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Meal Break Waiver Form Template

Effortlessly manage meal break waivers for employees

Are you struggling to keep track of employee meal break waivers? Our Meal Break Waiver Form Template is designed to help HR professionals and managers effortlessly obtain consent from employees who choose to waive their meal breaks. This customizable template streamlines the approval process, ensures compliance with labor laws, protects your organization, and maintains accurate records, all while saving you time. Discover how easy it can be to manage meal break waivers-try our live template today!

Full legal name
Job title
Primary work state (two-letter abbreviation)
Email address
I choose to waive the first meal period for shifts of 6 hours or less, where permitted by law and policy.
Yes
No
Effective date
End date (if any)
I choose to waive the second meal period for shifts over 10 hours and up to 12 hours, where permitted by law and policy.
Yes
No
I am entering into this waiver voluntarily and without pressure.
Strongly disagree
Disagree
Neither
Agree
Strongly agree
I understand I may revoke this waiver at any time in writing, and future meal periods will be provided in accordance with law and policy.
Strongly disagree
Disagree
Neither
Agree
Strongly agree
I understand this waiver applies only where permitted by applicable law and company policy.
Strongly disagree
Disagree
Neither
Agree
Strongly agree
I have received and read the employer's meal and rest break policy.
Strongly disagree
Disagree
Neither
Agree
Strongly agree
Additional comments or limitations (if any)
Employee signature (type full legal name)
Employee signature date
Employer representative name (type full legal name)
Employer signature date
Employer acknowledgment of mutual consent
Yes
No
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Paper art illustration depicting a meal break waiver form for FormCreatorAI article

When to use this form

Use this form when a California hourly employee chooses to waive a meal period under allowed conditions: the first meal on a shift of 6 hours or less, or the second meal on a 10 to 12 hour shift after taking the first. You get clear, written consent tied to a specific date and shift, which helps HR and managers plan coverage and pass audits. Typical cases include a retail associate who wants to leave early, a nurse who skips a second meal to support patient care, or a technician on a short production run. If a schedule falls outside policy, route it with an Exception request form. For a written confirmation to file, use the Letter request form. If staff need portal access to submit waivers, request it via the IT Access request form V2 form.

Must Ask Meal Break Waiver Questions

  1. What is your full name, employee ID, and work location?

    These details let you match the waiver to the right person and site. They prevent mix-ups across teams or facilities.

  2. Which date, start time, and end time does this waiver cover?

    Tying the waiver to a single shift prevents blanket approvals and confusion. It also speeds your audits and payroll checks.

  3. Are you voluntarily waiving your first 30-minute meal period because your shift is 6 hours or less?

    This confirms the permitted scenario and that the choice is voluntary. Clear consent lowers your dispute risk.

  4. If your shift is 10 to 12 hours, are you waiving only the second meal period and confirming you took the first?

    This separates first and second meal rules and avoids invalid waivers. It documents that the first meal was taken before any second meal waiver.

  5. Do you understand you can revoke this waiver at any time and without penalty?

    This protects your team and shows the choice is voluntary. It prompts managers to honor day-of changes.

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