Weekly Time Study for Federal Financial Participation

Name: Time Study Period (Mo/Yr):

Job Title: Program A: Program D:

Location: Program B: Program E:

Time Base: Program C: Program F:

Total Hrs.

Date: 7:00 7:30 8:00 8:30 9:00 9:30 10:00 10:30 11:00 11:30 12:00 12:30 1:00 1:30 2:00 2:30 3:00 3:30 4:00 4:30 5:00 5:30 6:00 6:30

_______________

Date: 7:00 7:30 8:00 8:30 9:00 9:30 10:00 10:30 11:00 11:30 12:00 12:30 1:00 1:30 2:00 2:30 3:00 3:30 4:00 4:30 5:00 5:30 6:00 6:30

_______________

Summary Information

Total Weekly Hours:

Program

Function Code

A B C D E F Allocated

1. Outreach

2. SPMP Administrative Medical Case Management

3. SPMP Intra/Interagency Coordination, Collaboration and Administration

4. Non-SPMP Intra/Interagency Collaboration and Coordination

11. Other Activities

12. Paid Time Off

Total Hours by Program:

Total hours worked in all programs:

I hereby certify that this is a true and accurate report of my time and that the functions were performed as shown above. I hereby certify that the employee's time records have been examined and that, to the best of my knowledge,

Employee's Signature Date Supervisor's Signature Date