Mercyhealth Commitment Bonus Payment

The department leader (Manager or Director) or timekeeper must submit this form for partners who have worked eligible shifts to earn the commitment bonus as approved by HR. If the program has not been approved by HR, the partner is not eligible for this form of payment.

For questions regarding eligibility, please contact your HR Business Partner for assistance.

Name of Leader/Timekeeper Submitting the Form Name of Leader/Timekeeper Submitting the Form First Last
Email Address of Leader/Timekeeper Submitting the Form
By checking the box below, you are confirming that the below partner has been approved to use the commitment bonus program.

By checking the box below, you are confirming that the below partner has been approved to use the commitment bonus program. I confirm the above statement
Partner Work Location (Entity)

Partner Work Location (Entity) Rock, Walworth, or McHenry county Winnebago, Boone, or Ogle county (all entities)
Partner Name Partner Name First Last
Partner Number
Partner Cost Center Worked
Was this work related to COVID-19 coverage?

Was this work related to COVID-19 coverage? Yes No
Pay Period Start Date
Commitment Bonus Program Type

Check the appropriate box(es) below for the admissions completed and the pay period week and days they were completed.
	N/A	1 Admission	2 Admissions	3 Admissions	4 Admissions
Sunday - Week 1	Sunday - Week 1N/A	Sunday - Week 11 Admission	Sunday - Week 12 Admissions	Sunday - Week 13 Admissions	Sunday - Week 14 Admissions
Monday - Week 1	Monday - Week 1N/A	Monday - Week 11 Admission	Monday - Week 12 Admissions	Monday - Week 13 Admissions	Monday - Week 14 Admissions
Tuesday - Week 1	Tuesday - Week 1N/A	Tuesday - Week 11 Admission	Tuesday - Week 12 Admissions	Tuesday - Week 13 Admissions	Tuesday - Week 14 Admissions
Wednesday - Week 1	Wednesday - Week 1N/A	Wednesday - Week 11 Admission	Wednesday - Week 12 Admissions	Wednesday - Week 13 Admissions	Wednesday - Week 14 Admissions
Thursday - Week 1	Thursday - Week 1N/A	Thursday - Week 11 Admission	Thursday - Week 12 Admissions	Thursday - Week 13 Admissions	Thursday - Week 14 Admissions
Friday - Week 1	Friday - Week 1N/A	Friday - Week 11 Admission	Friday - Week 12 Admissions	Friday - Week 13 Admissions	Friday - Week 14 Admissions
Saturday - Week 1	Saturday - Week 1N/A	Saturday - Week 11 Admission	Saturday - Week 12 Admissions	Saturday - Week 13 Admissions	Saturday - Week 14 Admissions
Sunday - Week 2	Sunday - Week 2N/A	Sunday - Week 21 Admission	Sunday - Week 22 Admissions	Sunday - Week 23 Admissions	Sunday - Week 24 Admissions
Monday - Week 2	Monday - Week 2N/A	Monday - Week 21 Admission	Monday - Week 22 Admissions	Monday - Week 23 Admissions	Monday - Week 24 Admissions
Tuesday - Week 2	Tuesday - Week 2N/A	Tuesday - Week 21 Admission	Tuesday - Week 22 Admissions	Tuesday - Week 23 Admissions	Tuesday - Week 24 Admissions
Wednesday - Week 2	Wednesday - Week 2N/A	Wednesday - Week 21 Admission	Wednesday - Week 22 Admissions	Wednesday - Week 23 Admissions	Wednesday - Week 24 Admissions
Thursday - Week 2	Thursday - Week 2N/A	Thursday - Week 21 Admission	Thursday - Week 22 Admissions	Thursday - Week 23 Admissions	Thursday - Week 24 Admissions
Friday - Week 2	Friday - Week 2N/A	Friday - Week 21 Admission	Friday - Week 22 Admissions	Friday - Week 23 Admissions	Friday - Week 24 Admissions
Saturday - Week 2	Saturday - Week 2N/A	Saturday - Week 21 Admission	Saturday - Week 22 Admissions	Saturday - Week 23 Admissions	Saturday - Week 24 Admissions

