Title V Time Study

Fred Chow, Chief

Program Allocations, Integrity and Support

Maternal, Child and Adolescent Health Program

Title V Time Study

Part I Title V 30/30 Earmarking Overview

• Title V Federal Block Grant

• Definitions

• Suggested Qualifying Activities

• Audit Findings

• Corrective Action Plan

Title V Time Study

Title V Federal Block Grant:

• Title V of the Social Security Act, Section 505, requires that the State shall use:

1. At least 30 percent of Federal MCH Block Grant funds received for Preventive and Primary Care Services for Children (PPCSC); and

2. At least 30 percent of Federal MCH Block Grant funds received for services for Children with Special Health Care Needs (CSHCN).

Title V Time Study

• Definitions - Preventive and Primary Care Services for Children (PPCSC):

– Activities aimed at reducing the incidence of health problems or disease prevalence in the community, or the personal risk factors for such diseases or conditions and the provision of comprehensive personal health services that include health maintenance and preventive services, initial assessment of health problems, treatment of uncomplicated and diagnosed chronic health problems, and the overall management of an individual’s health care services for a child 1 year old through 21 years old.

Title V Time Study

• Definitions - Children with Special Health Care Needs (CSHCN):

– For Budgetary Purposes - Infants or children from birth through 21st year with special health care needs who the State has elected to provide with services funded through Title V. CSHCN are children who have health problems requiring more than routine and basic care including children with or at risk of disabilities, chronic illnesses and conditions and health-related education and behavioral problems.

Title V Time Study

• Definitions - Children with Special Health Care Needs (CSHCN):

– For Planning and Systems Development - Those children who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that generally required by children.

Title V Time Study

• Suggested Qualifying Activities for Title V 30/30 Earmarking:

– Provided is a listing of PPCSC and CSHCN activities categorized as Title V expenditures that could be reported under the requirements of 30/30 Earmarking.

Title V Time Study

• Audit Findings:

– The Bureau of State Audits (BSA) through their contractor KPMG audited California MCH Title V Block Grant program and determined that California had inadequate support for 30/30 earmarking requirements and recommended that we develop a system that will properly track and provide timely reporting of grant fund expenditures for these two categories.

Title V Time Study

• Audit Findings:

– Documenting Title V expenditures will ensure the continuation of Federal funding by demonstrating CDPH’s compliance to Federal guidelines and the effectiveness of the Department’s corrective action plan.

Title V Time Study

• Corrective Action Plan:

– MCAH performed an analysis of Title V expenditures and has identified programs where 30/30 earmarking can be documented.

– Two areas that need further documentation are Local MCAH and CDHCS’s Primary and Rural Health Care program.

Title V Time Study

• Corrective Action Plan:

– CDPH has worked closely with MCAH Action and MCAH Action Executive Committee on this audit finding and agreed to implement a simplified Time Study to document 30/30 activities.

– The Title V Time Study process will be implemented with All MCAH Agencies and All MCAH Subcontractors on July 1, 2008.

Title V Time Study

Part I Title V 30/30 Earmarking Recap

• Title V Federal Block Grant

• Definitions

• Suggested Qualifying Activities

• Audit Findings

• Corrective Action Plan

Title V Time Study

Part I Title V 30/30 Earmarking Recap

• Title V Federal Block Grant

• Definitions

• Suggested Qualifying Activities

• Audit Findings

• Corrective Action Plan

Title V Time Study

Part I Title V 30/30 Earmarking Recap

• Title V Federal Block Grant

• Definitions

• Suggested Qualifying Activities

• Audit Findings

• Corrective Action Plan

Title V Time Study

Part I Title V 30/30 Earmarking Recap

• Title V Federal Block Grant

• Definitions

• Suggested Qualifying Activities

• Audit Findings

• Corrective Action Plan

Title V Time Study

Part I Title V 30/30 Earmarking Recap

• Title V Federal Block Grant

• Definitions

• Suggested Qualifying Activities

• Audit Findings

• Corrective Action Plan

Title V Time Study

Part I Title V 30/30 Earmarking Recap

• Title V Federal Block Grant

• Definitions

• Suggested Qualifying Activities

• Audit Findings

• Corrective Action Plan

Title V Time Study

Part II Time Study Process Overview

• Who Must Complete Title V Time Studies

• Time Study Period

• How To Complete Title V Time Study Form

• Submitting Title V Time Studies

Title V Time Study

Who Must Complete Title V Time Studies:

