Title Page
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Conducted on
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Prepared by
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Location
Employee Information
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Employee Name
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Date:
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Day of week:
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
- Saturday
- Sunday
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Supervisor/Foreman
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Project Manager/Approval
Job 1
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Job Number:
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Job Address
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Start Time:
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End Time:
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Total Hours
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Injured on the job?
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Was lunch taken?
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Driver or Non-Driver?
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Total Drive Time
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Vehicle Number
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Starting Mileage
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Ending Mileage
Job 2
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Job Number:
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Job Address
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Start Time:
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End Time:
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Total Hours
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Injured on the job?
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Was lunch taken?
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Driver or Non-Driver?
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Total Drive Time
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Vehicle Number
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Starting Mileage
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Ending Mileage
Job 3
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Job Number:
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Job Address
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Start Time:
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End Time:
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Total Hours
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Injured on the job?
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Was lunch taken?
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Driver or Non-Driver?
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Total Drive Time
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Vehicle Number
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Starting Mileage
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Ending Mileage
Job 4
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Job Number:
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Job Address
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Start Time:
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End Time:
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Total Hours
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Injured on the job?
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Was lunch taken?
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Driver or Non-Driver?
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Total Drive Time
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Vehicle Number
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Starting Mileage
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Ending Mileage
Job 5
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Job Number:
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Job Address
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Start Time:
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End Time:
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Total Hours
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Injured on the job?
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Was lunch taken?
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Driver or Non-Driver?
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Total Drive Time
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Vehicle Number
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Starting Mileage
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Ending Mileage
Job 6
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Job Number:
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Job Address
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Start Time:
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End Time:
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Total Hours
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Injured on the job?
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Was lunch taken?
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Driver or Non-Driver?
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Total Drive Time
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Vehicle Number
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Starting Mileage
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Ending Mileage
Job 7
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Job Number:
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Job Address
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Start Time:
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End Time:
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Total Hours
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Injured on the job?
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Was lunch taken?
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Driver or Non-Driver?
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Total Drive Time
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Vehicle Number
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Starting Mileage
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Ending Mileage
Job 8
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Job Number:
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Job Address
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Start Time:
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End Time:
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Total Hours
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Injured on the job?
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Was lunch taken?
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Driver or Non-Driver?
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Total Drive Time
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Vehicle Number
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Starting Mileage
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Ending Mileage
Job 9
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Job Number:
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Job Address
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Start Time:
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End Time:
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Total Hours
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Injured on the job?
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Was lunch taken?
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Driver or Non-Driver?
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Total Drive Time
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Vehicle Number
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Starting Mileage
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Ending Mileage
Job 10
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Job Number:
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Job Address
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Start Time:
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End Time:
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Total Hours
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Injured on the job?
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Was lunch taken?
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Driver or Non-Driver?
-
Total Drive Time
-
Vehicle Number
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Starting Mileage
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Ending Mileage