Check the appropriate box(es) below for the evaluations completed and the pay period week and days they were completed.
	N/A	1 Evaluation	2 Evaluations	3 Evaluations	4 Evaluations
Sunday - Week 1	Sunday - Week 1N/A	Sunday - Week 11 Evaluation	Sunday - Week 12 Evaluations	Sunday - Week 13 Evaluations	Sunday - Week 14 Evaluations
Monday - Week 1	Monday - Week 1N/A	Monday - Week 11 Evaluation	Monday - Week 12 Evaluations	Monday - Week 13 Evaluations	Monday - Week 14 Evaluations
Tuesday - Week 1	Tuesday - Week 1N/A	Tuesday - Week 11 Evaluation	Tuesday - Week 12 Evaluations	Tuesday - Week 13 Evaluations	Tuesday - Week 14 Evaluations
Wednesday - Week 1	Wednesday - Week 1N/A	Wednesday - Week 11 Evaluation	Wednesday - Week 12 Evaluations	Wednesday - Week 13 Evaluations	Wednesday - Week 14 Evaluations
Thursday - Week 1	Thursday - Week 1N/A	Thursday - Week 11 Evaluation	Thursday - Week 12 Evaluations	Thursday - Week 13 Evaluations	Thursday - Week 14 Evaluations
Friday - Week 1	Friday - Week 1N/A	Friday - Week 11 Evaluation	Friday - Week 12 Evaluations	Friday - Week 13 Evaluations	Friday - Week 14 Evaluations
Saturday - Week 1	Saturday - Week 1N/A	Saturday - Week 11 Evaluation	Saturday - Week 12 Evaluations	Saturday - Week 13 Evaluations	Saturday - Week 14 Evaluations
Sunday - Week 2	Sunday - Week 2N/A	Sunday - Week 21 Evaluation	Sunday - Week 22 Evaluations	Sunday - Week 23 Evaluations	Sunday - Week 24 Evaluations
Monday - Week 2	Monday - Week 2N/A	Monday - Week 21 Evaluation	Monday - Week 22 Evaluations	Monday - Week 23 Evaluations	Monday - Week 24 Evaluations
Tuesday - Week 2	Tuesday - Week 2N/A	Tuesday - Week 21 Evaluation	Tuesday - Week 22 Evaluations	Tuesday - Week 23 Evaluations	Tuesday - Week 24 Evaluations
Wednesday - Week 2	Wednesday - Week 2N/A	Wednesday - Week 21 Evaluation	Wednesday - Week 22 Evaluations	Wednesday - Week 23 Evaluations	Wednesday - Week 24 Evaluations
Thursday - Week 2	Thursday - Week 2N/A	Thursday - Week 21 Evaluation	Thursday - Week 22 Evaluations	Thursday - Week 23 Evaluations	Thursday - Week 24 Evaluations
Friday - Week 2	Friday - Week 2N/A	Friday - Week 21 Evaluation	Friday - Week 22 Evaluations	Friday - Week 23 Evaluations	Friday - Week 24 Evaluations
Saturday - Week 2	Saturday - Week 2N/A	Saturday - Week 21 Evaluation	Saturday - Week 22 Evaluations	Saturday - Week 23 Evaluations	Saturday - Week 24 Evaluations

