HUMAN RESOURCES ORIENTATION CHECKLIST EMPLOYEE NAME: Position:
DATE OF HIRE:
REVIEW WITH NEW EMPLOYEE S
S
S
Job Description (on intranet) A - Human Resources Orientation Checklist D - Introductory Period Acknowledgement form F - TCS Employee Handbook Acknowledgement Form H - Confidentiality Agreement Form
Employment Letter B - District Mission and Vision Statement E - Benefit Summary
K - Hepatitis B Vaccine M - Payroll Handbook P - Electronic Funds Transfer **Copy of VOIDED CHECK** S - Payroll Information Sheet T – TCS Amendment to NonSubscription, Employee Injury Plan W - Auto Insurance Coverage Form
C - School Calendar F - TCS Employee Handbook
G - HIPPA Guide & PowerPoint
G - HIPAA Acknowledgement Form
I – Computer Confidentiality Statement K - Hepatitis B Vaccine Acceptance/Declination Form N – Time Correction Form Q - Social Security Statement Form T - Receipt and Arbitration Acknowledgment U - I-9 Form
J - Bloodborne Pathogens Exposure Control Plan with Receipt L - HIV/AIDS in the Workplace
X – New Health Insurance Marketplace
X - New Health Insurance Marketplace Acknowledgement
O - Pay Schedule R - W-4 Form T - Amendment to Employee Occupational Injury Benefit Plan V – Staff Emergency Contact Form
Y - Security Release Form (S – Signature Required)
I HAVE READ AND UNDERSTAND THE PERSONNEL POLICES OF TRINITY CHARTER SCHOOL. I ALSO UNDERSTAND THAT I HAVE 31 DAYS FROM MY DATE OF HIRE TO SUBMIT MY INSURANCE FORMS TO THE HUMAN RESOURCE DEPARTMENT FOR PROCESSING.
Signature (Employee)
Date Orientation Completed
Orientation Presented by – Name Printed
Signature
BENEFIT INFORMATION TO REVIEW WITH NEW EMPLOYEE (if applicable) (all forms listed below must be completed & turned in within 31 days of hire) Z1- TRS-ActiveCare Enrollment Guide Z2 - TRS-ActiveCare Enrollment Application (paper) Z3 - Employee Benefit Guide Z4- Cafeteria Plan (Section 125) Z5 - Special Enrollee Notification Z6 - General Notice of Special Enrollment Rights and Preexisting Condition Exclusion
CENTRAL OFFICE use only Time Reporting System New Hire Reporting – Office of Attny General Mid-Tex Benefits Cooperative
HRB TRS Insurance EIF
7/14
PURPOSE The purpose of Trinity Charter Schools is to empower lifelong learners to transition successfully into the world.
MISSION Mission — a brief, clear, and compelling goal that serves to unify an organization’s efforts. An effective mission must stretch and challenge the organization, yet be achievable. It is tangible, value-driven, energizing, highly focused and moves the organization forward. It is crisp, clear, engaging — it reaches out and grabs people in the gut. People “get it” right away; it requires little or no explanation. A mission has a finish line for its achievement and is proactive. A mission should walk the boundary between the possible and impossible.
Trinity Charter Schools educates and empowers STUDENTS to transform and reclaim their lives.
SHARED VISION Shared visions emerge from personal visions. This is how they derive their energy and how they foster commitment . . . If people don’t have their own vision, all they can do is “sign up” for someone else’s. The result is compliance, never commitment. Senge, The Fifth Discipline
Specific description of what it will be like when the mission is achieved. Provokes emotion and generates excitement. Transforms the mission from words into pictures. Brings the mission to life.
TRINITY CHARTER SCHOOL VISION 2012 Students will be engaged in a transformation process that begins with behavior modification, and utilizes challenging curriculum, includes individualized and engaging instruction, provides ongoing assessment and feedback of student progress, and occurs in a safe, structured and caring environment. When the mission of TCS is implemented … 1. Information will be shared horizontally and vertically across the district to facilitate the exchange of data and best practices. 2. Teachers will be working together to analyze data and collaborate on instruction. 3. Classrooms will be clean and organized to promote a safe, learner-centered environment. 4. Students will show ownership of education and will be active learners who drive their own instruction. 5. When students leave, they will add to and continue successful habits to garner high achievement throughout their lives. In driving the vision of our shared mission the district leadership will provide structure and support for:
Continued cross-campus communication and collaboration.
Opportunities for professional growth.
Repositories and transparent access to district and campus data.
Programs and tools for curriculum and instruction.
Safe, clean and appropriate facilities and environments.
All structures, supports and initiatives will be continually evaluated to best serve the needs of our students and faculty. TCS teachers plan instructional context and learning goals based on Texas State Standards. Students at TCS are engaged in intellectually demanding tasks that require higher order and critical thinking skills. TCS Staff uses multiple sources of data from formative and summative assessments to target instruction and measure program effectiveness. The learning environment at TCS is caring, inviting, and safe. It is achieved as staff members model the way for students, for each other, and for the community.
2014-2015 School Calendar AUGUST 2014 S M T W T F 3
4
5
6
7
SEPTEMBER 2014
OCTOBER 2014
S S M T W T F
S S M T W T F
S
1
2
6
4
8
9
7
1
2
3
4
5
8
9
10 11 12 13
5
6
7
1
2
3
8
9
10 11
10 11 12 13 14 15 16 14 15 16 17 18 19 20 12 13+ 14 15 16 17 18 17 18 19 20 21 22 23 21 22 23 24 25 26 27 19 20 T 21 T 22 T 23 T 24 25 24
LEGEND
n
25n
26 27 28 29 30 28 29 30
26 27 28 29 30 31
31
Student/Staff Holiday
18-22 - Full Day all staff in-service
1 - Labor Day Holiday
6 - End of 1st Six week grading pd.
