Dss Form 1302 - Family Independence Supervised Homework Hours Page 2
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2INSTRUCTIONS FOR DSS FORM 1302
This form has been designed by the South Carolina Department of Social Services to be used for supervising homework
hours. The instructor/school designee/monitor should complete and sign the form. The completed form should be
returned to DSS by due date.
This form is required to be completed when student attends a supervised study activity, such as a monitored
study hall or a facilitated study group.
Part I – To be completed by the Case Manager before sending to school.
Student Name: The complete name of the student.
Case Number: The student’s case number.
Name of School: Name of school student is attending.
Address of School: Address of school student is attending.
Case Manager: Case Manager’s name.
Case Manager’s Telephone Number: Case manager’s telephone number.
Social Security Number: Last four (4) digits of student’s social security number.
Name of Class: The complete name of the class for which the student is enrolled.
Quarter/Semester: Indicate the quarter/semester for which the student is enrolled.
Begin Date and End Date of Class: Indicate begin/end date of student’s class.
Report Month/Year: Indicate which month and year information is needed.
1st Week Beginning and 2nd Week Ending: Indicate appropriate beginning and ending dates for report.
Part II – To be completed by the school.
Scheduled Activity: Please check appropriate block as it relates to student.
Class Name: Indicate name of class if applicable.
Attendance: Enter hours that the client attended in the appropriate block.
Instructor’s Name: Self-Explanatory
Instructor’s Signature/Date: Self-Explanatory
DSS Form 1302 (OCT 09)
PAGE 2
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