X-24 Employee Involved in University Extra-Services Employment Activities

NORTHWESTERN STATE UNIVERSITY

Employee Involved in University Extra-Services
Employment Activities

I. Purpose and Scope: To outline the procedures for executing the University policy on employees involved in extra services employment for University activities, regardless of source of University funding.

II. Reference: NSU Faculty Handbook Chapter two, pages 24 & 25; Board of Supervisors for the University of Louisiana Systems; Civil Service, State and Federal Regulations, Policy, Procedure and Law.

III. Responsible Area: All

General Conditions

1. Occasionally, employees are asked to assume responsibility for additional duties relatively unrelated to, or independent of, their normal work. When such assignments are clearly not a part of the employee's normal assignment, additional compensation may be permitted. Such additional compensation must be justified on a case-by-case basis and approved prior to the beginning of the assignment.

2. Each applicable Vice President is responsible for assuring that:

a) before a university employee is recommended to perform the services, a search for a qualified outside individual/contractor was performed and was found not to be available,

b) before a classified or unclassified non-nine (9) month faculty employee is recommended to perform the service, a search for a qualified nine (9) month faculty employee was performed and was found not to be available,

c) that after the search failed to find an outside individual/contractor or nine (9) month faculty employee, the recommended classified or unclassified non-nine (9) month faculty employee is recommended/approved to perform the service.

3. Faculty, non-faculty unclassified and classified employees should not engage in extra services activities during their regularly scheduled work day. The University's normal work day for non-faculty unclassified and classified employees generally is 8:00 AM to 4:30 PM.

Faculty work days are flexible and may include weekends. Faculty therefore may engage in extra services activities if not in conflict with their regularly scheduled and assigned duties.

4. Under no circumstances should an unclassified annual leave earning employee or the equivalent, be allowed to take leave to earn additional compensation under an extra services contract or any other method during the regular work hours of the University, 8:00 AM to 4:30 PM or the employee's regularly assigned work day.

5. Unclassified annual leave earning employees or the equivalent may be allowed to earn extra compensation, after the University's official work day (8:00 AM - 4:30 PM) on holidays, closures and week-ends for credit and/or non-credit instruction and additional duties unrelated to or independent of their normal work assignment as approved by their supervisor, Budget Unit/Department Head, Division Head/Dean, Vice-President, and/or President.

6. The approval of Extra Services Contracts for credit and non-credit instruction is delegated to the employee's Vice President and the Vice President of Academic Affairs.

If the employee's Vice President and the Vice President of the area/budget unit for which services are being performed are different, the Extra Services Contract requires the approval of both Vice Presidents.

7. An employee must be certified by the Budget Unit/Department Head as working a full load in addition to the activity for which extra compensation shall not in any way interfere with the regular duties of the individual, as certified by the Budget Unit Head/Department Head and Dean/Department Head.

8. The individual seeking extra compensation must enter into and sign a "contract for extra services" in advance of performance of the work. A copy of a "contract for extra services" is available through the individual's Budget Unit Head. By signing the "Contract for extra services", the Budget Unit Head/Department Head, Division Head/Dean and Vice President are certifying and assuring that (a) normal operations are not being jeopardized; (b) quality of work is not affected by personnel substitution; (c) the individual is not abusing the privilege; (d) record of attendance for the University employee is maintained; and (e) the employment activities are not within the employee's duties and responsibilities to the University for the position the employee is being compensated for by the University.

9. Total paid compensation from all NSU sources between July 1, and June 30, inclusive, may not exceed the employee's twelve-month equivalent salary times 1.25 (or rate currently published in the University's employee handbooks). It is the employee's responsibility to monitor the allowable compensation and not exceed the limit. Nine (9) month faculty calculations for paid compensation should begin with the summer session and end at the beginning of the successive summer session of the University.

Academic-year employees using this computation should first multiply their regular academic-year salaries by 12/9 to obtain a twelve-month equivalent salary, then multiply this base by 1.25.

These limitations apply to all income covered by any check issued by NSU for any compensation purpose.

10. Federal funds may not be used to pay extra compensation unless specifically authorized by the sponsoring agency. The extra compensation must be authorized to be paid at the regular payroll period for the time period in which it is earned.

11. Classified employees are paid overtime in accordance with State Civil Service and Fair Labor Standards law. Extra services contracts may be allowed for classified employees, however, each request must be reviewed separately and approved by the Director of Human Resources.

