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Technical College System of Georgia: Office of Adult Education
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Time and Effort Work Activity Report Certification
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This certification is to be used by employees whose salary is charged to multiple funding sources and multiple cost objectives.
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All employees who are paid in full or in part with federal funds must keep specific documents to demonstrate the amount of time they spent on grant activities. (2 C.F.R. ยง 200.430(i)(1)) Charges to federal awards for salaries/wages must be based on records that accurately reflect the work performed. Please note, this form will automatically populate based on the hours the employee enters in the Work Activity Report Tab. If you are unable to sign the form electonically, please print the form and sign it by hand, or print it as a PDF and electornically sign the PDF form. Please be sure to save both tabs for your records.
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Employee Name:
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Reporting Period (Quarter/Month/Year):
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Work Activity Report Summary
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Hours WorkedAccounting Summary
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Funding Source
Number of Hours Worked
Overall % of TimeFunding SourceHours Worked% to Charge
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Select Funding Source0.000.0%Select Funding Source0.000.0%
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Select Funding Source0.000.0%Select Funding Source0.000.0%
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Select Funding Source0.000.0%Select Funding Source0.000.0%
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Total Hours Worked0.000.0%TOTAL0.000.0%
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Leave Taken
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Leave TypeHours TakenOverall % of Time
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Sick0.000.0%
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Annual0.000.0%
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Holiday0.000.0%
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Administrative0.000.0%
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Other0.000.0%
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Total Hours of Leave Taken0.000.0%
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Total Hours
(including hours worked and leave taken)		0.000.0%
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Signatures
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Employee Signature
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I certify that I performed work consistent with the above schedule and distribution percentages during the certification period.
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 Employee Name:
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 Date:
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Supervisor Signature
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I certify that I have firsthand knowledge that the above employee performed work consistent with the attached schedule and distribution percentages during the certification period.
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Supervisor Name:
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Date:
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