Form 22-8690 Time Record (Work-Study Program)

OMB Control No. 2900-0379
Respondent Burden: 5 Minutes
Expiration Date: XX/XX/XXXX

TIME RECORD (WORK-STUDY PROGRAM)
2. NAME OF STUDENT

3. FILE NUMBER (If Ch. 35, include prefix)

4. APPROVED PERIOD OF EMPLOYMENT (Month, day, year)

5. TOTAL NO. OF HOURS TO BE WORKED

1. AGREEMENT CONTROL NUMBER

A. FROM

B. TO

INSTRUCTIONS: Use Item 8, Remarks, to show changes in Items 6A and 6B. Include effective dates.
6A. PLACE OF EMPLOYMENT

6B. NAME OF SUPERVISOR

6D. TELEPHONE NO. OF SUPERVISOR
(Include Area Code)

6C. MAILING ADDRESS OF SUPERVISOR

7. SCHEDULE OF HOURS WORKED
DATE

NO. OF
HOURS

CUMULATIVE
TO DATE

INITIALS
STUDENT

SUPV.

DATE

NO. OF
HOURS

CUMULATIVE
TO DATE

INITIALS
STUDENT SUPV.

8. REMARKS

CERTIFICATION

By signing below, I certify that this schedule of hours worked is true and accurate to the best of my ability. If this work-study student was pursuing a
program of work-study services at a non-VA site under my supervision, I also certify that this individual performed only appropriate work-study duties
as outlined in the approved position description and that he or she performed these duties in a satisfactory manner.
9A. SIGNATURE OF WORK-STUDY SUPERVISOR

VA FORM
XXX XXXX

22-8690

SUPERSEDES VA FORM 22-8690, JUN 2011,
WHICH WILL NOT BE USED.

9B. DATE SIGNED

PRIVACY ACT INFORMATION: VA will not disclose information collected on this form to any source other than what has been
authorized under the Privacy Act of 1974 or Title 38, code of Federal Regulations 1.576 for routine uses as identified in the VA
system of records, 58VA21/22/28, Compensation, Pension, Education, and Vocational Rehabilitation and Employment Records VA, published in the Federal Register. An example of a routine use (e.g., VA sends educational forms or letters with a veteran's
identifying information to the veteran's school or training establishment to (1) assists the veteran in the completion of claims forms
or (2) for VA to obtain further information as may be necessary from the school for VA to properly process the veteran's education
claim or to monitor his or her progress during training. Your obligation to respond is "required to obtain or retain educational
benefits." while you do not have to respond, VA cannot pay the work-study student any further work-study benefits (payment for
hours completed in a work-study program) until we receive this information. The responses you submit are considered confidential
(38 U.S.C. 5701). Any information provided by applicant, recipients, and others may be subject to verification through computer
matching programs with other agencies.
RESPONDENT BURDEN: We need this information to determine the student's continued eligibility for work-study benefits and
the proper amount payable. (38 U.S.C. section 3485). Title 38, United States code, allows us to ask for this information. We
estimate that you will need an average of 5 minutes to review the instructions, find the information, and complete this form. VA
cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. Yu are not required to
respond to a collection of information if this number is not displayed. Valid OMB control numbers can be located on the OMB
Internet Page at www.reginfo.gov/public/do/PRAMain. If desired, you can call 1-888-GI-BILL-1 (1-888-442-4551) to get
information on where to send comments or suggestions about this form.

VA FORM 22-8690, XXX XXXX