12. Extra compensation or extra services contracts will not be allowed if a conflict of interest is involved or is it is in any way in violation of law. See the Governmental Code of Ethics, the Louisiana Constitution, and other statutory law.

13. For employees receiving "extra services payment" for credit hour instruction, their Time and Attendance Report or Monthly Leave Report (for nine (9) month faculty) will serve as authorization for payment.

For employees receiving "extra services payment' for any additional duty other than credit hour instruction, the Request for Payment for Extra Services is required before payment.

14. Payment for extra service contracts are made to the employee in their regularly scheduled pay check, once approved for payment.

15. Graduate students who are assigned paid graduate assistantships are not to be assigned Extra Services Contracts.

IV. Procedure:

Director of Activity

1. Notify the person to be employed for the activity.

Supervisor, Budget Unit Head & Employee

2. Initiate/review work schedule of employee using the form shown as (Attachment #1). Assure that the employee's regularly assigned duties are completed (activity cannot conflict with assigned duties).


NOTE: Employee cannot take leave to perform an extra-services activity.

Budget Unit Head

3. Initiate the "extra-services contract" by (of employee where completing the Summer Faculty, Part-Time regularly assigned) Faculty and Extra-Services Appointment Form in accordance with Instructions for Completion of the Summer Faculty, Part-Time Faculty and Extra Services Appointments Form for Extra Services Appointments/Contracts. (Attachment #2).

4. Ensure that description of services to be rendered, fee rates and other required information for "extra service contract" are properly completed.

5. Obtain employee's signature and social security number. Inform employee that services are not to commence until the contract has been approved in accordance with Board of Supervisors for the University of Louisiana System procedures.

6. Route the contract to the Approving Agent for approval.

NOTE: If funds are not budgeted in your account for the extra services contract, the Budget Unit Head must initiate a Budget Revision form which will require the President's budget revision approval if the Vice President cannot revise budgets, under his area of responsibility, to fund the unbudgeted request.

Approving Agent

7. Review the contract and sign if approved. If disapproved, return contract to Director of Activity.

8. Forward approved contract to the appropriate Vice President.

NOTE: Services being provided for another Vice President's area require the approval of the employee's Vice President and the other area's Vice President.

Vice President

9. Review the contract and sign if the services being contracted for are approved.

10. Forward approved contract to Business Affairs - Human Resource Section.


NOTE: Unbudgeted request will continue to require the President's budget revision approval if the Vice President cannot revise budgets, under his area of responsibility, to fund the unbudgeted request.

11. Return disapproved request to Approving Agent for resolution.

NOTE: The authority to approve "extra services contracts" for credit and non-credit instruction is delegated to the employee's Vice President and the Vice President of Academic Affairs.

Business Affairs-Human Resource Section 

12. Review and complete Form for review and approval.

13. Monitor extra services earnings limit.

14. If applicable, forwards Form to President.

President (If applicable)

15. Review and sign the contract if the services are approved.

16. Return approved and unapproved requests to Business Affairs.

Business Affairs-Human Resource Section

17. Return unapproved request to appropriate Vice President to be discussed with Budget Unit Head and employee.

18. Inform Budget Unit Head when request is approved by the President or Vice President. Budget Unit Head informs employee and Director of Activity.

19. Report "extra services contracts" to the President for review monthly.

NOTE: Extra services contracts must be submitted and fully approved before employee is assigned duties for extra service payment. Employee must not begin work before the appointment is approved by the appropriate individuals.

Employee

20. After approval of the contract, perform the task requested by the Director of Activity.

Payment Process

NOTE: For employees receiving "extra services payment" for credit hour instruction, their Time and Attendance Report or Monthly Leave Report will serve as authorization for payment.

For employees receiving "extra service payment" for any additional duty other than credit hour instruction, the Request for Payment for Extra Services with Supplemental Schedule of Effort and Trainee/Participant Sign-In Sheets are required before payment.

Payment for extra services are made to the employee in their regularly scheduled pay check, once approved for payment.

Budget Unit Head

21. For "extra services payment" for any additional duty other than credit hour instruction, initiates Request for Payment-Extra Services for the employee with Supplemental Schedule of Effort and Trainee/Participant Sign-In Sheets (see Attachments 3, 4, 5, & 6) when services are complete.

22. For employees being paid "extra services" for credit hour instruction, the Time and Attendance Report or Monthly Leave Report will serve as payment authorization.

