THIS FORM IS REQUIRED EACH MONTH TO VERIFY YOUR PARTICIPATION
INSTRUCTIONS – PARTICIPANT
1. Please document daily attendance in your education/training activity by completing the following:
(See example below). Do not report employment information on the form.
Activity: Vocational Training (Clerical Program) Scheduled Hours 32
Provider: Valley College
• Days of the Month - document actual hours attended per day
• Absence Reporting- if absent document date(s) and reason(s) you did not attend.
Below are reasons for excused absences:
Excused Absences
Absences approved by your activity provider
Holidays observed by the school administrators/provider
Medical appointments for you or children
Appointment with Eligibility or GAIN Services Worker
No child care
Transportation problems
School appointments
Job interviews
Illness for you or children
Family issues such as death in family, domestic violence…
• Verification of absences must be attached to the Monthly Attendance Report form, GN 6365.
Verification can include doctor statement, provider statement or personal note signed
by participant explaining reason for absence.
• Total – add the hours for the entire month
2. Once you have filled in your hours, sign and date the form, submit form to the CalWORKs Office in
your school or training provider for signature.
3. Return completed form to your GAIN Services Worker by the due date indicated on the front of the
form.
INSTRUCTIONS – SERVICE PROVIDER
• Please review form with participant and sign, print name, title, phone number, date, and use agency stamp.
• Once completed, the form may be faxed to the GAIN Services Worker listed in the front of the form, or
given to participant to forward to GAIN Services Worker.
GN 6365 Back rev.(08/10)
Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Hours H 6 6 6 6 8 6 6 6 6 8
Day 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Total
Hours H 6 6 6 8 8 6 6 6 6 122
* Colleges verify enrollment only Provider Stamp:
Contact Name: ___Jane Doe_____________________ Title: __CalWORKs Coordinator__
Phone: _(888) 891-8923________________ Signature: ____Jane Doe_________ Date: __1/31/09
I still need transportation child care and/or other services
I am requesting to begin receiving transportation child care and/or other services
Absence Reporting
Date(s) Hours absent Reason(s) you did not Attend
County use only: Number of hours GSW validates and lists source
1/7/09 6 Child was sick 6 Hours validated/ Dr. Statement
1/1/09 & 1/19/09
12 School Holiday 10 Hours validated/School Calendar