– All MCAH Agencies and All MCAH Subcontractors that are allocated or receive Title V funding.

– All MCAH Staff who are listed on an Agency’s MCAH Budget.

– All MCAH Staff and All MCAH Subcontractors performing any of the MCAH objectives (1-4).

– Are required to complete quarterly Title V Time Studies to be in compliance with Federal regulation.

Title V Time Study

Time Study Period:

– Time studies must be performed for one full week during each fiscal quarter.

– Each agency must select the week per quarter that Title V time studies will be completed.

– Failure to document Title V activities (i.e. the timely submission of Title V time studies) may lead to the reduction of funding available to the deficient agency.

Title V Time Study

Time Study Period:

– If an agency fails to select a week to complete the required Title V time studies then MCAH will assign one.

– For example, if County "A" chooses "Week 4" to report then time studies must be completed for all relevant staff during the weeks of July 21, 2008; October 20, 2008; January 19, 2009; and April 20, 2009.

Week 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter

Week 1 6/30/2008 9/29/2008 12/29/2008 3/30/2009Week 2 7/7/2008 10/6/2008 1/5/2009 4/6/2009Week 3 7/14/2008 10/13/2008 1/12/2009 4/13/2009Week 4 7/21/2008 10/20/2008 1/19/2009 4/20/2009Week 5 7/28/2008 10/27/2008 1/26/2009 4/27/2009Week 6 8/4/2008 11/3/2008 2/2/2009 5/4/2009Week 7 8/11/2008 11/10/2008 2/9/2009 5/11/2009Week 8 8/18/2008 11/17/2008 2/16/2009 5/18/2009Week 9 8/25/2008 11/24/2008 2/23/2009 5/25/2009Week 10 9/1/2008 12/1/2008 3/2/2009 6/1/2009Week 11 9/8/2008 12/8/2008 3/9/2009 6/8/2009Week 12 9/15/2008 12/15/2008 3/16/2009 6/15/2009

FISCAL YEAR 2008-09 WEEKLY TIME STUDY CALENDAR TITLE V 30/30 EARMARKING

Title V Time Study

How To Complete The Title V Time Study Form:

– An electronic copy of the Title V Time Study (Excel) workbook is available on the MCAH web-page under Title V 30/30 Earmarking at the following link: http://www.cdph.ca.gov/services/funding/mcah/Pages/default.aspx.

– MCAH recommends that you place this workbook in a document

folder that is easily accessible or place a shortcut on your desktop for easy access on a daily basis.

Title V Time Study

How To Complete The Title V Time Study Form:

1. All the information located at the top of each weekly time study should be completed.

– Name (As listed on your Agency’s MCAH Budget),– Job Title (As listed on your Agency’s MCAH Budget),– Location (City, State Zip Code),– Agency (List Agency Name),– Subcontractor (if you are a subcontractor enter your Entity’s

Name and identify the Agency that you contract with on the line above),

– Time-Study Period (Week/Date), and– Percent FTE (Full time equivalency, should match your

budget),

Weekly Time Study for Title V 30/30 Earmarking

Name: Time Study Period (Week/Date):Job Title: Location:Agency:Subcontractor: % FTE 50.00%

Total Hrs.