Request for Payment

NOTE: For service other than credit hour instruction, a request for payment with Supplemental Schedule of Effort and Trainee/Participant Sign-In Sheets are required.

23. When services are completed or partial services are completed as agreed upon in the "extra services contract", complete the Extra Services Contract Request for Payment, Supplemental Schedule of Effort and Trainee/Participant Sign-In Sheets (see Attachments 3,4,5 & 6) entering the following information:

1. Date of Request
2. Extra Services Contract number
3. Employee Name
4. Employee Campus Wide ID Number
5. Account Title, Budget Unit (Account) Number and Amount to be charged.

NOTE: Must agree to contract.

24. Certify that,

(a) the contract is complete, or
(b) partial payment as agreed upon, by marking with "X" in the appropriate space.

NOTE: The Budget Unit Head certifies that the services described in the "extra services contract" have been completed in whole or in part in accordance with the contract with Supplemental Schedule of Effort and Trainee/Participant Sign-In Sheets and all University policies.

Employee

25. Review the "Request for Payment" and Supplemental Schedule of Effort and Trainee/Participant Sign-In Sheets. Confers with Budget Unit Head on disagreements.

If in agreement, sign "Request for Payment" and Supplemental Schedule of Effort and Trainee/Participant Sign-In Sheets.

NOTE: The employee, by signing the "Request for Payment" and Supplemental Schedule of Effort and Trainee/Participant Sign-In Sheets; certifies that the services described in the "extra services contract" have been completed in whole or in part in accordance with the "contract" and all University policies.

Budget Unit Head

26. Sign "Request for Payment" and Supplemental Schedule of Effort and Trainee/Participant Sign-In Sheets and route to Business Affairs if approved.

NOTE: Payment for services requested in the contract will be in the next regularly scheduled payroll for the employee's class of employment.

 

 

 

 

 

 

 

Request for Payment Extra Services

Supplemental Schedule of Effort

Trainee/Participant Sign In Sheet

Multi-Class/Module Sign In Sheet

 

NORTHWESTERN STATE UNIVERSITY
Instructions for Completion of the
Summer Faculty, Part-Time Faculty
and Extra Services Appointments Form for
EXTRA SERVICES APPOINTMENTS/CONTRACTS

Purpose: This form is used to request the appointment of Summer Faculty, Part-Time Faculty, including Adjunct Instructors, Adjunct Lecturers, Cooperating Teachers or Principals, Supervising Teachers or Principals and the approval for "Extra Services" duties for current employees.

Copies: It is the responsibility of each individual, "Approving Official/Officer" to make/retain file copies.

Routing: Project Director/Budget Unit Head completes appropriate sections of form and routes to "potential employee".

The "potential employee" completes appropriate section and routes to Project Director/Budget Unit Head. If appointment is rejected, Project Director/Budget Unit Head voids form and files as needed.

Project Director/Budget Unit Head completes appropriate sections, reviews, signs, dates and forwards to Approving Agent/Dean/Division Head. If disapproved, returns to Project Director/Budget Unit Head.

Approving Agent/Dean/Division Head completes appropriate sections, reviews, signs, dates and forwards to Appropriate Vice President, if applicable. If not applicable, forwards to Academic Vice President.

If current employee outside the Academic Vice President's area of responsibility is negotiating an extra-services appointment, the employee's Vice President must approve the appointment.

See NSU Fiscal Policy and Procedure manual, section X-24, Employee Involved in University Extra-Services Employment Activities for further information concerning "extra services appointments".

Appropriate Vice President reviews, signs, dates and forwards to Academic Vice President. If disapproved, returns to Approving Agent/Dean/Division Head.

Vice President of Academic Affairs completes appropriate sections, reviews, signs, dates and forwards to Business Affairs. If disapproved, returns to appropriate Vice President or Approving Agent/Dean/Division Head.

Business Affairs reviews appropriate sections, signs, dates and forwards to President, if applicable. Resolves any discrepancies with appropriate "Approving Official/Officer".

If applicable, President reviews, signs, dates and forwards to Business Affairs. If disapproved, returns to Academic Vice President or appropriate Vice President.

