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

Form Dcc-94e - Child Care Daily Attendance Record

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DCC-94E

COMMONWEALTH OF KENTUCKY

(R.07/13)

Cabinet for Health and Family Services

922 KAR 2:160

Department of Community Based Services

Division of Child Care

Page

Child Care Daily Attendance Record

Provider's Name

Provider's Registered/Certified/Licensed #

Week of:

(mm/dd/yyyy)

through

(mm/dd/yyyy)

Daily Attendance Record: 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., of each child must be recorded daily. A parent or the parent's designated person (i.e., somone other than a child care employee) must sign at the end of

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

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

Signature of Parent

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

or Designated

Child's Name

Person to Verify

(as it appears on

Time In

Time Out

Time In

Time Out

Time In

Time Out

Time In

Time Out

Time In

Time Out

Time In

Time Out

Time In

Time Out

Accuracy of

PBF)

Attendance for the

Initials

week

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

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