116 HHSA Monthly Attendance Verification (11-17)
Instructions for Completing the 116 HHSA Monthly Attendance Verification Form
Attendance Month/Year: The month and year the student is reporting school attendance for.
This form is due to the Employment Case Manager (ECM) by the 5
th
of the month after the
attendance month.
For example, if reporting attendance for June, this form must be turned in to the ECM by July
5
th
.
Section A: Changes
Complete this section if there are any changes to report in school or class status including date(s)
when the change occurred. If the student missed school, include the absence date(s) and reason
why class was missed.
Section B: Attendance Hours
Date: Enter a date for each day of the week that actual attendance hours are being reported.
Class/Lecture: Enter the actual number of hours the student attended class.
Supervised Lab: Supervised lab must have an instructor present during the lab time. The lab
requirement should also be listed on the student’s class schedule. For example, a student may
be required to attend a Biology lab in addition to a Biology class. Enter the actual number of
hours the student attended.
Supervised Study: Supervised study time is set up and monitored by the school. Enter the
actual number of supervised study time hours the student completed.
Unsupervised Study Time: Unsupervised study time is assigned by the school. Unsupervised
study time counted towards Welfare-to-Work (WTW) participation is based on the time the
student actually completed unsupervised study, up to allowable limits. Enter the actual
number of unsupervised study time hours the student completed.
Section C: Certification
Participant Signature: The participant must sign and date the form to certify that the
information provided is true and correct.
Participation Verified By: A school official or ECM must sign and date the form to verify that
the information provided is accurate.
