The University of Vermont
Community Restitution Agreement
Time Verification and Performance Evaluation

Student's Name:

 

Student's Phone Number:

                                                                                                                       

Date Referred:

 

Number of Hours Required:

                                                                                                                       

Completion Date:

                                                                                                       
                                                                                                                       

Agency:

 

Agency Phone Number:

                                                                                                                       

Agency Address:

 

Supervisor's Name:

Supervisorís Email:

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Date(s) Worked

__________________

__________________

__________________

__________________

Number of Hours Worked

_____________

_____________

____________


_____________

Total Hours Worked:______

Description of Work Accomplished:

Attitude/Performance:

Comments:

__________________________________
Supervisor's Signature and Phone Number

To the student: This verification form and your reflection paper are due by the date stated on your original sanction letter. Submit the verification form and reflection paper to Community Restitution Coordinator (656-4360), in the Center for Student Ethics and Standards, 41 South Prospect Street. Please feel free to contact us at any time with questions or concerns.

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