/ WIOA Participant Time & Attendance Evaluation Report
PLEASE FILL OUT IN BLUE/ BLACK INK, ONLY NO WHITE OUT
/ X
Site No.
Acct Code:
Field Office/Region:
County:
x

x\

Name:

Last

/ First / MI / SSN

x

Training Site: / Job Title: / State ID#

x

☐ / WIOA Younger Youth / ☐ / WIOA Older Youth / Activity: / ☐ / W/E / ☐ / WIOA Tutoring/ Training (Paid) / ☐ / ☐
x
Paid Period from: / to / Projected Termination Date:

x

Month/Year:
/

Days of the Month/Hours Worked

/ Rate of Pay: / $

x

1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / 11 / 12 / 13 / 14 / 15 / 16 / 17 / 18 / 19 / 20 / 21 / 22 / 23 / 24 / 25 / 26 / 27 / 28 / 29 / 30 / 31

x

Month/Year: / PLEASE NOTE: All 14 and 15 year old participants MUST fill out Work Permit.

Tutox

1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / 11 / 12 / 13 / 14 / 15 / 16 / 17 / 18 / 19 / 20 / 21 / 22 / 23 / 24 / 25 / 26 / 27 / 28 / 29 / 30 / 31

x

SPECIFIC TASKS: Duties Performed and Skills learned during the reporting period (see training outline): /
Total Hours/Days

x

EVALUATION REPORT / Excellent / Good / Need Improvement / Comments (Required for “Need Improvement” Rating):
Evaluation Factors: / ☐ / ☐ / ☐ /
Punctuality& Attendance / ☐ / ☐ / ☐ /
Initiative/Interest in Work / ☐ / ☐ / ☐ /
Grooming / ☐ / ☐ / ☐ /
Attitude / ☐ / ☐ / ☐ /
Accepts Direction/Responsibility / ☐ / ☐ / ☐ /
Compliance With Worksite Regulations / ☐ / ☐ / ☐ /
Performance Progress / ☐ / ☐ / ☐ /

WORKSITE/CONTRACTOR CERTIFICATIONS: Gray area filled out by Field Office/ Region

I certify that the attendance report above is true and correct and that Evaluations of specific tasks performed and learned are based on my best judgement. / I certify that the attendance report above is correct and that it was discussed with me. / Total Hrs/ Beginning Balance:
Hour Used this Pay Period/ Payment: / ______
Balance Forward (Hours/ Payment):

X

Worksite/Contractor Supervisor Signature / Date / WIOA Participant Signature / Date
WIOA Case Manager Signature / Date / Regional Manager Signature / Date

This is a Southwestern Area Workforce Development Board Form and cannot be Changed/Revised Without Prior Approval. Revised: February 21, 2018

“An Equal Opportunity Employer”