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 6:307/21/08 0 #1

0 #20 #3

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 6:307/22/08 0 #1

0 #20 #3

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 6:307/23/08 0 #1

0 #20 #3

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 6:307/24/08 0 #1

0 #20 #3

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 6:307/25/08 0 #1

0 #20 #3

Day 1 Day 2 Day 3 Day 4 Day 5 TOTALS

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

Employee's Signature Date Supervisor's Signature Date

Categories

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

2. Children with Special Health Care Needs (CSHCN)

Employee Name

Position Title

City, State Zip Code

Agency Name

Week 4 / July 21, 2008

* Special Note: All AFLP, BIH, FIMR, BIH/FIMR, and SIDS Related Time Should Be Reported Only Under Category 3

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.

#DIV/0!

%

#DIV/0!

#DIV/0!

3. * Other

Use the FTE Percentage for your position,as listed on your Agency’s Fiscal Year 2007-08 MCAH Budget,

to complete your individual Title V time studies.

Title V Time Study

How To Complete The Title V Time Study Form:

2. Enter the “Date” for each of the five days time studied during the week reported (note “Date” column for each of the five days reported).

Weekly Time Study for Title V 30/30 Earmarking

Name: Time Study Period (Week/Date): Week 4 / July 21, 2008Job Title: Location:Agency:Subcontractor: % FTE 50.00%

Total Hrs.

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 6:307/21/08 0 #1

0 #20 #3

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 6:307/22/08 0 #1

0 #20 #3

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 6:307/23/08 0 #1

0 #20 #3

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 6:307/24/08 0 #1

0 #20 #3

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 6:307/25/08 0 #1

0 #20 #3

Day 1 Day 2 Day 3 Day 4 Day 5 TOTALS

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

Employee's Signature Date Supervisor's Signature Date

* Special Note: All AFLP, BIH, FIMR, BIH/FIMR, and SIDS Related Time Should Be Reported Only Under Category 3

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.

#DIV/0!

%

#DIV/0!

#DIV/0!

3. * Other

Categories

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

2. Children with Special Health Care Needs (CSHCN)

Employee Name

Position Title

City, State Zip Code

Agency Name

Title V Time Study

How To Complete The Title V Time Study Form:

3. Only three “Categories” are identified and reportable on the Title V time study:

– Category 1 (Row #1) - Preventive and Primary Care Services for Children (PPCSC),

– Category 2 (Row #2) - Children with Special Health Care Needs (CSHCN), or

– Category 3 (Row #3) - Any “Other” work.

– Note: All AFLP, BIH, FIMR, BIH/FIMR, and SIDS activities should be identified under Category 3 (Row #3).

Title V Time Study

How To Complete The Title V Time Study Form:

4. Each Title V time study includes five “Date Records” for the “Time Study Week” chosen by an Agency:

– Report Only half hour increments during each reported Date.

– Enter data Only on rows applicable to each specific Category: Row #1 (Category 1 – PPCSC), Row #2 (Category 2 – CSHCN), or Row #3 (Category 3 – Other).

– Specific Categories are identified by Number (#1, #2, or #3) on the right side of the worksheet.

– Totals by Date and Category are auto-calculated for each day (formulas within the worksheet auto-calculate these totals).

Weekly Time Study for Title V 30/30 Earmarking

Name: Time Study Period (Week/Date): Week 4 / July 21, 2008Job Title: Location:Agency:Subcontractor: % FTE 50.00%

Total Hrs.

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 6:307/21/08 0 #1

0 #2 0 #3

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 6:307/22/08 0 #1

0 #2 0 #3

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 6:307/23/08 0 #1

0 #2 0 #3

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 6:307/24/08 0 #1

0 #20 #3

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 6:307/25/08 0 #1

0 #2 0 #3

Day 1 Day 2 Day 3 Day 4 Day 5 TOTALS

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

Employee's Signature Date Supervisor's Signature Date

Employee Name

Position Title

City, State Zip Code

Agency Name

%

#DIV/0!

#DIV/0!

