LUZERNE COUNTY COMMUNITY COLLEGE
Public Safety Training Institute
1333 South Prospect Street
Nanticoke, PA 18634
Phone: 570-740-0521 or 481 Fax: 570-740-0664
Course Instructor’s Report
(Separate report each instructor)
Course Code:
Name of Course:
Name of Instructor:
Complete Address where course was heldincluding building, name, street, city, zip code:
ATTENDANCE
DATE
** TIME
STARTED
** TIME
ENDED
NUMBER
ENROLLED
NUMBER
DROPPED
NUMBER
ABSENT
NUMBER
PRESENT
Primary
(P)
Secondary
(S)
CERTIFICATION
I certifiy that the above report is true and correct and that I conducted ______ hours of training.
Signature of Instructor:
Social Security Number:
Document Check List: Submitted Attached To Follow
Contract: _____ _____ _____
Enrollment Forms: _____ _____ _____
Evaluation Forms: _____ _____ _____
Roll Sheet(s): _____ _____ _____
Travel Expense: _____
** “Time Started”, “Time Ended” and “Total Hours” must match
contract. If notcontact Public Safety Training Institute
Total
Hours
**
Rate/Hour
Total Pay
Check #
Course Supervisor (lead
Instructor)
Signature:_____________
Date Report Received:
click to sign
signature
click to edit
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome