Help carry individual to safety

TO EVACUATE PEOPLE USING WHEELCHAIRS

Non-ambulatory persons' needs and preferences vary
Individuals at ground floor locations may exit without help
Others have minimal ability to move--lifting may be dangerous
Some non-ambulatory persons have respiratory complications
Remove them from smoke and vapors immediately
Wheelchair users with electrical respirators get priority assistance
Most wheelchairs are too heavy to take down stairs
Consult with person to determine best carry options
Reunite person with the chair as soon as it safe to do so

WHEN YOU CALL TO REPORT AN EMERGENCY:

Tell the Operator
1. The type of emergency
2. If there are victims
3. The location of the emergency
4. Your name, location, and phone number
Stay on the phone until the Operator ends the call
During a major emergency or disaster, use the provided COMMUNITY HEALTH CENTER EMERGENCY
REPORT/FAX FORM to update your Community Health Center Chair’s DOC and the Medical School’s.
COMMUNITY HEALTH CENTER EVACUATION ROUTES

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COMMUNITY HEALTH CENTER EMERGENCY PLANNING GUIDELINES

C) RECOVERY
SUPPORT SERVICES AND ASSISTANCE
After a major emergency or disaster, many people in our community will be distressed by personal and
professional difficulties. It is likely that affected students, faculty and staff may need some scheduling
flexibility or other temporary help in order to return to their customary activities. The following are only
some of the resources available on campus and in our community:

University Resources
Counseling for employees – Through Employee Assistance Program, People Resources

Counseling for students – Through Health Services,

Short and long-term loans

Credit Union (members)

Housing listings

Transportation information

Child care referrals

Special service referrals

Academic assistance

DOCUMENTING EMERGENCY OUTCOMES

Once the safety and status of your staff has been assured, and emergency conditions have abated,
assemble your Community Health Center Emergency Recovery Team to support the Emergency
Management Team and the Facilities Management Community Health Center in the restoration of the
Community Health Center’s programs. Your Team’s earlier work on defining critical mission-critical
operations and staffing will be a starting point for the recovery process.

It will be important to begin a timely and comprehensive assessment of the emergency’s physical and
operational effects. Plan ahead for how you will collect this important impact information. Be aware that

Your Community Health Center will need ongoing status reports from your unit during the
emergency to estimate when your program can be fully operational and to identify special facility,
equipment, and personnel issues or resources that will speed business resumption

It may need detailed facilities data for the area to estimate temporary space reallocation needs
and strategies

Most insurance and FEMA assistance claims will require extensive documentation of damaged
facilities, lost equipment and resources, and special personnel expenses. Workers’
Compensation claims may arise if there are injuries in your Community Health Center.

All of your documentation on emergency impacts should be coordinated with your Community Health
Center Chair and the Emergency Management Team. The following forms provide formats for
summarizing this crucial information.

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COMMUNITY HEALTH CENTER EMERGENCY PLANNING GUIDELINES

Take note that you should also plan to photograph or videotape facility or equipment damage
in your Community Health Center to provide a visual supplement for the written impact data.
It is very important that you record the emergency’s physical effects before you clean your
area or make repairs.

EMERGENCY RECOVERY TEMPLATES FOLLOW...


SUMMARY: COMMUNITY HEALTH CENTER EMERGENCY STATUS
Date/time___________________

# of pages in this report_______

To: Emergency Management Team EOC FAX:

Community Health Center Chair: FAX:

DOC site FAX:

From: Div. Head/Dept. Head: ______________________ FAX:

Dept/Bldg _____________________________

CURRENT OPERATIONAL SITUATION

Immediate facility and space needs:

Urgent equipment requirements to become operational:

Critical personnel issues:

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COMMUNITY HEALTH CENTER EMERGENCY PLANNING GUIDELINES


RECOVERY: DETAILED SPACE ASSESSMENT
Use this form to describe damage to utilities, fixtures, ceilings, walls, floors, windows, etc. on each floor of your Community Health Center’s building(s).
Send the information to your Community Health Center Chair/DOC Emergency Coordinator. The Community Health Center Chair or Community
Health Center Emergency Coordinator should then send a prioritized list to the Emergency Operations Center with a signed cover memo.

DEPT/BLDG_____________________________________ ROOM____________

DAMAGE______________________________________________________

______________________________________________________________

______________________________________________________________

page _____of_____

RECOVERY: DETAILED EQUIPMENT ASSESSMENT

Use this form to describe all damaged furnishings, office-laboratory-research equipment, and materials
expended during the emergency. Send the information to the Emergency Management Team, with the
Community Health Center head’s signed cover memo.

DEPT/BLDG____________________________________________ROOM_________

Item________________________________Manufacturer______________________

Model#_____________ Inventory#_____________Original Cost______________

Damage description____________________________________________________

Est. repair$______________ Est. replacement$ _____________

page _____of _____

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
RECOVERY: DETAILED PERSONNEL IMPACTS
Use this form to describe the emergency’s impact on staffing. Describe personnel issues related to program
resumption. Document employee overtime related to your emergency response and recovery. Send this
information to the Emergency Management Team, with the Community Health Center head’s signed cover
memo.
Summary: EMERGENCY IMPACTS TO COMMUNITY HEALTH CENTER STAFFING
SUMMARY: EMERGENCY IMACTS TO COMMUNITY HEALTH CENTER STAFFING

______________________________________________________________________________

_________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

LIST: STAFF OVERTIME HOURS RELATED TO THE EMERGENCY

gency duties performed. Include data for temps hired for emergency recovery
LIST STAFF OVERTIME HOURS RELATED TO THE EMERGENCY
And emergency duties performed. Include data for temps hired for emergency recovery.

Name_____________________________________________ Employee#_________________

Job Title___________________________________________ Hourly Rate ____________

OT Rate ____________

Benefits % ____________

Date(s) Worked Hours Duties Performed

______________ ____________ _______________________________________

______________ ____________ _______________________________________

______________ ____________ _______________________________________

Name_____________________________________________ Employee#_________________

Job Title___________________________________________ Hourly Rate ____________

OT Rate ____________

Benefits % ____________

Date(s) Worked Hours Duties Performed

______________ ____________ _______________________________________

______________ ____________ _______________________________________

______________ ____________ _______________________________________

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