My work record (keep this at home, not at work)
A printable from Workers' Rights Complete Guide. Fill it in by hand. Nothing you write is collected by this website.
My work record (keep this at home, not at work)
Employer: business name ________ address where I work ________ Owner and supervisor: ________ License plate of the person who pays me (if no business name): ________ My pay rate: $____ an hour, or ____ How I am paid: cash / check / deposit / app
| Date | Start | Meal break (from, to) | Rest breaks | End | Total hours | Paid how much, how, when |
|---|---|---|---|---|---|---|
Problems this week (date, what happened, who said it, who saw it):
- I did not get a pay stub
- I missed a meal or rest break
- I worked over 8 hours in a day or over 40 in a week
- It was hot and I could not rest, or there was no water or shade
- I was hurt or got sick from work
- I was threatened, or my hours were cut after I spoke up
Do not write your immigration status on this sheet. Take it with you to a clinic.
From Workers' Rights Complete Guide. Facts checked October 21, 2026. Free information, not legal or medical advice.