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Nursing Schedule Requests
DO NOT USE THIS FOR A CALL IN. ALL CALL IN’S MUST BE MADE TO FACILITY TO THE NURSE ON DUTY. 402-447-6203
Please Use this form to Submit your Scheduling Requests and Issues. Reminder if you are unable to work a scheduled shift, it is your responsibility to find your own replacement. **LuAnn and Kortni are to only be contacted after hours in an EMERGENCY.
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STAFF MEMBER SUBMITTING REQUEST (First and Last Name)
*
Your Contact Phone Number (Include Area Code)
*
Which Position (Check all that Apply)
*
Charge Nurse
RN
LPN
CNA
Med-Aide
Assisted Living
Date of Request (01/01/2026)
*
Time of Request
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Describe your Request
*
Submitting this request does not guarantee that your request will be approved, You must receive a confirmation from Alyson or Kortni.
Additional Details
*
Include the Original Scheduled date, and additional information that relates to the request.
Submit
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