Name
*
First Name
Last Name
Employee ID#
*
Entry Start Date
*
-
Month
-
Day
Year
Date Picker Icon
Entry End Date
*
-
Month
-
Day
Year
Date Picker Icon
Classes/Sections Taught
*
(List each class/section on a separate line)
Other Duties
(Developmental Time/Training, Meetings, etc.)
Total Hours Worked
*
CERTIFY
*
I certify that the hours entered above is true and correct.
Instructor Name
*
Enter your name as certification of this submission.
Email
*
example@example.com
Enter the message as it's shown
*
Submit
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