Revised 2-26-15

TRANSLATOR BILLING FORM / TIMESHEET

You must complete a separate form for each student OR use a “Multiple Sessions/Students Form” for Conferences

Submit this form to: Attn: Sue VanRyswyk @ Brookside Ed. Center

Translator Name: ______Employee I.D. ______

Street ______

City, State, Zip Code ______

Signature of Translator ______Phone: ______

1-Hr. Minimum - Applies X

(See note**)

Date of Service: ______Start time: ______End time: ______Subtotal hrs: ______

Date of Service: ______Start time: ______End time: ______Subtotal hrs: ______

Date of Service: ______Start time: ______End time: ______Subtotal hrs: ______

Date of Service: ______Start time: ______End time: ______Subtotal hrs: ______

Total service hrs: ______

** Minimum of 1 hour applies when translators travel to site to provide service & have no time overlaps of other employee duties . ***Dates on this form must be in a single pay period.

Pay days are on the 5th & 20th of each month except when they fall on a weekend or holiday, then they are on the day prior to.

Timesheet deadlines are as follows: time for the 6th to 20th are due on the 20th & paid on the 5th, time for the 21st to 5th are due on the 5th & paid on the 20th.

Student’s Name ______School ______Grade: ______

Student Date of Birth: ____ / ____ / _____

Purpose/Reason for service: ______

Medical Assistance Translator per IEP Group Size:______

Initiated by:______Authorized by:______Signature of Dist. 241 Staff Signature of Building Principal

I have examined the above report and I hereby certify that to the best of my knowledge the information above is correct & is herewith approved.

This box MUST be completed by Dist. 241 staff. Put an X by correct student description:

Student Descriptions: à __ 1) Regular Ed. student – Conferences OR No IEP

à __ 2) Special Ed. student ______

Disability-code (see choices below)

If student is Spec.Ed.(has an IEP). Choose - disability code and enter on space above.

401 – Speech 402- DCD-Mild/Moderate 403-DCD-Severe /Profound 404-Physically impaired 405-Deaf & H.H. 406-Visually Impaire 407-SLD 408-EBD 409-Deaf-Blind 410-OHD 411-Autism 412-Developmentally Delayed

416-Severely Multiply Impaired

Code: ____/_____/_____/_____/_____/______x ______= $______

Hours Rate Amount

______

Authorized by: Director of Special Services

I have examined the above report and I hereby certify that to the best of my knowledge the information above is correct & is herewith approved.

Multiple Session Form
To be completed by staff initiating translator services and then submitted with request for payment when multiple students are served. See examples to help with accurate completion of this form.
School / Student Last Name / Student First Name / DOB / IEP/ Disability / Regular Ed / Begin Time / End Time / Total Service Hours
Halv. / Example / SuzieQ / 1-2-1990 / EBD/408 / ------ / 3:00pm / 3:30pm
Halv. / Example / JohnD / 4-5-1989 / ------ / Reg. / 3:30pm / 4:00pm
Translator Signature