(unless it is a specified In-Service day)
25 - First day of school
15 - Progress Reports
20-23 TAKS Exit Level Assessments 27 - Progress Reports
First/Last day of classes (Unless more than 2 make-up days required)
Full Day All Staff In-service
NOVEMBER 2014 S M T W T F
DECEMBER 2014 S S M T W T F
S S M T W T F
S
1
6
(7:30 a.m. - 3:30 pm)
+ Bad Weather Make-Up Day *School in session only if needed
4
5
6
JANUARY 2015
7
8
1 2 3 4 5 7
8
9
10 11 12 13
T TAKS Assessment
6
7
3
8
9
10
3
9
10 11 12 13 14 15 14 15 16 17 18 19 20 11 12 13 14 15 16 17
16 17 18 19 20 21 22 21 22 23 24 25 26 27 18 19 20 21 22 23+ 24 25 26 27 28 29 30 31
30 17 - End of 2nd Six week grading pd.
1-5 - STAAR Assessments
1 - Winter Break Holiday
25 - Full Day all staff in-service
5 - Make-up date for STAAR English
2 - Full day all staff in-service
26-28 - Thanksgiving Holiday
12 - Progress Reports
16 - End of 3rd Six weeks grading pd.
22-31 - Winter Break Holiday
19 - MLK Day Holiday
Progress Reports
20 - Full day all staff in-service
(mailed 2 days after this date)
FEBRUARY 2015
September 15, 2014
MARCH 2015
APRIL 2015
October 27, 2014
S M T W T F
S S M T W T F
S S M T W T F
S
December 12, 2014
1
2
7
1
7
4
February 10, 2015
8
9 10 11 12 13 14
8
April 2, 2015
15 16 17 18 19 20 21 15 16 17 18 19+ 20 21 12 13 14 15 16 17 18
May 15, 2015
22 23 24 25 26 27 28 22 23 24 25 26 27 28 19 20 2122 23 24 25
3
4
5
6
2 T 3 T 4 T 5T 9
6
10 11 12 13 14
29 3031 Six Week Grading Period Ends
1 2 3 5
6
7
8
9
10 11
26 27 28 29 30
10 - Progress Reports
2-5 - TAKS Assessment
1 - STAAR Assessment
1st Six Weeks - October 6, 2014
16 - President's Day
5 - End of 4th Six weeks grading pd.
2 - STAAR Assessment Make up
2nd Six Weeks - November 17, 2014
17 - Full Day all staff in-service
9-13 - Spring Break Holiday
3 - Good Friday Holiday
30-31 - STAAR Assessments
21-22 - STAAR Assessments
3rd Six Weeks - January 16, 2015
24 - End of 5th Six weeks grading pd.
4th Six Weeks - March 5, 2015
MAY 2015
5th Six Weeks - April 24, 2015 6th Six Weeks - June 8, 2015
JUNE 2015
S M T W T F
Report cards mailed
3
4 5 6 7 8
JULY 2015
S S M T W T F
1+ 2
+
5
2
2
23 24+ 25 26 27 28 29 28 29 30 31
STAAR Assessment
4
1
1
2
3
4
5
S S M T W T F
S
6
4
1
2
3
9
October 13, 2014
7 8n 9 10+ 11+ 12 13 5 6T 7T 8T 9T 10 11 10 11 12 13 14 15 16 14 15+ 16 17 18 19 20 12 13 14 15 16 17 18
November 24, 2014
17 18 19 20 21 22 23 21 22 23 24 25 26 27 19 20 21 22 23 24 25
January 23, 2015
24 25 26 27 28 29 30 28 29 30
March 19, 2015
31
26 27 28 29 30 31
May 1, 2015
4-8 - STAAR Assessments
8 - Last Day of School
6 - STAAR & TAKS Assessment
June 15, 2015
12- STAAR Assessment
8 - End of 6th Six weeks grading pd.
7 - STAAR & TAKS Assessments
15 - STAAR Assessment Make-up
9 - Full Day all staff in-service
8- STAAR & TAKS Assessments
15 - Progress Reports
10-11 - *Bad weather make-up day
9 - TAKS Assessment
25 - Memorial Day Holiday
23- STAAR Assessment
10 - STAAR Assessments
180 Student Instructional Full Days
Trinity Charter School 8305 Cross Park Drive Austin, Texas 78754
26 - STAAR Assessment Make-up
512-459-1000 www.trinitycharterschools.org
BOARD APPROVED 7/30/2014
Revised 072014
INTRODUCTORY PERIOD (90 DAYS) New employees are in an introductory period during their first three months of employment. During this Introductory Period, an employee has an opportunity to get acquainted with his or her job, other employees and Trinity Charter School as an employer. Likewise, Trinity Charter School has an opportunity to evaluate the employee’s job performance and to assist the employee in correcting performance and work standard deficiencies. During the Introductory Period, the following applies: Vacation leave accrues from the date of hire and is available as it accrues. Accrued vacation may be used by the employee during the Introductory Period. Sick leave accrues from the date of hire but is not available to be used by the employee until the completion of the Introductory Period. Upon completion of the Introductory Period, the employee will be subject to a performance evaluation by his or her supervisor. Health Benefits shall begin from date of hire, subject to any introductory period required by particular benefit plan. The Introductory Period for any employee may be extended in the discretion of the employee’s supervisor and normally such an extension will be from one to three months. The employee will be notified in writing of any extension of the Introductory Period. In such cases, a performance evaluation will be complete at the end of the original Introductory Period and another will be completed at the end of the extension. Completion of an Introductory Period does not mean that employment with Trinity Charter School is guaranteed for any specific duration nor does it alter the at-will status of any employee. I have read and understand the Introductory Period (Employee Handbook, Section 3) and agree to its terms.
Employee’s Signature
Date
BENEFIT SUMMARY – 2014-2015
DAYS PER SCHOOL YEAR Number of Workdays
PERSONAL LEAVE
SICK
3 days
5 days
190, 195 Personal Leave 1st year
Personal Leave 2nd year
SICK
206, 210, 220
7 days
7 days
7 days
250
15 days
20 days
10 days
Administrative Positions
Please Note: The carryover date for campus staff is August 10th and the carryover date for central office staff is September 1st. Employees may carryover available unused leave, but not to exceed one school years earnings
HOLIDAYS **All TCS employees work according to a board approved calendar. New Life, Krause, Bokenkamp and Pegasus campuses will observe the following Holiday Breaks** Labor Day (September 1) Thanksgiving Break (November 26 - 28) Christmas Break (December 22 - December 31) New Year's Day (January 1-2) MLK Day (January 19) *Presidents Day (February 16) Spring Break (March 9 - March 13) *Good Friday (April 3) Memorial Day (May 25)
***Central Staff work 250 calendar days, and will observe the following Holiday Breaks** Labor Day (September 1) Thanksgiving Day, the day after Thanksgiving Day (November 27 & 28) Christmas Eve and Christmas Day (December 24 & 25) New Year's Day (January 1) MLK Day (January 19) Good Friday (April 3) Memorial Day (May 25) Independence Day (July 4)
**Employees who normally work Monday-Friday will observe Good Friday instead of Easter Sunday**
TRS-ACTIVE CARE
Group health insurance coverage is provided through TRS-ActiveCare, the statewide public school health insurance program. Employees eligible for health insurance coverage include the following: Employees who are active, contributing TRS members
Employees who are regularly scheduled to work at least 10 hours per week
The insurance plan year is from September 1st through August 31st. New hires must enroll within 31days from their hire date. New hires have 2 options for the effective date of health coverage: 1) Actively at work date 2) First of the month following the actively at work date Effective Date of Rate Changes: 09/01/2014 2014-2015 Monthly Premium Rates (Out-of-Pocket): All enrollees in TRS-ActiveCare 3 will be transitioned to TRS-ActiveCare 2 effective September 1, 2014, unless the employees select another TRS-ActiveCare plan option during the annual enrollment periods for the 2014-15 plan year.
ActiveCare 1 HD
Employee Only Employee and Spouse Employee and Child(ren) Employee and Family
2013-14 $325.00 $794.00 $572.00 $1060.00
TRS Select Plan
2014-15 $325.00 $850.00 $572.00 $1145.00
2013-14 N/A N/A N/A N/A
FirstCare
Employee Only Employee and Spouse Employee and Child(ren) Employee and Family
2013-14 $391.50 $985.06 $607.86 $994.84
2014-15 $390.14 $977.76 $618.94 $987.44
ActiveCare 2
2014-15 $450.00 $1044.00 $709.00 $1238.00
2013-14 $529.00 $1203.00 $841.00 $1323.00
2014-15 $555.00 $1287.00 $875.00 $1323.00
Scott & White 2013-14 $418.42 $945.10 $664.00 $1048.54
ActiveCare 3
2014-15 $452.80 $1020.08 $717.32 $1131.50
2013-14 $523.50 $1537.50 $996.50 $1717.50
2014-15 N/A N/A N/A N/A
Valley Baptist 2013-14 $387.06 $941.04 $607.86 $960.14
2014-15 $400.20 $969.60 $627.14 $989.22
TCS Employer Benefit Contribution per Month - $272.50 TRS-RETIREMENT PLANS All personnel employed on a regular basis for at least 10 hours per week work schedule are members of the Teacher Retirement System of Texas (TRS). Substitutes not receiving TRS service retirement benefits who work at least 90 days a year are also eligible for TRS membership and to purchase a year of creditable service. TRS provides members with an annual statement of their account showing all deposits and the total account balance for the year ending August 31, as well as an estimate of their retirement benefits. Information on the application procedures for TRS benefits is available at central office. Additional inquiries should be addressed to: Teacher Retirement System of Texas, 1000 Red River Street, Austin, TX 78701-2698, or call 800-223-8778 or 512-542-6400. TRS information is also available on the Web (www.trs.state.tx.us). PAYROLL DEDUCTION Automatic payroll deductions for the Teacher Retirement System of Texas (TRS), federal income tax and Medicare are required for all full-time employees. Temporary and part-time employees not eligible for TRS membership must have Social Security contributions deducted. The employees' share of premiums for TRS ActiveCare Health Insurance is payroll deducted. DIRECT DEPOSIT Direct deposit to a checking or saving account is available for your payroll check. For more information regarding direct deposit, please contact the payroll department at 512-706-7566. *Note: Direct deposit is only for Full Time Employees. WORKERS' COMPENSATION Trinity Charter School (TCS) does not subscribe to Workers' Compensation. TCS does provide employee injury benefits to employees who suffer a work-related illness or are injured on the job, as a non-subscriber. Please see campus Principal or your HR representative for further information. Employee Injury & Compliance Coordinator - Sheila Wadley is also available to answer any questions
[email protected] or (512)706-7542.
Acknowledgement
I acknowledge receipt of this Employee handbook. I understand that it is intended for informational purposes. This Handbook in no way insinuates or communicates an employee has entered into a contract or term of employment with Trinity Charter School. No oral or written promise has been made, and no employee of Trinity Charter School has the authority to enter into any such contract except the President and Superintendent of Trinity Charter School. All the information I will need during my employment is not included in this policy manual. It is intended to communicate general policies and benefit information currently in effect. It is my responsibility to ask questions and seek more detailed information as needed. I understand management is committed to reviewing policies, procedures, and benefits continually in order to comply with changing legal requirements and in order to maintain a competitive status in the industry. Accordingly, the contents of this policy manual are subject to review and change by management at any time and without prior notice or discussion. I understand I will receive information through various notices as well as through departmental meetings and information available on the intranet. I understand that I have the right to terminate my employment at any time and for any reason and that the Trinity Charter School has that same right.
_____________________________________ Employee Name (Please Print)
_____________________________________ Employee signature
_____________________ Date
_____________________________________ Witness
_____________________ Date
8/7/2014
Statute: 20 U.S.C. § 1232g Regulations: 34 CFR Part 99
FERPA basics Key FERPA definitions Exceptions to FERPA’s general consent rule Interactions between FERPA and other la
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FERPA is the Federal law that protects the privacy of students’ education records. FERPA applies to educational agencies and institutions that receive funds under any program administered by the Secretary of Education. § 99.1. Most private and parochial schools at the elementary and secondary levels do not receive such funds and are, therefore, not subject to FERPA.
Right to inspect and review education records. Right to seek to amend education records. Right to consent to the disclosure of information from education records, except as provided by law.
These rights under FERPA transfer to the student when he or she turns 18 years of age or enters a postsecondary institution at any age (“eligible student”).
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“Education records” are records that are – (1) (2)
Directly related to a student; and Maintained by an educational agency or institution or by a party acting for the agency or institution.
§ 99.3 “Education records”
Records on a student receiving services under Part B of the Individuals with Disabilities Education Act (IDEA) are “education records” subject to FERPA. Medical or health related records are “education records” subject to FERPA.
Exceptions to “education records” include – Records created and maintained by a law enforcement unit for a law enforcement purpose. Medical and psychological treatment records of eligible students if they are made, maintained, and used only in connection with treatment of the student and disclosed only to professionals providing the treatment.
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“Personally identifiable information” (PII) includes, but is not limited to: The student’s name; The name of the student’s parent or other family
members;
A personal identifier, such as the student’s social
security number, student number, or biometric record;
Other indirect identifiers, such as the student’s date of
birth, place of birth, and mother’s maiden name;
Other information that, alone or in combination, is
linked or linkable to a specific student that would allow a reasonable person in the school community, who does not have personal knowledge of the relevant circumstances, to identify the student with reasonable certainty; or Information requested by a person who the educational agency or institution reasonably believes knows the identity of the student to whom the education records relates. § 99.3
“Directory information” is –
Information not generally considered harmful or an invasion of privacy if disclosed. Includes, but is not limited to: name, address, telephone listing, electronic mail address date and place of birth, photographs participation in official recognized activities and sports field of study weight and height of athletes enrollment status (full-,part-time, undergraduate, graduate) degrees & awards received dates of attendance
most previous school attended grade level
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“Directory information” cannot generally include a student’s social security number of student ID number. A student’s ID number may be designated as “directory information” when the ID cannot, alone, be used to access education records. § 99.3
“Student” means any individual –
who is or has been in attendance at a school; and regarding whom the school maintains education records.
§ 99.3
§ 99.10 What rights exist for a parent or eligible student to inspect and review education records?
School must comply with request within 45 days.
Generally required to give copies only if failure to do so would effectively deny access – example would be a student or former student who does not live within commuting distance.
School may not destroy records if request for access is pending.
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§ 99.30 Under what conditions is prior consent required to disclose information?
Except for specific exceptions, a parent or eligible student shall provide a signed and dated written consent before a school may disclose education records. The consent must: Specify records that may be disclosed; State the purpose of disclosure; and Identify the party or class of parties to whom disclosure may
be made.
§ 99.31 Under what conditions is prior consent not required to disclose information? The exceptions which relate to K-12 schools and school districts are: To school officials with legitimate educational interests
(defined in the school’s annual notification).
To schools in which a student seeks or intends to enroll. To Federal, State, and local educational authorities conducting
an audit, evaluation, or enforcement of education programs.
Exceptions, cont.
To organizations conducting studies for or on behalf of the school. To parents of a dependent student. To comply with a judicial order or subpoena (reasonable effort to notify). In connection with a health or safety emergency. Directory information. To State and local officials in connection with serving the student under the juvenile justice system (established by State law).
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§ 99.31(a)(1) The disclosure is to school officials, including teachers, within the agency or institution whom the agency or institution has determined to have legitimate educational interests. Criteria for who is considered a “school official” and what is a “legitimate educational interest” must be include in annual notification of rights to parents and students currently in attendance. § 99.7
A contractor, consultant, volunteer, or other party to whom an agency or institution has outsourced institutional services or functions may be considered a “school official” under FERPA provided that the outside party – Performs an institutional service or function for which the agency or institution would otherwise use employees; Is under the direct control of the agency or institution with respect to the use and maintenance of education records; and Is subject to the requirements of § 99.33(a) governing the use and redisclosure of PII from education records.
§ 99.36 What conditions apply to disclosure of information in health or safety emergencies? Disclosure must be to appropriate parties in connection with an emergency if knowledge of information is necessary to protect the health or safety of the student or others. “Appropriate parties” may include parents of an eligible student.
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If school determines that there is an articulable and significant threat to the health or safety of a student or other individuals, it may disclose information from education records to any party whose knowledge of the information is necessary to protect the health or safety of the student or other individuals. If, based on the information available at the time, there is a rational basis for the determination, the Department will not substitute its judgment for that of the school’s in evaluating the circumstances and making its determination.
An educational agency or institution must record the following information when it discloses PII under the health or safety emergency exception in FERPA:
The articulable and significant threat to the health or safety of a student or other individuals that form the basis for the disclosure; and The parties to whom the institution disclosed the information.
§ 99.32(a)(5)
§ 99.31(a)(6) The disclosure is to organizations conducting studies for, or on behalf of, educational agencies or institutions to: Develop, validate, or administer predictive tests; Administer student aid programs; or Improve instruction.
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The school must have a written agreement with the receiving organization that: Specifies the purpose, scope and duration of the study or studies and the information to be disclosed; Requires the organization to use information only to meet the purpose of the study; Requires the organization to conduct the study in a manner that does not permit PII of parents and students by anyone other than organization representatives with legitimate interests; Requires the organization to destroy or return all PII when no longer needed for purposes of the study; and Specifies the time period in which the information must be returned or destroyed.
§ 99.33 What limitations apply to the redisclosure of information?
When disclosing information from education records to one of the parties listed under § 99.31, a school should inform the receiving party that the information may not be further disclosed, except when: The receiving party discloses information on behalf of the
school under § 99.31.
