22-8690 Time Record (Work Study Program

OMB Control No. 2900-0379
Respondent Burden: 5 minutes
Expiration Date: XX/XX/20XX

TIME RECORD (WORK STUDY PROGRAM)
1. AGREEMENT CONTROL NUMBER

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

2. NAME OF STUDENT

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

A. FROM

5. TOTAL NO. OF HOURS TO BE WORKED

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

6B. NAME OF SUPERVISOR

6C. MAILING ADDRESS OF SUPERVISOR

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

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 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, AUG 2021,
WHICH WILL NOT BE USED.

9B. DATE SIGNED
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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 Veteran Readiness and Employment Records - VA, published in the
Federal Register. An example of a routine use (e.g., VA sends educational forms 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: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information
unless it displays a currently valid OMB control number. The OMB control number for this project is 2900-0379, and it expires
XX/XX/20XX. Public reporting burden for this collection of information is estimated to average 5 minutes per respondent, per year,
including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing
and reviewing the collection of information. Send comments regarding this burden estimate and any other aspect of this collection of
information, including suggestions for reducing the burden, to VA Reports Clearance Officer at VACOPaperworkReduAct@va.gov. Please
refer to OMB Control No. 2900-0379 in any correspondence. Do not send your completed VA Form 22-8690 to this email address

VA FORM 22-8690, XXX XXXX

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