Time Study Form Directions


On each Time Study Day, Particpating Staff members are expected to complete a Time Study Form tracking the amount of time spent on the various parallel coding activities during the day. This form may be provided by the building coordinator or found on this site and printed. The original form has 2 sides: the front side is where time is tracked; the back contains minimal instructions for how to fill out the form.

Below is a replica of the front side of the Time Study form. Those areas with a yellow background are required to be filled in when completing the form. Those areas with a blue background may be required to be filled in based on your activities during the day. Those areas with a white background should not have any information entered when completing the form.

When you move your mouse into an area that you can fill out, the border and background of that area will turn green. Clicking in that area opens a window with more information about that area.

NOTE: When entering amount in the Total Time column, the time should be coded in decimal format, using 15 minute increments:
.25 = 15 minutes   .50 = 30 minutes   .75 = 45 minutes

STAFF NAME (PRINT) JOB TITLE DATE OF TIME STUDY
(MM/DD/YY):
SCHOOL DISTRICT SCHOOL BUILDING
This time study form represents the codable activities that I performed during the "Date of Time Study" above. I did not alter my normal routine for the time study. I did not use any other form to track my time for purposes of claiming administrative match funds.
STAFF SIGNATURE DATE
I reviewed this time study form and it is complete and in compliance with Medicaid Administrative Match program guidelines.
SUPERVISOR'S SIGNATURE DATE
CODE IDENTIFIERS Total Time
Code 3 - EDUCATIONAL SCHOOL RELATED ACTIVITES - Regular assigned duties, teaching, extra-curriculr activities, IEP development, coordinating/.monitoring IEPs, discipline, evaluating curriculum or isntruction, career guiadance, & general supervision of students  
Code 4 - DIRECT MEDICAL SERVICES - Provision of care, treatment/patient follow up, counseling services, related administrative/clerical activities, and staff related travel.  

SYSTEM SUPPORT/PERSONAL ACTIVITIES
Tick Marks 15-Min Each Provide a Brief Narrative
Description For "b" codes

Total Time
Code 10 - SYSTEM SUPPORT OR PERSONAL TIME (Staff meetings, breaks, lunch, annual leave, and sick leave and Mediciad Ad Match Time Study Training.)      
PARALLEL CODING ACTIVITIES      
OUTREACH      
Code 1a - Inform students/families about general health education, wellness and preventation programs, IDEA and Child Find activities      
Code 1b - Inform students/families about Medicaid and Medicaid management care and encourage access      
FACILITATING APPLICATIONS      
Code 2a - Explain eligibility process and how to apply for programs like IDEA, TANF, and reduced lunches      
Code 2b - Explain and assist students/families with Medicaid application process, verify current status      
TRANSPORTATION      
Code 5a - Scheduling or arranging transportation not in support of Medicaid covered services (e.g. social, vocational, and/or educational programs or activities)      
Code 5b - Scheduling or arranging transportation to Medicaid covered services      
PROGRAM PLANNING, POLICY DEVELOPMENT AND INTERAGENCY COORDINATION
Code 7a - Improving coordination/delivery/planning for non-medical services (e.g. social, vocational, state mandated child health screening, policy development, for school aged children      
Code 7b - Improving coordination/delivery/planning of medical/dental/mental health/chemical dependency services to children      
TRAINING (PARTICIPATION IN OR COORDINATION)      
Code 8a - Improving delivery and referral to non-Medicaid services like IDEA/Child Find activities/programs      
Code 8b - Improving delivery and referral to Medicaid related services, early identification and referral for special health sercvices like well-child exams. Training for the time study should be recorded under Code 10.      
REFERRAL, MONITORING OF MEDICAID SERVICES      
Code 9a - Referrals for non-medical services or state education agency mandated child health screens (free Care) e.g., vision, hearing, scoliosis services      
Code 9b - Referrals, coordination, monitoring of Medicaid medical, dental, mental health, substance abuse, and family planning services      
Total paid time this day: Total time tracked this day (must equal paid time):



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