WEST VIRGINIA DEPARTMENT OF TRANSPORTATION Form DOT-12 (Rev. 11/98) A C C O U N T I N G I N F O R M A T I O N DAILY WORK REPORT 1 2 3 4 Date: RECEIVING ORG. AUTH./ E.D. NO

Home Org: ACTIVITY CODE “N” OR “P” D O C U M E N T C O N T R O L ROUTE NUMBER Number: Type: BEG. MILE POST END. MILE POST MAINT: UNITS ACCOMPLISHED / WORK ORDER NO. MAINT: UNITS OF MEASURE / TYPE OF WORK

EMPLOYEE SOCIAL WAGE H O U R S R E P O R T E D NAME SECURITY CODE 1 2 3 4

TOTAL HOURS REPORTED

EQUIPMENT END. METER H O U R S O R M I L E S R E P O R T E D DESCRIPTION E.D. NO. & STATUS 1 2 3 4

TOTAL HOURS/MILES REPORTED

INVENTORY ORG. CLASSIFICATION I N V E N T O R Y U S A G E B Y U N I T S DESCRIPTION LOC. CLASS - TYPE - SUB. 1 2 3 4

TOTAL UNITS REPORTED Prepared By: Approved By: Entered Into System By:

______COMMENTS

Document workday issues, such as: unauthorized absences, work rule violations and disciplinary action, work related injuries, supplemental reporting of work hours unreported within a week, etc. The preparer must sign and date the information.