Weekly Time Study for Title V 30/30 Earmarking

Position #:
Name:
Job Title:
Location:
Agency:
Subcontractor:

Time Study Period (Week/Date):

% FTE
Total Hrs.

Date:

Date:

Date:

Date:

7:00

7:00

7:00

7:00

7:30

7:30

7:30

7:30

8:00

8:00

8:00

8:00

8:30

8:30

8:30

8:30

9:00

9:00

9:00

9:00

9:30

9:30

9:30

9:30

10:00 10:30 11:00 11:30 12:00 12:30

10:00 10:30 11:00 11:30 12:00 12:30

10:00 10:30 11:00 11:30 12:00 12:30

10:00 10:30 11:00 11:30 12:00 12:30

1:00

1:00

1:00

1:00

1:30

1:30

1:30

1:30

2:00

2:00

2:00

2:00

2:30

2:30

2:30

2:30

3:00

3:00

3:00

3:00

3:30

3:30

3:30

3:30

4:00

4:00

4:00

4:00

4:30

5:00

4:30

5:30

5:00

4:30

5:30

5:00

4:30

5:30

5:00

5:30

6:00

6:00

6:00

6:00

6:30
0
0
0

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0
0
0

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0
0
0

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0
0

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6:30

6:30

6:30

Date:

7:00

7:30

8:00

8:30

9:00

9:30

10:00 10:30 11:00 11:30 12:00 12:30

1:00

1:30

2:00

2:30

3:00

3:30

4:00

4:30

5:00

5:30

6:00

6:30
0
0
0

Categories

Day 1

Day 2

Day 3

Day 4

Day 5

TOTALS

1. Preventive & Primary Care Services for Children (PPCSC)

#DIV/0!

2. Children with Special Health Care Needs (CSHCN)

#DIV/0!

3. * Other

#DIV/0!

* Note: If you appear on your Agency's MCAH Budget and are performing AFLP, BIH, FIMR, BIH/FIMR, and/or SIDS activities you should report the time spent performing these
activities under Category 3 - Other.

I hereby certify that this is a true and accurate report of my

time and that the categories were performed as shown
above.

I hereby certify that the employee's time records have been examined and that, to the best of my
knowledge, this time record is valid and correct and the categories were performed as shown
above.

Employee's Signature

Supervisor's Signature

Date

Date

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