• The disclosure was made pursuant to a court order, subpoena, or in connection with litigation between the school and parent/student. • The disclosure is to the parent or eligible student. • The disclosure is to the parents of a dependent student. • The information disclosed is directory information.
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Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule
Educational institutions that provide health or medical services to students may qualify as “covered entities” under the HIPAA Privacy Rule. However, the HIPAA Privacy Rule specifically excludes from its coverage those records that are protected by FERPA. See definition of “Protected health information” in 45 CFR
45 CFR § 160.103
Joint Guidance on the Application of the Family Educational Rights and Privacy Act (FERPA) and the Health Insurance Portability and Accountability Act of 1996 (HIPAA) to Student Health Records (November 2008)
http://www2.ed.gov/policy/gen/guid/fpco/do c/ferpa-hipaa-guidance.pdf
Individuals with Disabilities Education Act (IDEA) – IDEA has additional or separate confidentiality requirements in addition to FERPA:
Part B – 34 CFR § 300.610 - § 300.627. Part C – 34 CFR § 303.402 and § 303.460.
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Federal Child Abuse Prevention and Treatment Act (CAPTA).
Provides that a State must have a State law that provides for the reporting of known or suspected instances of child abuse and neglect in order to receive a grant for child abuse prevention and treatment programs.
Protection of Pupil Rights Amendment (PPRA)
PPRA governs the administration to students of a survey, analysis, or evaluation that concerns one or more of the following eight protected areas: Political affiliations or beliefs of the student or the student’s parent; Mental or psychological problems of the student or the student’s family; Sex behavior or attitudes; Illegal, anti-social, self-incriminating, or demeaning behavior; Critical appraisals of other individuals with whom respondents have close family relationships; Legally recognized privileged or analogous relationships, such as those of lawyers, physicians, and ministers; Religious practices, affiliations, or beliefs of the student or student’s parents; or Income (other than that required by law to determine eligibility for participation in a program or for receiving financial assistance under such program).
PPRA requires that schools offer parents an opportunity to opt their children out of participating in the following activities: The administration of any survey containing one or more of the 8 areas of information listed previously. (Must contain prior written consent before a minor is required to take a survey containing one or more of the 8 areas of information that is funded in whole or in part with Department funds.) Certain non-emergency, invasive physical examination or screenings. Activities involving the collection, disclosure, or use of personal information collected from students for the purpose of marketing or for selling. 20 U.S.C. § 1232h; 34 CFR Part 98
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Q. 1. Which law – FERPA or the HIPAA Privacy Rule – governs records on health care delivered through a school-based health center when the center is organized and implemented by the school district? A. 1. Any records that a school nurse or health center maintains that are directly related to a student are considered “education records” subject to FERPA. This issue was explained in our joint guidance on FERPA and HIPAA, and reiterated in the guidance on FERPA and H1N1. If a person or entity is acting on behalf of a school subject to FERPA, such as a school nurse who is under contract with, is an employee of, or is otherwise under the direct control of the school, their student health records are “education records” subject to FERPA. This is the case regardless of whether the health care is provided to students on school grounds or offsite.
Q.2. What latitude do school nurses or school administrators have in divulging information about teen pregnancy to parents/guardians? Does the pregnant student have the right to refuse schools to notify their parents? A.2. Schools are not prohibited by FERPA from disclosing information about teen pregnancy to parents, even if the teen requests that the parents not be notified. In fact, if a parent requests to inspect and review records maintained by the school nurse on their minor child, FERPA would require the school official to provide the parents with an opportunity to review the records. Personal knowledge and observation are not governed by FERPA.
Q.3. How should conflicts among Federal and State laws, organizational policies, and professional ethical codes addressing confidentiality be resolved? A.3. FPCO routinely reviews potential conflicts with FERPA. In fact, school officials are required to report potential conflicts to FPCO within 45 days of making a determination there is such a conflict. Often times, what school officials believe are conflicts are not and we can provide advice on how to address the matter. Ultimately, however, if there is a conflict and a school wishes to continue to receive U.S. Department of Education funds, it must comply with FERPA.
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Q.4. If a school wants to contact a child’s doctor about an inaccuracy on an excuse note, do we need any special permission or may we contact the doctor directly? A.4. Under FERPA, the 2008 regulations changed the definition of “disclosure” to permit a school to contact the stated source of a record (such as a doctor’s note) for verification purposes. This is not considered a disclosure and, therefore, does not violate FERPA. In other words, FERPA permits a targeted release of records back to the stated source for verification purposes in order to provide schools with flexibility needed for this process while preserving a more general prohibition on the release of information from education records. I understand that, under the HIPAA Privacy Rule, it would depend on how the doctor’s note is addressed in order for the doctor to respond to the inquiry. If it is addressed to the school or a school official, then HIPAA would permit it to be verified as well. However, if it is a generic note, the school could demand that consent be given for the doctor to disclose the information before agreeing to the student being legitimately absent that day. In a situation in which there is no doctor’s excuse note where a school officials wishes to call a student’s doctor and discuss the student’s medication, restrictions, etc., the parent must provide written consent before the school official calls the doctor and discloses information from the student’s education records.
Q.5. May health records or other education records maintained by a school be disclosed, without consent, to the public health department? A.5. Yes, if the disclosure meets the conditions for FERPA’s health or safety emergency exception to the general consent rule. If school officials, taking into account the totality of the circumstances, determine that an articulable and significant threat exists to the health or safety of a student or other individuals, they may disclose PII from education records to appropriate officials, without consent, who need the information to protect the health or safety of the student of other individuals. Typically public health officials and trained medical personnel are among the types of appropriate parties to whom information may be disclosed under FERPA’s health or safety emergency provision.