3. * Other

Categories

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

2. Children with Special Health Care Needs (CSHCN)

* Special Note: All AFLP, BIH, FIMR, BIH/FIMR, and SIDS Related Time Should Be Reported Only Under Category 3

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.

#DIV/0!

Title V Time Study

How To Complete The Title V Time Study Form:

5. When entering time, a number one (1) should be entered for every half hour increment.

– The number “1” will indicate that a half hour was spent in that particular category during that half hour of the day.

– Only a number “1” should be entered in any half hour time slot.

– The formulas at the end of each row (right side) will calculate and convert the half hour increments into hours.

Weekly Time Study for Title V 30/30 Earmarking

Name: Time Study Period (Week/Date): Week 4 / July 21, 2008Job Title: Location:Agency:Subcontractor: % FTE 50.00%

Total Hrs.

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 6:307/21/08 1 1 1 1 1 1 3 #1

1 1 1 1 1 1 1 1 4 #21 1 1 #3

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 6:307/22/08 1 1 1 #1

1 1 1 1 1 1 3 #21 1 1 1 1 1 1 1 4 #3

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 6:307/23/08 1 1 1 1 1 1 3 #1

1 1 1 1 1 1 1 1 4 #21 1 1 #3

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 6:307/24/08 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 8 #1

0 #20 #3

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 6:307/25/08 0 #1

1 1 1 1 1 1 1 1 4 #21 1 1 1 1 1 1 1 4 #3

Day 1 Day 2 Day 3 Day 4 Day 5 TOTALS

3 1 3 8 0 15

4 3 4 0 4 15

1 4 1 0 4 10

Employee's Signature Date Supervisor's Signature Date

* Special Note: All AFLP, BIH, FIMR, BIH/FIMR, and SIDS Related Time Should Be Reported Only Under Category 3

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.

37.50%

37.50%

25.00%3. * Other

Employee Name

Position Title

City, State Zip Code

2. Children with Special Health Care Needs (CSHCN)

%

Agency Name

Categories

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

Title V Time Study

How To Complete The Title V Time Study Form:

6. In the “Categories” box total hours for each day will be calculated, as well as, total hours for the week reported:

– These hours will be utilized to determine the percentage of time spent in each category for the week reported, and

– The percentages will be displayed to the right of the “TOTALS” column.

Weekly Time Study for Title V 30/30 Earmarking

Name: Time Study Period (Week/Date): Week 4 / July 21, 2008Job Title: Location:Agency:Subcontractor: % FTE 50.00%

Total Hrs.

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 6:307/21/08 1 1 1 1 1 1 3 #1

1 1 1 1 1 1 1 1 4 #21 1 1 #3

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 6:307/22/08 1 1 1 #1

1 1 1 1 1 1 3 #21 1 1 1 1 1 1 1 4 #3

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 6:307/23/08 1 1 1 1 1 1 3 #1

1 1 1 1 1 1 1 1 4 #21 1 1 #3

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 6:307/24/08 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 8 #1

0 #20 #3

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 6:307/25/08 0 #1

1 1 1 1 1 1 1 1 4 #21 1 1 1 1 1 1 1 4 #3

Day 1 Day 2 Day 3 Day 4 Day 5 TOTALS

3 1 3 8 0 15

4 3 4 0 4 15

1 4 1 0 4 10

Employee's Signature Date Supervisor's Signature Date

Employee Name

Position Title

City, State Zip Code

Agency Name

%

37.50%

25.00%

3. * Other

Categories

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

2. Children with Special Health Care Needs (CSHCN)

* Special Note: All AFLP, BIH, FIMR, BIH/FIMR, and SIDS Related Time Should Be Reported Only Under Category 3

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.

37.50%

Title V Time Study

How To Complete The Title V Time Study Form:

7. At the conclusion of the time study week, please print the document. The bottom of the hardcopy time study document should be finalized and submitted with:

– The employee’s signature and date.

