Fillable Path To Success Monthly Contact Sheet (Mcs) - Larimer County Workforce Center printable pdf download

--Save this file on your computer or flash drive before filling out--

LARIMER COUNTY WORKFORCE CENTER - PATH TO SUCCESS MONTHLY CONTACT SHEET (MCS)

Name: ___________________________________________________________________________

Report for the month of: ________________________________ Year: __________

Address: _________________________________________________________________________

City: _________________________________ State: __________ Zip Code: ___________________

Name of your Career Coach: _____________________________________________

Is this a new address? (Mark one response) YES ______ NO ______

Phone #: __________________________________

INSTRUCTIONS: You MUST complete this sheet and turn it in to your Colorado Works Career Coach

by the 5th of each month.

The form asks that you report the number of hours that you spent on activities listed on your Roadmap Contract

in the previous month. List each activity on a different row and then, in the boxes, enter the number of hours that you spent on that activity each day. USE BLACK INK ONLY. (The first row shows an example: if you spent 3 hours looking for

and applying to jobs on the 16th of the month and 2 hours on the 21st, you would enter 3 in the box under the number 16 and 2 in the box under the number 21.)

*** IMPORTANT *** If you do not turn in this form on time or you do not

report fully on your work activities, YOUR TANF CASH BENEFITS AND CHILD CARE ASSISTANCE COULD BE REDUCED OR STOPPED.

If you have any questions about the form, contact your Career Coach for assistance.

Total

WORK ACTIVITIES: List each of the activities included in your Roadmap

MONTHLY CALENDAR

hours this

Contract on a separate row.

month

EXAMPLE: Job Search / Job Readiness (JS)

Your activities:

Choose an Activity from the list or write one down here

Total hours for all activities this month:

Other information for your Career Coach:

1. Did you miss any scheduled Roadmap activities (for example, workshops or coaching meetings) that you had agreed to participate in this month?

Select one: YES ______ NO ______

If YES, which activities did you miss?

Why did you miss these activities?

2. Do you need help with any issues that are making it difficult for you to participate in your work activities or make progress toward your goals/employment - for example, transportation, child care, housing or other issues?

Select one: YES ______ NO ______

If YES, explain:

3. Did you do any work for pay in the reported month? ( Please count any work that you expect to be paid for even if you have not been paid yet.)

Select one: YES ______ NO ______

If YES, who was your employer and how much did you earn?

Employer's Name: ______________________________________________________________

Supervisor's Name: __________________________________________

Employer's Address: ____________________________________________________________

Total hours worked this month: _______________________________

Employer's Phone: _____________________________________________________________

Amount earned this month: $ ________________________________

I certify that the time entered represents a true and accurate record of my time: X

DATE: ________ / __________ / __________

_______________________________________________________________

*Remember to complete and submit your form by the 5th of each month*

FOR CAREER COACH USE ONLY: I have reviewed this form and certify, to the best of my knowledge, that the information that my client provided complies with Colorado Works requirements.

Coach Signature: __________________________________________________________________________

Date: _________ / ________ / __________



Entered into MCS Database

Inquiry/Issuance

Activities

Attendance

Supportive Services

Case Comments

--When you complete this form, Save it! --

Then either send your electronically signed copy to or print a copy, sign in the space provided and get it to your Coach by the 5th!