FERPA regulations: http://www2.ed.gov/policy/gen/reg/ferpa/index.html FERPA & H1N1: http://www2.ed.gov/policy/gen/guid/fpco/pdf/ferpa-h1n1.pdf FERPA & Emergencies & Other Disasters: http://www2.ed.gov/policy/gen/guid/fpco/pdf/ferpa-disasterguidance.pdf Amendments to FERPA regulations (2008): http://www2.ed.gov/legislation/FedRegister/finrule/20084/120908a.pdf
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U.S. Department of Health and Human Services
U.S. Department of Education
Joint Guidance on the Application of the Family Educational Rights and Privacy Act (FERPA) And the Health Insurance Portability and Accountability Act of 1996 (HIPAA) To Student Health Records
November 2008
Contents I. Introduction ........................................................................................................................ 1 II. Overview of FERPA …………………………………………………………………….. 1 III. Overview of HIPAA ……………………………………………………………………... 2 IV. Where FERPA and HIPAA May Intersect …………………………………………….. 3 V. Frequently Asked Questions and Answers …………………………………………….. 3 1. Does the HIPAA Privacy Rule apply to an elementary or secondary school? 2. How does FERPA apply to health records on students maintained by elementary or secondary schools? 3. Does FERPA or HIPAA apply to elementary or secondary school student health records maintained by a health care provider that is not employed by a school? 4. Are there circumstances in which the HIPAA Privacy Rule might apply to an elementary or secondary school? 5. Where the HIPAA Privacy Rule applies, does it allow a health care provider to disclose protected health information (PHI) about a troubled teen to the parents of the teen? 6. Where the HIPAA Privacy Rule applies, does it allow a health care provider to disclose protected health information (PHI) about a student to a school nurse or physician? 7. Does FERPA or HIPAA apply to records on students at health clinics run by postsecondary institutions? 8. Under FERPA, may an eligible student inspect and review his or her “treatment records”? 9. Under FERPA, may an eligible student’s treatment records be shared with parties other than treating professionals? 10. Under what circumstances does FERPA permit an eligible student’s treatment records to be disclosed to a third-party health care provider for treatment? 11. Are all student records maintained by a health clinic run by a postsecondary institution considered “treatment records” under FERPA? 12. Does FERPA or HIPAA apply to records on students who are patients at a university hospital? 13. Where the HIPAA Privacy Rule applies, does it permit a health care provider to disclose protected health information (PHI) about a patient to law enforcement, family members, or others if the provider believes the patient presents a serious danger to self or others? 14. Does FERPA permit a postsecondary institution to disclose a student’s treatment records or education records to law enforcement, the student’s parents, or others if the institution believes the student presents a serious danger to self or others? 15. Are the health records of an individual who is both a student and an employee of a university at which the person receives health care subject to the privacy provisions of FERPA or those of HIPAA? 16. Can a postsecondary institution be a “hybrid entity” under the HIPAA Privacy Rule? VI.
Conclusion ……………………………………………………………………………… 11
I.
Introduction
The purpose of this guidance is to explain the relationship between the Family Educational Rights and Privacy Act (FERPA) and the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule, and to address apparent confusion on the part of school administrators, health care professionals, and others as to how these two laws apply to records maintained on students. It also addresses certain disclosures that are allowed without consent or authorization under both laws, especially those related to health and safety emergency situations. While this guidance seeks to answer many questions that school officials and others have had about the intersection of these federal laws, ongoing discussions may cause more issues to emerge. Contact information for submitting additional questions or suggestions for purposes of informing future guidance is provided at the end of this document. The Departments of Education and Health and Human Services are committed to a continuing dialogue with school officials and other professionals on these important matters affecting the safety and security of our nation’s schools. II.
Overview of FERPA
FERPA is a Federal law that protects the privacy of students’ “education records.” (See 20 U.S.C. § 1232g; 34 CFR Part 99). FERPA applies to educational agencies and institutions that receive funds under any program administered by the U.S. Department of Education. This includes virtually all public schools and school districts and most private and public postsecondary institutions, including medical and other professional schools. If an educational agency or institution receives funds under one or more of these programs, FERPA applies to the recipient as a whole, including each of its components, such as a department within a university. See 34 CFR § 99.1(d). Private and religious schools at the elementary and secondary level generally do not receive funds from the Department of Education and are, therefore, not subject to FERPA. Note that a private school is not made subject to FERPA just because its students and teachers receive services from a local school district or State educational agency that receives funds from the Department. The school itself must receive funds from a program administered by the Department to be subject to FERPA. For example, if a school district places a student with a disability in a private school that is acting on behalf of the school district with regard to providing services to that student, the records of that student are subject to FERPA, but not the records of the other students in the private school. In such cases, the school district remains responsible for complying with FERPA with respect to the education records of the student placed at the private school. An educational agency or institution subject to FERPA may not have a policy or practice of disclosing the education records of students, or personally identifiable information from education records, without a parent or eligible student’s written consent. See 34 CFR § 99.30. FERPA contains several exceptions to this general consent rule. See 34 CFR § 99.31. An “eligible student” is a student who is at least 18 years of age or who attends a postsecondary institution at any age. See 34 CFR §§ 99.3 and 99.5(a). Under FERPA, parents and eligible students have the right to inspect and review the student’s education records and to seek to have them amended in certain circumstances. See 34 CFR §§ 99.10 – 99.12 and §§ 99.20 – 99.22. The term “education records” is broadly defined to mean those records that are: (1) directly related to a student, and (2) maintained by an educational agency or institution or by a party acting for the 1
agency or institution. See 34 CFR § 99.3. At the elementary or secondary level, a student’s health records, including immunization records, maintained by an educational agency or institution subject to FERPA, as well as records maintained by a school nurse, are “education records” subject to FERPA. In addition, records that schools maintain on special education students, including records on services provided to students under the Individuals with Disabilities Education Act (IDEA), are “education records” under FERPA. This is because these records are (1) directly related to a student, (2) maintained by the school or a party acting for the school, and (3) not excluded from the definition of “education records.” At postsecondary institutions, medical and psychological treatment records of eligible students are excluded from the definition of “education records” if they are made, maintained, and used only in connection with treatment of the student and disclosed only to individuals providing the treatment. See 34 CFR § 99.3 “Education records.” These records are commonly called “treatment records.” An eligible student’s treatment records may be disclosed for purposes other than the student’s treatment, provided the records are disclosed under one of the exceptions to written consent under 34 CFR § 99.31(a) or with the student’s written consent under 34 CFR § 99.30. If a school discloses an eligible student’s treatment records for purposes other than treatment, the records are no longer excluded from the definition of “education records” and are subject to all other FERPA requirements. The FERPA regulations and other helpful information can be found at: http://www.ed.gov/policy/gen/guid/fpco/index.html. III.