– The signature of the employee’s supervisor verifying the “Title V 30/30 Earmarking” Time Study information is true.

Title V Time Study

Submitting Title V Time Studies:

8. When all agency staff have completed the required Title V time studies, please e-mail them (with all workbooks compiled into one email) directly to Dale Price, at: dale.price@cdph.ca.gov.

– For questions related to the Title V Time Study process please contact Dale Price, Research Analyst II, at (916) 341-6702 or by e-mail at dale.price@cdph.ca.gov.

Title V Time Study

Submitting Title V Time Studies:

9. Please package and send all signed original Title V Time Studies to the following address:

California Department of Public Health

Maternal, Child and Adolescent Health Program

PO Box 997420, MS 8305

Sacramento, CA 95899-7420

Attention: Dale Price

Title V Time Study

Submitting Title V Time Studies:

10. Finally, please keep a copy of all signed original Title V Time Studies in a separate file for archival purposes.

Title V Time Study

Part II Title V Time Study Process Recap

• Who Must Complete Title V Time Studies

• Time Study Period

• How To Complete Title V Time Study Form

• Submitting Title V Time Studies

Title V Time Study

Part II Title V Time Study Process Recap

• Who Must Complete Title V Time Studies

• Time Study Period

• How To Complete Title V Time Study Form

• Submitting Title V Time Studies

Title V Time Study

Part II Title V Time Study Process Recap

• Who Must Complete Title V Time Studies

• Time Study Period

• How To Complete Title V Time Study Form

• Submitting Title V Time Studies

Title V Time Study

Part II Title V Time Study Process Recap

• Who Must Complete Title V Time Studies

• Time Study Period

• How To Complete Title V Time Study Form

• Submitting Title V Time Studies

Title V Time Study

Part II Title V Time Study Process Recap

• Who Must Complete Title V Time Studies

• Time Study Period

• How To Complete Title V Time Study Form

• Submitting Title V Time Studies

Title V Time Study

• Please document questions and concerns, and contact Dale Price, at (916) 341-6702, or

• Fred Chow, at (916) 650-0387, with any questions related to the Title V Time Study process.

Title V Time Study

Example Training Exercise

Completing the Title V Time Study Form

• Scenario 1: Your personal FTE is 50%.

• Scenario 2: On July 21, 2008 you spent 3 hours (7:00 AM to 10:00 AM) working with a group of school nurses to improve the availability of Services For Children.

• Scenario 3: On July 21, 2008 you worked 2 hours (10:00 AM to 12:00 PM) assisting parents to obtain appropriate services for Children with Special Needs/Disabilities.

• Scenario 4: On July 21, 2008 you worked 3 hours (1:00 PM to 4:00 PM) assisting a group of adolescent teen mothers with access to the Adolescent Family Life Program.

Weekly Time Study for Title V 30/30 Earmarking

Name: Time Study Period (Week/Date):Job Title: Location:Agency:Subcontractor: % FTE 50.00%

Total Hrs.

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 6:307/21/08 1 1 1 1 1 1 3 #1

1 1 1 1 2 #21 1 1 1 1 1 3 #3

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 6:307/22/08 0 #1

0 #2 0 #3

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 6:307/23/08 0 #1

0 #2 0 #3

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 6:307/24/08 0 #1

0 #20 #3

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 6:307/25/08 0 #1

0 #2 0 #3

Day 1 Day 2 Day 3 Day 4 Day 5 TOTALS

3 0 0 0 0 3

2 0 0 0 0 2

3 0 0 0 0 3

Employee's Signature Date Supervisor's Signature Date

Agengy Name

Categories

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

2. Children with Special Health Care Needs (CSHCN)

Week 4 / July 21, 2008Employee Name

Position Title

City, State Zip Code

%

25.00%

37.50%

3. * Other

* Special Note: All AFLP, BIH, FIMR, BIH/FIMR, and SIDS Related Time Should Be Reported Only Under Category 3

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.

37.50%