DATA RESPONSIBILITIES
Summer Faculty, Part-Time Faculty
and Extra Services Appointments for
Extra Services Appointments/Contracts

ITEM DESCRIPTION RESPONSIBILITY
1 FORM NUMBER BUSINESS AFFAIRS
2 DATE FORM PREPARED BUDGET UNIT HEAD
3 NAME OF INDIVIDUAL TO BE EMPLOYED BUDGET UNIT HEAD
4 TYPE OF EMPLOYMENT/APPOINTMENT BUDGET UNIT HEAD
5 CLASS OF EMPLOYEE'S EMPLOYMENT FOR EXTRA SERVICES BUDGET UNIT HEAD
6 BUDGET UNIT TITLE AND ACCOUNT NUMBER ENTERING INTO AGREEMENT BUDGET UNIT HEAD
7 ACCOUNT TITLE TO BE CHARGED BUDGET UNIT HEAD
8 ACCOUNT NUMBER TO BE CHARGED BUDGET UNIT HEAD
9 OBJECT CODE TO BE CHARGED BUSINESS AFFAIRS
10 EMPLOYMENT PERIOD BUDGET UNIT HEAD
11 BEGINNING AND ENDING DATE OF EMPLOYMENT FOR THIS AGREEMENT BUDGET UNIT HEAD
12 GRANT, CONTRACT, OTHER AGREEMENT AWARD PERIOD: BEGIN DATE BUDGET UNIT HEAD
13 GRANT, CONTRACT, OTHER AGREEMENT AWARD PERIOD: END DATE BUDGET UNIT HEAD
14 SALARY RATE TO BE PAID BUDGET UNIT HEAD
15 PAYMENT TERMS: MONTHLY, END OF SEMESTER, ETC. BUDGET UNIT HEAD
16 DUTIES TO BE PERFORMED. USE ATTACHMENT IF NECESSARY BUDGET UNIT HEAD
17 COURSE AND SECTION FOR TEACHING ASSIGNMENTS BUDGET UNIT HEAD
18 COURSE HOURS FOR COURSES ASSIGNED BUDGET UNIT HEAD
19 ESTIMATED/CONFIRMED CLASS ENROLLMENT BUDGET UNIT HEAD
20 CAMPUS/SITE WHERE COURSE IS TAUGHT BUDGET UNIT HEAD
21 TIME CLASS IS SCHEDULED, E.G. 8MWF, 5M, ETC. BUDGET UNIT HEAD
22 TOTAL NUMBER OF COURSE HOURS FOR THIS AGREEMENT BUDGET UNIT HEAD
23 APPOINTMENT ACCEPTED OR REJECTED INDIVIDUAL/EMPLOYEE
24 SIGNATURE OF INDIVIDUAL/EMPLOYEE ACCEPTING OR REJECTING APPOINTMENT OFFER, INCLUDING DATE INDIVIDUAL/EMPLOYEE
25 INDIVIDUAL/EMPLOYEE SOCIAL SECURITY NUMBER INDIVIDUAL/EMPLOYEE
26 OFFICE OR UNIVERSITY REPRESENTATIVE FORM IS TO BE RETURNED TO FROM INDIVIDUAL OR EMPLOYEE BUDGET UNIT HEAD
27 DATE FORM SHOULD BE RETURNED TO OFFICE OR UNIVERSITY REPRESENTATIVE BY INDIVIDUAL/EMPLOYEE BUDGET UNIT HEAD
28 PRINTED OR TYPED NAME, MAILING ADDRESS AND CONTACT PHONE NUMBER FOR INDIVIDUAL/EMPLOYEE. ADDRESS SHOULD BE THE CHECK MAILING ADDRESS INDIVIDUAL/EMPLOYEE
29 SIGNATURE AND DATE OF PROJECT DIRECTOR/BUDGET UNIT HEAD RECOMMENDING APPOINTMENT PROJECT DIRECTOR/