Overview of HIPAA
Congress enacted HIPAA in 1996 to, among other things, improve the efficiency and effectiveness of the health care system through the establishment of national standards and requirements for electronic health care transactions and to protect the privacy and security of individually identifiable health information. Collectively, these are known as HIPAA’s Administrative Simplification provisions, and the U.S. Department of Health and Human Services has issued a suite of rules, including a privacy rule, to implement these provisions. Entities subject to the HIPAA Administrative Simplification Rules (see 45 CFR Parts 160, 162, and 164), known as “covered entities,” are health plans, health care clearinghouses, and health care providers that transmit health information in electronic form in connection with covered transactions. See 45 CFR § 160.103. “Health care providers” include institutional providers of health or medical services, such as hospitals, as well as non-institutional providers, such as physicians, dentists, and other practitioners, along with any other person or organization that furnishes, bills, or is paid for health care in the normal course of business. Covered transactions are those for which the U.S. Department of Health and Human Services has adopted a standard, such as health care claims submitted to a health plan. See 45 CFR § 160.103 (definitions of “health care provider” and “transaction”) and 45 CFR Part 162, Subparts K–R. The HIPAA Privacy Rule requires covered entities to protect individuals’ health records and other identifiable health information by requiring appropriate safeguards to protect privacy, and setting limits and conditions on the uses and disclosures that may be made of such information without patient authorization. The rule also gives patients rights over their health information, including rights to examine and obtain a copy of their health records, and to request corrections.
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IV.
Where FERPA and HIPAA May Intersect
When a school provides health care to students in the normal course of business, such as through its health clinic, it is also a “health care provider” as defined by HIPAA. If a school also conducts any covered transactions electronically in connection with that health care, it is then a covered entity under HIPAA. As a covered entity, the school must comply with the HIPAA Administrative Simplification Rules for Transactions and Code Sets and Identifiers with respect to its transactions. However, many schools, even those that are HIPAA covered entities, are not required to comply with the HIPAA Privacy Rule because the only health records maintained by the school are “education records” or “treatment records” of eligible students under FERPA, both of which are excluded from coverage under the HIPAA Privacy Rule. See the exception at paragraph (2)(i) and (2)(ii) to what is considered “protected health information” (PHI) at 45 CFR § 160.103. In addition, the exception for records covered by FERPA applies both to the HIPAA Privacy Rule, as well as to the HIPAA Security Rule, because the Security Rule applies to a subset of information covered by the Privacy Rule (i.e., electronic PHI). Information on the HIPAA Privacy Rule is available at: http://www.hhs.gov/ocr/hipaa/. Information on the other HIPAA Administrative Simplification Rules is available at: http://www.cms.hhs.gov/HIPAAGenInfo/. V.
Frequently Asked Questions and Answers
1.
Does the HIPAA Privacy Rule apply to an elementary or secondary school?
Generally, no. In most cases, the HIPAA Privacy Rule does not apply to an elementary or secondary school because the school either: (1) is not a HIPAA covered entity or (2) is a HIPAA covered entity but maintains health information only on students in records that are by definition “education records” under FERPA and, therefore, is not subject to the HIPAA Privacy Rule. •
The school is not a HIPAA covered entity. The HIPAA Privacy Rule only applies to health plans, health care clearinghouses, and those health care providers that transmit health information electronically in connection with certain administrative and financial transactions (“covered transactions”). See 45 CFR § 160.102. Covered transactions are those for which the U.S. Department of Health and Human Services has adopted a standard, such as health care claims submitted to a health plan. See the definition of “transaction” at 45 CFR § 160.103 and 45 CFR Part 162, Subparts K–R. Thus, even though a school employs school nurses, physicians, psychologists, or other health care providers, the school is not generally a HIPAA covered entity because the providers do not engage in any of the covered transactions, such as billing a health plan electronically for their services. It is expected that most elementary and secondary schools fall into this category.
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The school is a HIPAA covered entity but does not have “protected health information.” Where a school does employ a health care provider that conducts one or more covered transactions electronically, such as electronically transmitting health care claims to a health plan for payment, the school is a HIPAA covered entity and must comply with the HIPAA Transactions and Code Sets and Identifier Rules with respect to such transactions. However, even in this case, many schools would not be required to comply with the HIPAA Privacy Rule because the school maintains health information only in student health records that are “education records” under FERPA and, thus, not “protected health information” under
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HIPAA. Because student health information in education records is protected by FERPA, the HIPAA Privacy Rule excludes such information from its coverage. See the exception at paragraph (2)(i) to the definition of “protected health information” in the HIPAA Privacy Rule at 45 CFR § 160.103. For example, if a public high school employs a health care provider that bills Medicaid electronically for services provided to a student under the IDEA, the school is a HIPAA covered entity and would be subject to the HIPAA requirements concerning transactions. However, if the school’s provider maintains health information only in what are education records under FERPA, the school is not required to comply with the HIPAA Privacy Rule. Rather, the school would have to comply with FERPA’s privacy requirements with respect to its education records, including the requirement to obtain parental consent (34 CFR § 99.30) in order to disclose to Medicaid billing information about a service provided to a student. 2.
How does FERPA apply to health records on students maintained by elementary or secondary schools?
