GN 6365 (07/14) Revised
Date:
Case Name:
Case Number:
Worker Name:
Worker ID:
Worker Phone Number:
Customer ID:
Report for the Month of 20
In order to make sure that we provide you with transportation and other services, we need you to record your monthly
attendance in each of your Welfare-to-Work Activities. In the boxes below, tell us about your Welfare-to-Work Activities listed
below for the month of Year . Please give this form to your service provider listed so they can verify
your hours. Return this form to your GAIN Services Worker/REP Case Manager (GSW/RCM) on or before the 10th of the
month following the Report Month. Failure to provide this form by the due date may affect your eligibility to receive
transportation and other services. If you have any questions, please contact your GSW/RCM.
GSW/RCM Name: Worker ID:
GSW/RCM Phone: Fax:
Please record hours of attendance and excused absences. If absent please write reason for absence and attach verification.
Activity: Scheduled Hours:
Provider #1:
Day
Hours
1
2 4
3 5
6 8
7 9
10 12
11 13
14 16
15
Day
Hours
17 18 2019 21 22 2423 25 26 2827 29 30 Total31
* Colleges verify enrollment only Provider #1 Stamp:
Contact Name: Title:
Phone:
Signature:
Date:
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
One Stamp
per Provider
Activity: Scheduled Hours:
Provider #2:
* Colleges verify enrollment only Provider #2 Stamp:
Contact Name: Title:
Phone: Signature: Date:
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
Day
Hours
1 2 43 5 6 87 9 10 1211 13 14 1615
Day
Hours
17 18 2019 21 22 2423 25 26 2827 29 30 Total31
One Stamp
per Provider
DPSS/State/Federal agencies for purposes of auditing, monitoring and verifying information.
I hereby certify the information listed above is true and correct. In addition, I authorize the release of information to
Participant Signature:
Date:
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Monthly Attendance Report Form
COUNTY OF LOS ANGELES
DEPARTMENT OF PUBLIC SOCIAL SERVICES
