Free 44720.pdf - Indiana

CM

RECORD OF IMPACT ATTENDANCE
State Form 44720 (R / 8-95) / IMP 2077 For month of: Due by:

Name of participant

Social Security number

Case number

Activity

Site

Code

Name of instructor

Telephone number

( INSTRUCTIONS:

)

Hours ________ per ___________

1. Indicate the number of hours of attendance or work in the appropriate day's box. 2. The supervisor or instructor must verify the information by signing this form.
MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY

SUNDAY

RELEASE OF INFORMATION

I authorize the release of information concerning my attendance at the above-named location in order to comply with requirements for the IMPACT program.
Signature of participant Date signed (month, day, year)

I certify that this report is accurate.
Signature of instructor or supervisor Date signed (month, day, year)

OFFICE USE ONLY
Hours scheduled Hours participated