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 Phone Number:


Agency Address:


Supervisor's Name:

Supervisorís Email:


Date(s) Worked





Number of Hours Worked





Total Hours Worked:______

Description of Work Accomplished:



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 (802-656-4360), in the Center for Student Conduct, 41 South Prospect Street, Burlington, VT 05405. You can send these as a pdf to Please feel free to contact us at any time with questions or concerns.

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