Check the appropriate box(es) below for the eligible callbacks completed and the pay period week and day(s) they were completed.
	N/A	1 Callback shift	2 Callback shifts	3 Callback shifts
Sunday - Week 1	Sunday - Week 1N/A	Sunday - Week 11 Callback shift	Sunday - Week 12 Callback shifts	Sunday - Week 13 Callback shifts
Monday - Week 1	Monday - Week 1N/A	Monday - Week 11 Callback shift	Monday - Week 12 Callback shifts	Monday - Week 13 Callback shifts
Tuesday - Week 1	Tuesday - Week 1N/A	Tuesday - Week 11 Callback shift	Tuesday - Week 12 Callback shifts	Tuesday - Week 13 Callback shifts
Wednesday - Week 1	Wednesday - Week 1N/A	Wednesday - Week 11 Callback shift	Wednesday - Week 12 Callback shifts	Wednesday - Week 13 Callback shifts
Thursday - Week 1	Thursday - Week 1N/A	Thursday - Week 11 Callback shift	Thursday - Week 12 Callback shifts	Thursday - Week 13 Callback shifts
Friday - Week 1	Friday - Week 1N/A	Friday - Week 11 Callback shift	Friday - Week 12 Callback shifts	Friday - Week 13 Callback shifts
Saturday - Week 1	Saturday - Week 1N/A	Saturday - Week 11 Callback shift	Saturday - Week 12 Callback shifts	Saturday - Week 13 Callback shifts
Sunday - Week 2	Sunday - Week 2N/A	Sunday - Week 21 Callback shift	Sunday - Week 22 Callback shifts	Sunday - Week 23 Callback shifts
Monday - Week 2	Monday - Week 2N/A	Monday - Week 21 Callback shift	Monday - Week 22 Callback shifts	Monday - Week 23 Callback shifts
Tuesday - Week 2	Tuesday - Week 2N/A	Tuesday - Week 21 Callback shift	Tuesday - Week 22 Callback shifts	Tuesday - Week 23 Callback shifts
Wednesday - Week 2	Wednesday - Week 2N/A	Wednesday - Week 21 Callback shift	Wednesday - Week 22 Callback shifts	Wednesday - Week 23 Callback shifts
Thursday - Week 2	Thursday - Week 2N/A	Thursday - Week 21 Callback shift	Thursday - Week 22 Callback shifts	Thursday - Week 23 Callback shifts
Friday - Week 2	Friday - Week 2N/A	Friday - Week 21 Callback shift	Friday - Week 22 Callback shifts	Friday - Week 23 Callback shifts
Saturday - Week 2	Saturday - Week 2N/A	Saturday - Week 21 Callback shift	Saturday - Week 22 Callback shifts	Saturday - Week 23 Callback shifts

Check the appropriate box(es) below for the eligible call shifts completed and the pay period week and day(s) they were completed.
	N/A	1 Call shift	2 Call shifts	3 Call shifts
Sunday - Week 1	Sunday - Week 1N/A	Sunday - Week 11 Call shift	Sunday - Week 12 Call shifts	Sunday - Week 13 Call shifts
Monday - Week 1	Monday - Week 1N/A	Monday - Week 11 Call shift	Monday - Week 12 Call shifts	Monday - Week 13 Call shifts
Tuesday - Week 1	Tuesday - Week 1N/A	Tuesday - Week 11 Call shift	Tuesday - Week 12 Call shifts	Tuesday - Week 13 Call shifts
Wednesday - Week 1	Wednesday - Week 1N/A	Wednesday - Week 11 Call shift	Wednesday - Week 12 Call shifts	Wednesday - Week 13 Call shifts
Thursday - Week 1	Thursday - Week 1N/A	Thursday - Week 11 Call shift	Thursday - Week 12 Call shifts	Thursday - Week 13 Call shifts
Friday - Week 1	Friday - Week 1N/A	Friday - Week 11 Call shift	Friday - Week 12 Call shifts	Friday - Week 13 Call shifts
Saturday - Week 1	Saturday - Week 1N/A	Saturday - Week 11 Call shift	Saturday - Week 12 Call shifts	Saturday - Week 13 Call shifts
Sunday - Week 2	Sunday - Week 2N/A	Sunday - Week 21 Call shift	Sunday - Week 22 Call shifts	Sunday - Week 23 Call shifts
Monday - Week 2	Monday - Week 2N/A	Monday - Week 21 Call shift	Monday - Week 22 Call shifts	Monday - Week 23 Call shifts
Tuesday - Week 2	Tuesday - Week 2N/A	Tuesday - Week 21 Call shift	Tuesday - Week 22 Call shifts	Tuesday - Week 23 Call shifts
Wednesday - Week 2	Wednesday - Week 2N/A	Wednesday - Week 21 Call shift	Wednesday - Week 22 Call shifts	Wednesday - Week 23 Call shifts
Thursday - Week 2	Thursday - Week 2N/A	Thursday - Week 21 Call shift	Thursday - Week 22 Call shifts	Thursday - Week 23 Call shifts
Friday - Week 2	Friday - Week 2N/A	Friday - Week 21 Call shift	Friday - Week 22 Call shifts	Friday - Week 23 Call shifts
Saturday - Week 2	Saturday - Week 2N/A	Saturday - Week 21 Call shift	Saturday - Week 22 Call shifts	Saturday - Week 23 Call shifts

Date extra shift/call was completed Date extra shift/call was completed / MM / DD YYYY
How long was the extra shift completed?

How long was the extra shift completed? 4-hour shift 8-hour shift 10-hour shift 15-hour shift 12-hour shift 24-hour shift Other Other
Total Commitment Bonus to be Paid for the day(s) listed above. $ Dollars . Cents