Form Ece-Cc-10g - Child Care Attendance Sheet - West Virginia Department Of Health & Human Resources Page 2
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1
2Child’s Name: _______________________________ Month: ______________ Year: ________
Date
Time
AM/
Time
AM/
0-2
2-4
4+
Non
Parents Signature
Parents Signature
In
PM
Out
PM
Hrs
Hrs
Hrs
Trad
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Totals for Month:
Parents shall sign child in and out each day to accurately verify their child’s attendance. If children are there in the morning and again in the afternoon, sign in and out both
times. To ensure accuracy of payment, provider must highlight those days claimed as a non-traditional day. Provider shall retain copies for 5 years for review by the DHHR staff.
A copy must be submitted with Request for Payment for subsidized children on a monthly basis. The providers signature certifies this is an accurate record of the attendance for
this child. Failure to keep accurate records may result in negative action to include corrective and/or legal action, referral for misrepresentation and/or requests for repayment of
funds by the provider.
Provider Signature:
Date:
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