3/2012
Meal Break Waiver Form
Employee Name: _________________________________ ID Number: ___________
(print name)
Waiver Effective Date: ___________
I understand that under California Labor Law, after a work period of 5 hours, I am entitled to
receive an unpaid meal break of not less than 30 minutes during which I am relieved of all
duties.
I give my consent that I may waive my 30-minute unpaid meal break only when my work and/or
scheduled shift will be completed in 6 hours or less in one workday. I understand that if my shift
exceeds 6 hours, I am required to take an unpaid meal break of at least 30 minutes.
In order for this waiver to be valid, my supervisor must also authorize the waiver in writing by
signing below.
Employee Authorization
Employee Signature: ____________________________ Date: _____________
Supervisor Authorization
Supervisor Signature: ___________________________ Date: _____________
Please return the completed Meal Break Waiver Form to the Payroll Office, located in Filippi
Hall (Administrative Building). Be sure to keep a copy for your department on file.
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