SCHOOL:							{For office use only}
EMPLOYEE NAME							{empl #}
							{code # }
Payroll		Half day/	SUBSTITUTED FOR:
Week # 1	Date	Full day	Name of teacher			Local	Spec Ed	Title I	Other
Monday
Tuesday
Wednesday
Thursday
Friday
Payroll		Half day/	SUBSTITUTED FOR:
Week # 1	Date	Full day	Name of teacher			Local	Spec Ed	Title I	Other
Monday
Tuesday
Wednesday
Thursday
Friday
Totals:
I request payment of the above listed dates on which I substituted.
EMPLOYEES SIGNATURE:							DATE:
APPROVED BY:							DATE:
Number of days substituted for Teachers:
Local		-	Amount per day		$	for		Days =	$
Spec. Ed.		-	Amount per day		$	for		Days =	$
Title IA		-	Amount per day		$	for		Days =	$
Other:		-	Amount per day		$	for		Days =	$
	(specify)
Number of hours substituted for Ed Techs:
Local		-	Amount per hour		$	for		hours	$
Spec. Ed.		-	Amount per hour		$	for		hours	$
Title IA		-	Amount per hour		$	for		hours	$
Other:		-	Amount per hour		$	for		hours	$
	(specify)
Number of hours substituted for:
Cafeteria		-	Amount per hour		$	for		hours	$
Custodian		-	Amount per hour		$	for		hours	$
Secretary		-	Amount per hour		$	for		hours	$
BusDriver		-	Amount per day		$	for		days	$
Other:		-	Amount per hour		$	for		hours	$
	(specify)