New Jersey Department of Education

Governor Phil Murphy • Lt. Governor Tahesha Way

Fiscal Indicator 5d: Sample Time and Activity Report

This sample report is for illustrative purposes only.

Enclosure A: Sample Illustrative Time and Activity Report for Title 1 Instructional Staff

20XX-20XX School Year Schedule

Employee: Jane Doe

Position: Instructional Assistant

School: Lincoln Elementary

Certification Period: 8/15/20XX to 2/15/20XX

Type of Schedule: (select one)

  • Daily
  • Weekly
  • Bi-Weekly
  • Other
Table 1: Weekly Schedule
Time Monday Tuesday Wednesday Thursday Friday
8:00–8:30 Consult with staff regarding Title 1 students Consult with staff regarding Title 1 students Consult with staff regarding Title 1 students Consult with staff regarding Title 1 students Consult with staff regarding Title 1 students
8:30–8:55 Break Break Break Break Break
9:00–9:50 English 11 English 11 English 11 English 11 English 11
9:55–10:45 9th Grade Title 1 English 9th Grade Title 1 English 9th Grade Title 1 English 9th Grade Title 1 English 9th Grade Title 1 English
10:50–11:30 Lunch Break Lunch Break Lunch Break Lunch Break Lunch Break
11:35–12:25 Title 1 Small Group Math Title 1 Small Group Math Title 1 Small Group Math Title 1 Small Group Math Title 1 Small Group Math
12:30–1:20 Prep Prep Prep Prep Prep
1:25–2:10 American Playwrights Elective American Playwrights Elective American Playwrights Elective American Playwrights Elective American Playwrights Elective
2:15–3:05 Creative Writing Elective Creative Writing Elective Creative Writing Elective Creative Writing Elective Creative Writing Elective
Table 2: Distribution of Time for Each Program or Cost Objective
Program or Cost Objective Distribution of Time
Title 1, Part A—Improving the Academic Achievement of the Disadvantaged 50%
State or Local 50%
Total 100%
Instructional Staff Certification

I certify that I performed work consistent with the attached schedule (Table 1) and as distributed in the above percentages (Table 2) during the Certification Period.

Signature: Jane Doe Employee

Date: 2/20/20XX

Supervisor Certification

I certify that I have firsthand knowledge that the above employee performed work consistent with the attached schedule (Table 1) and as distributed in the above percentages (Table 2) during the Certification Period.

Signature: Mary Smith

Date: 2/21/20XX


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