Service Activities to ALL North Carolina School Districts
Activity Report

College Affiliation: Please choose one CALS-Agriculture & Life Science CED-Education CHASS-Humanities & Social Sciences DES-Design CNR-Natural Resources ENG-Engineering MGT-Management PAMS-Physical & Mathematical Sciences VET-Veterinary Medicine TEX-Textiles EXT-Extension,Engagment,Economic Dev. other

Faculty Involved:

Number of university faculty/staff involved:

Date(s) of Service (mm/dd/yyyy):

From: To:

Numbers served:

Administrators:      

Teachers:      Students:

Service measure (include service days and preparation days):

Example for 1 employee: Service days: 2 days
Preparation days: 2 x service days = 4 days
Service measure: 2 service + 4 preparation = 6 days at $300 each = $1,800 total

1. no. of days (see Instructions: include service and preparation days)

2.no. of faculty

3. multiply step 1 x step 2 x $300 = $ service measure total (see Instructions)

4. Travel: $

5. Materials: $

6. Miscellaneous: $  

 Please identify:

Add steps 3 through 6 =Total: $

Description of Activity:

District(s) served:

District 1:	School(s):
District 2:	School(s):
District 3:	School(s):
District 4:	School(s):
District 5:	School(s):
District 6:	School(s):
District 7:	School(s):
District 8:	School(s):
District 9:	School(s):
District 10:	School(s):

 

Description of activity

Location:

Service was provided in a (check all that apply):

University facility       School district facility      
Technical assistance center

Other       If "Other," please specify:

City:

County:

Person Who Prepared This Report :

Name:

Telephone Number (xxx-xxx-xxxx):

Please refer to the Instructions accompanying this form for more information.