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Child Care Center Attendance Calendar
Center: Address: Phone:
Prepared by: Date Prepared: Mo./Year:
Attendance By Days, the 1st through the 15th
Child’s Name 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 TOTAL TOTAL
1. IN Hours Days
OUT
IN
OUT
Total number of hours per day
Transportation Trips
2. IN
OUT
IN
OUT
Total number of hours per day
Transportation Trips
3. IN
OUT
IN
OUT
Total number of hours per day
Transportation Trips
4. IN
OUT
IN
OUT
Total number of hours per day
Transportation Trips
Provider’s Signature: Date:
The exact number of hours (to the quarter hour) of care provided must be indicated for each day you provided care.
Submit the original to the local office and retain the copy for your records.
Report only time that the child is actually in attendance.
DHHS
Nebraska Department of Health
and Human Services
CC-19 10/07 (56088) Page 1
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