Fillable Employment and Training Weekly Activity Verication Form (Lehigh Carbon Community College)

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Employment and Training Weekly Activity Verication Form (Lehigh Carbon Community College)

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Employment and Training Weekly Activity Verication Form
www.dpw.state.pa.us
This form is to be completed and returned to the County Assistance Ofce (CAO) each week to document time spent participating in approved activities.
Week ending (Saturday): __________________________ Return date to CAO: __________________________
CLIENT NAME CO/RECORD # CAO NAME AND ADDRESS CAO FAX # CASEWORKER CAO TELEPHONE
Job Search/Job
Readiness
Code 44, 28 (other)
Rehabilitative
Services
Code 49
Vocational Education
Training
Code 14, 16 or 24
Study time should be
listed on a separate line.
Program Major
Community
Service Programs
Code 20 or 32
Maximum weekly
hours
Work Study
Code 31
Providing
Child Care for
a Community
Service
Participant
Without Payment
Code 6
On-the-Job
Training
Code 22 (TANF only)
Work Experience
State Ofce
Demonstration
(WESOD)
Code 36
Other Activity
Explain
DATE TYPE OF ACTIVITY ACTIVITY CONTACT PERSON AND PHONE # ACTIVITY FAX #
AUTHORIZED ACTIVITY
CONTACT’S SIGNATURE
BEGIN
TIME
END
TIME
TOTAL DAILY HOURS
COMMENTS
My signature indicates that the information on this form accurately reects my attendance for the week.
CLIENT SIGNATURE DATE CAO SIGNATURE (signature conrms activity & hours based on AMR/EDP) DATE
PA 1895 5/12
RESET FORM
Employment and Training Activity Verication Form
www.dpw.state.pa.us
PA 1895 5/12
Client and Authorized Activity Contact Person Instructions
A: General Instructions for Completing the Form
1. Mark which activity(ies) you are participating in.
2. Enter the date, activity and all contact information.
3. Enter the actual hours and the total time spent in the activity.
4. Form must have your signature and the Authorized Activity Contact’s Signature
5. One signature per agency per week is acceptable.
B: Additional Information
1. Job Search/Job Readiness and Rehabilitative Services
a. Limited to 12 weeks in a rolling 12 month period. Job search/job readiness may only be counted for 4 consecutive weeks.
b. May include rehabilitative services (AC49) which includes treatment related to substance abuse, family violence, child services and mental
health counseling.
c. Form is completed for time spent at the CAO or CareerLink.
d. Form is completed for applications and interviews. Please enter (I) for interview, (L) at the employer’s location or (O) online under type of
activity.
e. Proof of completed applications must be given to the CAO. The following verication if submitted (though not required) will assist the CAO in
validating information provided but is not verication of the job alone: Business cards of employers; Copies of completed applications; Email
or electronic conrmation that an on-line application has been submitted; Information from job fairs or training offered by agencies such as
CareerLink.
2. Vocational Education
a. May count as your “core” activity for 12 months.
b. Enter actual time spent in the classroom.
c. Unmonitored study time may only count up to one (1) hour for every hour of classroom time.
d. Monitored study time must be validated by the Authorized Activity Contact.
e. Unmonitored study time should be listed separately.
C: Holidays
1. New Year’s Day 6. Labor Day
2. Martin Luther King, Jr. Day 7. Columbus Day
3. Presidents’ Day 8. Veterans Day
4. Memorial Day 9. Thanksgiving Day
5. Independence Day 10. Christmas Day
Place an “H” beside the “Date”.
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Employment and Training Weekly Activity Verication Form (Lehigh Carbon Community College)

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Completed 4 February 2021

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