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Appendix D OCISS Form HHI-3 STATE OF HAWAII o- lk DEPARTMENT OF EDUCATION Office of Curriculum Instruction and Student Support Student Support Services Branch P. O. Box 2360 Honolulu Hawaii 96804 Home-Hospital Instruction Hours of Instruction/Time Sheet INSTRUCTIONS 1. O. Box 2360 Honolulu Hawaii 96804 Home-Hospital Instruction Hours of Instruction/Time Sheet INSTRUCTIONS 1. Acquire form complete and submit to the school the HHI Hours of Instruction/Time Sheet for each student being seviced. 2. Report each semi-monthly period separately 1-15 or 16-EOM End Of Month. 3. Hours are paid only for days that school is in session. 4. Maximum hours per week is 17 hours regardless of the number of students assigned. 5. Incorrect or incomplete time sheet will be returned for correction or completion and must be re-submitted. 6. School will ensure that hours of instruction per week are in compliance with hours of instruction as designated on Form HHI-1 Request for Home-Hospital Instruction Services. 7. School distributes copy of HHI Hours of Instruction/Time Sheet to the district and to the tutor. Month Pay Period Check one Year 1-15 0 16-EOM Student Last MI First Grade School Dates of Instruction Number of Hours Total Hours GRAND TOTAL per Form HHI-1 unless this is a Section 504 Placement Decision Instruction will continue. Work with student terminated on for the reason checked below 0 Student returned to school on 0 I am unable to continue due to 0 Other Please specify I certify that the above is correct and that I have performed the services required on the dates specified. Tutor Please Print Signature Social Security Number Date SCHOOL SECTION PARENT SECTION I understand that my child received the number of hours as listed above and I hereby verify this time sheet to be correct. Check if Section 504 Placement Decision. SIGN THIS FORM ONLY IF IT IS COMPLETE Received By Signature of Parent/Legal Guardian DISTRIBUTION WHITE-School CANARY-District Office PINK-Home-Hospital Instruction Tutor Date Received Rev. O. Box 2360 Honolulu Hawaii 96804 Home-Hospital Instruction Hours of Instruction/Time Sheet INSTRUCTIONS 1. Acquire form complete and submit to the school the HHI Hours of Instruction/Time Sheet for each student being seviced. Acquire form complete and submit to the school the HHI Hours of Instruction/Time Sheet for each student being seviced. 2. Report each semi-monthly period separately 1-15 or 16-EOM End Of Month. 3. Hours are paid only for days that school is in session. 2. Report each semi-monthly period separately 1-15 or 16-EOM End Of Month. 3. Hours are paid only for days that school is in session. 4. Maximum hours per week is 17 hours regardless of the number of students assigned. 5. Incorrect or incomplete time sheet will be returned for correction or completion and must be re-submitted. 4. Maximum hours per week is 17 hours regardless of the number of students assigned. 5. Incorrect or incomplete time sheet will be returned for correction or completion and must be re-submitted. 6. School will ensure that hours of instruction per week are in compliance with hours of instruction as designated on Form HHI-1 Request for Home-Hospital Instruction Services.

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