Free 44721.pdf - Indiana

Name of case manager

RECORD OF IMPACT ATTENDANCE - MULTIPLE ACTIVITIES
State Form 44721 (R / 8-95) / IMP 2078 For month of: Due by:

Name of participant

Social Security number

Case number

Activity number 1

Site

Code

Name of instructor

Activity number 2

Site

Code

Name of instructor

INSTRUCTIONS:
CLASS DAYS LENGTH

Indicate the number of hours or partial hours each time the student is present. If absent, mark with an "A".
WEEK 1 Starting: WEEK 2 WEEK 3 WEEK 4 WEEK 5 SIGNATURE OF INSTRUCTOR AND DATE

RELEASE OF INFORMATION
Hours scheduled

OFFICE USE ONLY
Hours participated

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)