Unofficial and not legal advice. This log supports the work-requirement check; it is not a Medicaid application, certification or submission.

Key takeaways

Record each activity date, type and distinct hours within one calendar month.
Count overlapping time once, even if two categories describe it.
A printed log is not an officially approved Medicaid form.
Exemptions, qualifying education and income alternatives must be checked separately. 1

Month, activity, and hours

Personal activity log — unofficial; not an officially approved Medicaid reporting form.

Month you are organizing

Date

Activity type

Hours

Tracked hours

None entered

Hours the state counts: Not verified / needs confirmation

Rows in the selected month
Date	Activity type	Hours	Actions

No rows for this month. Empty hours are not treated as zero.

Save dates, activity types, and hours for this log on this device only.

A shared or public device can show saved entries to the next person. This does not save exemption answers, health information, names, or identification numbers. Nothing is uploaded to Medicaidwork.app.

Personal activity log — unofficial; not an officially approved Medicaid reporting form.

Month:

Manual initials (optional): __________

How should I record monthly Medicaid activity hours?

Use one row per dated activity and keep different calendar months separate.

First confirm with the state which month and activities it is assessing. Federal law permits combinations of qualifying activities, but an organizer cannot decide that a particular volunteer task or program qualifies. 1 2

How should I record monthly Medicaid activity hours?
Date	Activity type	Short activity description	Distinct hours
__________	__________	____________________	______
__________	__________	____________________	______
__________	__________	____________________	______
__________	__________	____________________	______
__________	__________	____________________	______
Month/year: __________		Monthly total	______

Keep descriptions brief and non-sensitive, such as “paid shift” or “community program.” Do not add a Social Security number, diagnosis or Medicaid ID. Store any employer or program verification separately and provide it only through an official channel if requested.

How can I avoid double counting hours?

Count actual qualifying time once rather than adding the same period under multiple labels.

How can I avoid double counting hours?
Example	Distinct time to record
A six-hour work shift described twice	Six hours, not 12.
Two non-overlapping four-hour qualifying activities	Eight hours.
Three hours of training inside an already recorded eight-hour shift	Eight total hours, not 11.

These examples demonstrate arithmetic, not state approval of the activity. If a program uses a special conversion or education-credit rule, confirm the allowed method with the state instead of entering invented hours. 2

Unofficial illustration of one calendar month with separate activity rows. Overlapping time is not added twice, and the sheet is not an agency form. — One calendar month, separate rows. This drawing is not an officially approved Medicaid reporting form.

What does 79 versus 80 hours mean?

A total of 79 is one hour below an 80-hour activity target; a total of 80 reaches that arithmetic target.

Neither result alone establishes compliance or loss of coverage. You must still check whether the rule applies, whether the activities count, which month is assessed, and whether an exemption, income route or education route applies. Federal law does not turn an independent hours total into an automatic eligibility decision. 1

How do I print and use this log?

Print only when you want a copy, after checking the month, rows and total.

You may print this blank table from your browser and complete it privately. If a browser-based editable log is available, review the filled preview before choosing Print; do not assume values were saved after closing the page.

The printout must say: “Personal activity log — unofficial; not an officially approved Medicaid reporting form.” It does not replace a state form or submit evidence. Follow the agency’s actual request about what to report and where to send it. Nebraska and Utah publish different assessment instructions. 3 4

What if hours are not the right compliance route for me?

Use the exemption guide and state instructions instead of trying to manufacture an 80-hour total.

At least half-time qualifying education can satisfy a separate route under the federal law, and an income route may also apply. Record only relevant activity time here; this worksheet cannot decide those alternatives or general Medicaid eligibility. 1 2

Which sources support this page?

The cited documents support this page’s treatment of Track Medicaid activity hours without double counting; government sources do not endorse this website. Last checked: 2026-11-08 (CET, Europe/Stockholm).

Track Medicaid activity hours without double counting