TIME & EFFORT/ACTIVITY REPORT

For Split Salaried and Grant Supported Employees

______________________________

Month/Year

Employee:

Activity Name: Strengthening Academic Support in Courses and Programs w/ High Attrition Rates

Activity Subhead: Supplemental Instruction Program

Percent of Time: State: Non-State: 100%

BRIEF DESCRIPTION OF WORK PERFORMED	State	Non-State Title III Other
Attend class:		30%
Conduct Supplemental Instruction Session:
Conduct Supplemental Instruction Session:
Conduct Supplemental Instruction Session:
Conduct Supplemental Instruction Session:

Prepare for Supplemental Instruction Sessions:
Prepare for Supplemental Instruction Sessions:
Prepare for Supplemental Instruction Sessions:

Meet with SI Coordinator (Training):		10%

SICK LEAVE
ANNUAL LEAVE
HOLIDAY
TOTAL PERCENT OF TIME		100%

I CERTIFY THAT THE ABOVE IS CORRECT:

_______________________ __________________________

Employee’s Signature Supervisor’s Signature

______________________

Activity Director’s Signature

BRIEF DESCRIPTION OF WORK PERFORMED