ST LUCIE PUBLIC SCHOOLS HOMEBOUND/HOSPITALIZED PROGRAM SERVICE PAY LOG A RECORD OF HOMEBOUND/HOSPITALIZED TEACHER SERVICES Teacher: ______________________________________________________ SS#:_XXX/XXXX/_______ Anticipated Dismissal Date: _______________________ Student: ___________________________________________ Address:_______________________________________________ Phone #:__________________ Student’s Home School: _______________________________________ Grade: ___________ Payroll Date Range: ______________ to ____________________ Assigned Time Range:__________________________ Assigned Subjects: ______________________________________________________________________ Day(s) and time(s) of the week student was served. PARENT/GUARDIAN SIGNATURE REQUIRED DAILY. Monday Tuesday Wednesday Thursday Friday Monday Tuesday Wednesday Thursday Friday Monday Tuesday Wednesday Thursday Friday Date Time (from/to) Total Hours Parent/Guardian Signature (Complete First and Last Name) __________ ___:___ ___:___ _____ _________________________________ __________ ___:___ ___:___ _____ _________________________________ __________ ___:___ ___:___ _____ _________________________________ __________ ___:___ ___:___ _____ _________________________________ __________ ___:___ ___:___ _____ _________________________________ __________ ___:___ ___:___ _____ _________________________________ __________ ___:___ ___:___ _____ _________________________________ __________ ___:___ ___:___ _____ _________________________________ __________ ___:___ ___:___ _____ _________________________________ __________ ___:___ ___:___ _____ _________________________________ Total time is calculated in 15-minute intervals. Payroll only
time reported in 15-minute interval format;
accepts
total
therefore, refer to the chart when
recording and calculating instructional time.
Total Hours + __________________
@$_________/hr= ______________ I certify that the above services were provided by me as indicated Date __________ ___:___ ___:___ _____ _________________________________ Teacher Signature __________ ___:___ ___:___ _____ _________________________________ __________ ___:___ ___:___ _____ _________________________________ _________________________________________
__________ ___:___ ___:___ _____ _________________________________ Program Specialist Signature Date __________ ___:___ ___:___ _____ _________________________________ _________________________________________
Administrator Approval Date White: Homebound Office Yellow: Student folder
Pink: Teacher HB0005 6/15
XED0103