BUDGET UNIT HEAD
30 SIGNATURE AND DATE OF APPROVING AGENT/DEAN/DIVISION HEAD RECOMMENDING APPOINTMENT DEAN/DIVISION HEAD
31  SIGNATURE AND DATE OF APPROPRIATE VICE PRESIDENT, OTHER THAN THE ACADEMIC VICE PRESIDENT APPROVING APPOINTMENT, IF APPLICABLE APPROPRIATE VICE PRESIDENT
32 SIGNATURE AND DATE OF ACADEMIC VICE PRESIDENT APPROVING APPOINTMENT ACADEMIC VICE PRESIDENT
33 SIGNATURE AND DATE OF PRESIDENT APPROVING APPOINTMENT, IF APPLICABLE PRESIDENT
34 HUMAN RESOURCE SYSTEM CODE FOR APPLICABLE SALARY/TAX/DEDUCTIONS, ETC. BUSINESS AFFAIRS
35 CURRENT STATUS OF APPLICABLE SALARY/TAX/DEDUCTION, ETC. BUSINESS AFFAIRS
36 STATUS OF APPLICABLE SALARY/TAX/DEDUCTIONS, ETC. AFTER CHANGE BUSINESS AFFAIRS
37 FRS (FINANCIAL RECORDS SYSTEM) OBJECT CODE OF EXPENDITURE FOR THIS APPOINTMENT BUSINESS AFFAIRS
38 HRS (HUMAN RESOURCES SYSTEM) EARNING CODE FOR THIS APPOINTMENT BUSINESS AFFAIRS
39 PAYROLL CYCLE, ETC. AFFECTED BY THIS APPOINTMENT BUSINESS AFFAIRS
40 JOB CODE FOR THIS APPOINTMENT BUSINESS AFFAIRS
41 HUMAN RESOURCE SYSTEM DIVISION, DEPARTMENT AND UNIT FOR THIS APPOINTMENT BUSINESS AFFAIRS
42 TIME KEEPING LOCATION BUSINESS AFFAIRS
43 POSITION NUMBER BUSINESS AFFAIRS
44 BEGINNING ASSIGNMENT DATES FOR THIS APPOINTMENT BUSINESS AFFAIRS
45 ENDING ASSIGNMENT DATES FOR THIS APPOINTMENT BUSINESS AFFAIRS
46 SIGNATURE AND DATE OF THE DIRECTOR OF HUMAN RESOURCES OR DESIGNEE ATTESTING TO PROPER REVIEW OF APPOINTMENT FOR COMPLIANCE, ACCURACY, ETC. BUSINESS AFFAIRS
47 SIGNATURE AND DATE OF ASSIGNED INDIVIDUAL WHO ENTERED DATA FOR PAYROLL UPDATES DIRECTOR OF HUMAN RESOURCES
48 SIGNATURE AND DATE OF ASSIGNED INDIVIDUAL WHO VERIFIED DATA ENTRY FOR PAYROLL UPDATES BUSINESS AFFAIRS
49 BUDGET BALANCE OF ACCOUNT TO BE CHARGED BEFORE THIS APPOINTMENT BUSINESS AFFAIRS
50 BUDGET BALANCE OF ACCOUNT TO BE CHARGED AFTER THIS APPOINTMENT BUSINESS AFFAIRS
51 BUDGET ENTRY REFERENCE NUMBER FOR BUDGET ENTRY REQUIRED BY THIS APPOINTMENT BUSINESS AFFAIRS
52 SIGNATURE AND DATE OF EMPLOYEE ASSIGNED BUDGET REVIEW ATTESTING PROPER BUDGET REVIEW AND ACTION HAS OCCURRED BUSINESS AFFAIRS
53 COPIES - DISTRIBUTE PER INSTRUCTIONS ON BOTTOM OF FORM BUSINESS AFFAIRS

