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Form Nhep275 - Nhep Distance Learning Log - New Hampshire Department Of Health And Human Services

NH Department of Health and Human Services

Form NHEP275

NH Employment Program

07/09

NHEP DISTANCE LEARNING LOG

Time spent on activities as part of your enrollment in a distance learning course is to be identified on this form. You are expected to submit

this form to your Employment Counselor Specialist (ECS) weekly and provide your ECS with examples of your work. Please submit one

activity log for each distance learning course you are taking. With your signature, you certify the information provided on this form is correct

and true. Please attach copies of work completed or feedback from the program for the work completed during this time.

School or Program:

Participant Name:

RID #:

WEEK BEGINNING SATURDAY:

Course Name:

School or Instructor’s Weekly Time

30 Hours

20 Hours

Other:

Expectation for Course:

Distance Learning Activities

Time Spent on

Describe in detail what you did during the time logged

Each Activity

Sat

Sun

Mon

Tues

Wed

Thur

Fri

Total Time Spent on Distance Learning Activities:

NHEP Participant Signature

Date

Employment Counselor Specialist Signature

Date

SR 09-22

(3YC)

Form Nhep275 - Nhep Distance Learning Log - New Hampshire Department Of Health And Human Services