Virginia Highlands Anesthesia, PC

Payroll Worksheet to Report Additional Pay

Employee:
Description Including
Dates Worked Location Names of Replacement
Double Back Pay
Incentive Pay
Replacement Pay*
LOCUMS
Other:
*Please indicate employee worked in place of
Approved By:
Additional Pay worksheet should be delivered to payroll dept at least 5 business days prior to paydate.
OFFICE USE ONLY, CHARGE TO:
JMH
NCH
RCH
SCCH

Virginia Highlands Anesthesia, PC
Payroll Worksheet to Report Additional Pay
Amount
Requested