 

NORTHWESTERN STATE UNIVERSITY
Instructions for completion
of
Supplemental Schedule of Effort/Participant Sign-In Sheet Forms

Purpose: These forms are used to document payment to employees and contractors for training, instruction or otherwise participating in activities for which documentation is required to facilitate the billing process or document payment requested for extra services or professional services as required by Grants, Contracts, Cooperative Endeavors, Self Generated Activities, ETC., (Does not include instruction for credit courses)

Responsibility: It is the Budget Unit Head's responsibility to insure this form is completed and submitted to the appropriate offices.

The Instructor/Employee/Contractor and Supervisor/Budget Unit Head is responsible for ensuring that all mathematical computations are correct and that any necessary reconciliations for per hour, per unit or per person rates are performed.

Routing: The Budget Unit Head should fill in required information and route to the Instructor/Employee/Contractor responsible for delivering the training/class activities/contracted services.

The Instructor/Employee/Contractor should insure the remaining information is accurately completed and then sign, date and return to Budget Unit Head for review, approval and decimation to the appropriate offices.

NOTE: Examples are attached that relate to the different types of request for which this Supplemental Schedule of Effort/Participant Sign-In Sheet Form will be required.

Extra Service Contracts

When used as documentation to request payment for services provided under an extra services contract this form should be attached to the request for payment. By signing this Schedule the Project Director, Instructor, Coordinator, Supervisor and/or Budget Unit Head is certifying that the information contained on this document, or any supporting attachments, as it relates to services performed are in accordance with the contract.

When a contract requires payment to be contingent upon the number of participants, or number of sessions, the Trainee/Participant Sign-In Sheet Form must also be attached to document attendance. If partial payment is requested under a contract which requires this documentation, each request for payment will be required to have adequate documentation to substantiate the payment amounts being requested.

Billing for Services

When using this form to Bill for Services that are provided by University Employees, but for which the employee is not going to be receiving extra services pay, these forms should be completed and forwarded to the Office responsible for compiling the invoice, to be used as documentation for amounts invoiced. Project Director/Coordinator/Instructor Work Log Instructions

Data Responsibilities

Item # Description By
1 Extra Services Contact Number Budget Unit Head
2 Non-Credit Presenter Number Budget Unit Head
3 Title of Grant/Contract or Project Budget Unit Head
4 Professional Services Purchase Order Number Budget Unit Head
5 Name of Person Receiving Payment Budget Unit Head
6 Physical Location of Instruction or Activity Budget Unit Head
7 Mark if Billing someone else for Services Rendered Instructor/
Employee
8 Training Institute responsible for training/activity Instructor/
Employee
9 Budget Unit Account to be charged for this payment Instructor/
Employee
10 Terms of payment Instructor/
Employee
11 Indicate if payment is based on a per hour rate; indicate amount per hour Instructor/
Employee
12 Indicate if payment is based on a number of persons or a per unit rate Instructor/
Employee
13 Indicate Day & Date of Event/Activity Instructor/
Employee
14 Indicate the Class or Activity for which payment is being requested Instructor/
Employee
15 Time Class or Activity Began Instructor/
Employee
16 Time Class or Activity Ended Instructor/
Employee
17 Total hours of instruction or activity Instructor/
Employee
18 Number of Units being billed for (If person attach Trainee/Participant Sign-In Sheet) Instructor/
Employee
19 Description of duties performed Instructor/
Employee
20 Signature of Person Providing instruction or coordinating activities Instructor/
Employee
21 Date Signed Instructor/
Employee
22 Signature of Supervisor or Budget Unit Head Budget Unit Head
23 Date Signed Budget Unit Head

 Trainee/Participant Sign-In Sheet Instructions
Data Responsibilities

Item # Description By
1 Name of Grant/Contract/Project Director Budget Unit Head
2 Location where activity is taking place Budget Unit Head
3 Employer requesting training/project for which activity is being performed Budget Unit Head
4 Training Institute that is responsible for Class deliverance Budget Unit Head
5 Date of training or participation Instructor/Employee
6 Time Activity begins Instructor/Employee
7 Time Activity ends Instructor/Employee
8 Course title/activity description Instructor/Employee
9 Total time of course deliverance or activity Instructor/Employee
10 Trainee/Participant Signature Trainee/Participant
11 Trainee/Participant Social Security Number Trainee/Participant
12 Instructor Signature Instructor/Employee
13 Date prepared by Instructor Instructor/Employee

 

 Multi-Class/Module Trainee/Participant Sign In Sheet (For Multi-Classes/Modules) 
Data Responsibilities

Item # Description By
1 Title of Grant/Contract/Project Budget Unit Head
2 Course title/Activity/Project Budget Unit Head
3 Training Institute that is responsible for Class deliverance Budget Unit Head
4 Name of person presenting course or directing activity Budget Unit Head
5 Physical Location of Instruction or Activity Budget Unit Head
6 Course title/activity description Budget Unit Head
7 Date of Training or Instruction Budget Unit Head
8 Begin and Ending time for class or activity Budget Unit Head
9 Total time of course deliverance or activity Budget Unit Head
10 Trainee/Participant Name - Printed or Typed Trainee/Participant
11 Trainee/Participant Social Security Number Trainee/Participant
12 Trainee/Participant's Employer Trainee/Participant
13 Trainee/Participant's Signature Trainee/Participant
14 Trainee/Participant's Signature if he/she participated in more than one class/activity on same day Trainee/Participant
15 Instructor Signature Instructor/Employee
16 Date prepared by Instructor Instructor/Employee