WORK ACTIVITY VERIFICATIONCLIENT NOTES
Note:A work activity verification clno must be entered on every client every month even if zero hours are entered. The required work search debriefing can be included in the format if you desire and must be noted in the clno title. If you are making a late entry after the 20th, include “Late Entry” in the title.
CLNO Title: WAV
Note:Add month year to beginning oftitle. Add debriefing to title if debriefing done today.
CLNO Body:
CWE or BWE
WORK SITE:
MAXIMUM HOURS ALLOWED IN A CWE (TA amount / state min wage ($9.80):
DO YOU HAVE A TIMESHEET WITH THE SUPERVISOR’S SIGNATURE?
REQUIRED HOURS VERIFIED:
VOLUNTARY HOURS COMPLETED OVER & ABOVE REQUIRED HOURS:
TOTAL # OF HOURS VERIFIED:
CODE ENTERED:
CWE – Subsistence for the Good of the Community
Note:all hours are countable if you have a CWE agreement, timesheet & signature
TYPE OF SUBSISTENCE ACTIVITY REPORTED:
# OF HOURS REPORTED ON TIMESHEET SIGNED BY A SUPERVISOR:
CODE ENTERED:
Excused Absences / Holidays
UNPAID ACTIVITY ASSIGNED:
# OF DAILY HOURS ASSIGNED:
DATE OF ABSENCE & REASON ABSENT (or what holiday):
EXCUSED BY SUPERVISOR & CM?
# OF HOURS ALLOWED & COUNTED (max 16hrs a month + federal holidays):
CODE ENTERED:
Job Readiness
HOW INFO WAS VERIFIED:
DEBRIEFING CLNO ENTERED THIS DATE:
# OF HOURS ENTERED:
CODE ENTERED:
Note:if debriefing was not done today, do not use the debriefing portion below
DEBRIEFING COMPLETED WITH CLIENT (in-person/telephonic):
SUMMARY OF JOBS APPLIED FOR & RESULTS:
PROGRESS ON FSSP ASSIGNMENTS:
CHALLENGES EXPERIENCED WHEN APPLYING OR INTERVIEWING:
WHAT AREAS FOR IMPROVEMENT WERE DISCUSSED?
COMMENTS:
Non-Countable Hours, B3, B7, P1, NR, NP or S2
NON-COUNTABLE – NO WORK VERIFICATION REQUIRED
TYPE OF ACTIVITY ASSIGNED:
HOW & WHEN REPORTED HOURS OBTAINED?
# OF HOURS ENTERED:
CODE ENTERED:
IF 0 HOURS ARE ENTERED, LIST GOOD CAUSE REASON, OR FURTHER ACTION TAKEN:
Paid Employment
Note:if you call the employer, list the date, name of contact and phone number
EMPLOYER NAME:
DID WORK BEGIN OR END DURING THIS MONTH? IF SO, WHAT DATE?
HOURLY WAGE:
HOW HOURS WERE VERIFIED
NUMBER OF HOURS ENTERED:
CODE ENTERED:
Self-Employment
TYPE OF SELF-EMPLOYMENT:
DID SE BEGIN OR END DURING THIS MONTH? IF SO, WHAT DATE?
HOW SELF-EMPLOYMENT WAS VERIFIED (client statement or CANO):
Note:use one of the 3 options below and delete the other 2 options that you did not use
NO EXPENSES (GROSS / FED MIN=HRS) SHOW CALCULATION:
EXPENSES LESS THAN 50% OF GROSS (gross / 2 / fed min=hrs) SHOW CALCULATION:
EXPENSES OVER 50% OF GROSS (use CANO calculation of net income / fed min ($7.25) =hrs):
# OF HOURS VERIFIED:
CODE ENTERED:
Short Term Medical for Work Readiness
Note:B1, B4, B5 & B6 can only be used for short term work readiness treatment
TYPE OF MEDICAL TREATMENT:
TYPE OF DOCUMENTATION RECEIVED FROM THE PROVIDER:
# OF HOURS VERIFIED BY:
CODE ENTERED:
Training
NAME OF TRAINING FACILITY:
NAME OF TRAINING CLASS:
HOURS OF CLASSROOM TIME VERIFIED ON ATTENDANCE FORM BY THE INSTRUCTOR:
HOURS OF UNSUPERVISED STUDY SESSION TIME ON HOMEWORK LOG:
TOTAL # OF HOURS VERIFIED:
CODE ENTERED:
DPAWS Field ServicesPage 1 of 4July 24, 2018