Form Dcc-94e - Child Care Daily Attendance Record printable pdf download

DCC-94E

COMMONWEALTH OF KENTUCKY

(R.07/13)

Cabinet for Health and Family Services

922 KAR 2:160

Department for Community Based Services

Division of Child Care

Child Care Daily Attendance Record

*only use this form for one week, Sunday-Saturday

Provider’s Name

Provider’s Registered/Certified/License #

Week of:

3/31/2013-4/6/2013

Enter the Provider name as it appears on the PBF

Enter the CLR from your PBF

(mm/dd/yyyy) through (mm/dd/yyyy)

Enter the child’s full name as listed on the DCC-97, Provider Billing Form. The physical arrival/departure time, including a.m. and p.m.,

Daily Attendance Record:

of each child must be recorded daily. A parent or the parent’s designated person (i.e., someone other than a child care employee) must sign at the end of each

week for each child to verify accuracy. If a child arrives/departs by bus, the child care employee must record the time and initial daily. DO NOT RECORD THIS

INFORMATION IN ADVANCE or make alterations to this form. No other version of this form will be accepted. This form must be fully completed.

Child’s Name

Signature of Parent

(as it appears on

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

or Designated Person to

PBF)

Verify Accuracy of

*Do not use

Attendance for the week

nicknames

Out

Initials

Arrival

Departure

Last Name, First

time

Time

time

Time

time

Time

time

Time

time

Time

Name

Initials

8:05/

8:45/

8:10/

8:45/

8:05/

8:45/

8:05/

8:45/

8:05/

8:45/

Doe, John

3:10

5:15

3:15

4:45

3:15

6:00

3:15

6:05

3:10

5:05

Initials

6:45

4:30

6:30

4:45

10:00

6:00

absent

6:35

4:45

Example, Eddie

Initials

Fake, Fred

Model, Molly

Sample, Sally

I certify that I have not altered this form in accordance with KRS 13A.130, and this information was used when completing the DCC-97, Provider Billing Form. I

understand that if I or staff acting on the child care provider’s behalf does not bill accurately in accordance with 922 KAR 2:160 for a child, the child care provider will

not be paid for days that are not verified and will be required to pay back any overpayment. An overpayment may be pursued as an intentional program violation in

accordance with 922 KAR 2:020.

Licensee/On-Site Director or Certified/Registered Provider’s Signature: _________________________________________ Date: __________________

“Licensee”, as defined by 922 KAR 2:090, is an owner or operator of a child care center to include sole proprietor, corporation, Limited Liability Company, partnership, association or organization.

NOTE: MISSING SIGNATURES MAY RESULT IN NON-PAYMENT OR RECOUPMENT OF CCAP PAYMENT IN ACCORDANCE WITH 922 KAR 2:160 and 922 KAR 2:020

Cabinet for Health and Family Services

An Equal Opportunity Employer M/F/D

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