SRCR Restorative Service Hours Reflection Form

Please fully complete the following Restorative Service Hours Reflection Form in order to submit verification of your hours and complete your required reflection.

This form will also collect your site supervisor's name(s) and contact information so the SRCR Team can confirm the completion and quality of your service hours. This outcome will not be considered completed until the SRCR Team is able to directly confirm your hours with the site supervisor. Please note that if the SRCR Team does not receive all of the required information for your site, your hours may not get approved.

Your Full Name:

Your LUC Email Address:

Your LUC Student ID Number:

Your Case Number (10-digit number found at the top of your outcome letter and begins with 2023 or 2024...):

Please name the primary site at which you completed your service hours. Your primary site is the one in which you completed all or the majority of your hours. Note: If you completed your service at multiple sites, you will list any secondary sites later on this form.

Please list the primary site supervisor's name and title.

Please list the primary site supervisor's professional email and phone number. Note: Only professional/service site affiliated emails will be accepted.

How many hours did you complete at your primary service site?

Did you also complete hours at an additional secondary site(s) in order to fulfill your total assigned hours?