The University of Vermont
Community Restitution Agreement
Time Verification and Performance Evaluation
Student's Name: |
Student's Phone Number: |
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Date Referred: |
Number of Hours Required: |
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Completion Date: |
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Agency: |
Agency Phone Number: |
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Agency Address: |
Supervisor's Name: Supervisor’s Email: |
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Date(s) Worked __________________ __________________ __________________ __________________ |
Number of Hours Worked _____________ _____________ ____________
Total Hours Worked:______ |
Description of Work Accomplished:
Attitude/Performance:
Comments:
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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.