At the elementary or secondary school level, students’ immunization and other health records that are maintained by a school district or individual school, including a school-operated health clinic, that receives funds under any program administered by the U.S. Department of Education are “education records” subject to FERPA, including health and medical records maintained by a school nurse who is employed by or under contract with a school or school district. Some schools may receive a grant from a foundation or government agency to hire a nurse. Notwithstanding the source of the funding, if the nurse is hired as a school official (or contractor), the records maintained by the nurse or clinic are “education records” subject to FERPA. Parents have a right under FERPA to inspect and review these health and medical records because they are “education records” under FERPA. See 34 CFR §§ 99.10 – 99.12. In addition, these records may not be shared with third parties without written parental consent unless the disclosure meets one of the exceptions to FERPA’s general consent requirement. For instance, one of these exceptions allows schools to disclose a student’s health and medical information and other “education records” to teachers and other school officials, without written consent, if these school officials have “legitimate educational interests” in accordance with school policy. See 34 CFR § 99.31(a)(1). Another exception permits the disclosure of education records, without consent, to appropriate parties in connection with an emergency, if knowledge of the information is necessary to protect the health or safety of the student or other individuals. See 34 CFR §§ 99.31(a)(10) and 99.36. 3.
Does FERPA or HIPAA apply to elementary or secondary school student health records maintained by a health care provider that is not employed by a school?
If a person or entity acting on behalf of a school subject to FERPA, such as a school nurse that provides services to students under contract with or otherwise under the direct control of the school, maintains student health records, these records are education records under FERPA, just as they would be if the school maintained the records directly. This is the case regardless of whether the health care is provided to students on school grounds or off-site. As education records, the information is protected under FERPA and not HIPAA.
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Some outside parties provide services directly to students and are not employed by, under contract to, or otherwise acting on behalf of the school. In these circumstances, these records are not “education records” subject to FERPA, even if the services are provided on school grounds, because the party creating and maintaining the records is not acting on behalf of the school. For example, the records created by a public health nurse who provides immunization or other health services to students on school grounds or otherwise in connection with school activities but who is not acting on behalf of the school would not be “education records” under FERPA. In such situations, a school that wishes to disclose to this outside party health care provider any personally identifiable information from education records would have to comply with FERPA and obtain parental consent. See 34 CFR § 99.30. With respect to HIPAA, even where student health records maintained by a health care provider are not education records protected by FERPA, the HIPAA Privacy Rule would apply to such records only if the provider conducts one or more of the HIPAA transactions electronically, e.g., billing a health plan electronically for his or her services, making the provider a HIPAA covered entity. 4.
Are there circumstances in which the HIPAA Privacy Rule might apply to an elementary or secondary school?
There are some circumstances in which an elementary or secondary school would be subject to the HIPAA Privacy Rule, such as where the school is a HIPAA covered entity and is not subject to FERPA. As explained previously, most private schools at the elementary and secondary school levels typically do not receive funding from the U.S. Department of Education and, therefore, are not subject to FERPA. A school that is not subject to FERPA and is a HIPAA covered entity must comply with the HIPAA Privacy Rule with respect to any individually identifiable health information it has about students and others to whom it provides health care. For example, if a private elementary school that is not subject to FERPA employs a physician who bills a health plan electronically for the care provided to students (making the school a HIPAA covered entity), the school is required to comply with the HIPAA Privacy Rule with respect to the individually identifiable health information of its patients. The only exception would be where the school, despite not being subject to FERPA, has education records on one or more students to whom it provides services on behalf of a school or school district that is subject to FERPA. In this exceptional case, the education records of only those publiclyplaced students held by the private school would be subject to FERPA, while the remaining student health records would be subject to the HIPAA Privacy Rule. 5.
Where the HIPAA Privacy Rule applies, does it allow a health care provider to disclose protected health information (PHI) about a troubled teen to the parents of the teen?
In most cases, yes. If the teen is a minor, the HIPAA Privacy Rule generally allows a covered entity to disclose PHI about the child to the child’s parent, as the minor child’s personal representative, when the disclosure is not inconsistent with state or other law. For more detailed information, see 45 CFR § 164.502(g) and the fact sheet regarding personal representatives at: http://www.hhs.gov/ocr/hipaa/guidelines/personalrepresentatives.pdf. In some cases, such as when a minor may receive treatment without a parent’s consent under applicable law, the parents are not treated as the minor’s personal representative. See 45 CFR § 164.502(g)(3). In such cases where 5
the parent is not the personal representative of the teen, other HIPAA Privacy Rule provisions may allow the disclosure of PHI about the teen to the parent. For example, if a provider believes the teen presents a serious danger to self or others, the HIPAA Privacy Rule permits a covered entity to disclose PHI to a parent or other person(s) if the covered entity has a good faith belief that: (1) the disclosure is necessary to prevent or lessen the threat and (2) the parent or other person(s) is reasonably able to prevent or lessen the threat. The disclosure also must be consistent with applicable law and standards of ethical conduct. See 45 CFR § 164.512(j)(1)(i). In addition, the Privacy Rule permits covered entities to share information that is directly relevant to the involvement of a family member in the patient’s health care or payment for care if, when given the opportunity, the patient does not object to the disclosure. Even when the patient is not present or it is impracticable, because of emergency circumstances or the patient’s incapacity, for the covered entity to ask the patient about discussing his or her care or payment with a family member, a covered entity may share this information with the family member when, in exercising professional judgment, it determines that doing so would be in the best interest of the patient. See 45 CFR § 164.510(b). 6.
Where the HIPAA Privacy Rule applies, does it allow a health care provider to disclose protected health information (PHI) about a student to a school nurse or physician?
Yes. The HIPAA Privacy Rule allows covered health care providers to disclose PHI about students to school nurses, physicians, or other health care providers for treatment purposes, without the authorization of the student or student’s parent. For example, a student’s primary care physician may discuss the student’s medication and other health care needs with a school nurse who will administer the student’s medication and provide care to the student while the student is at school. 7.
Does FERPA or HIPAA apply to records on students at health clinics run by postsecondary institutions?
FERPA applies to most public and private postsecondary institutions and, thus, to the records on students at the campus health clinics of such institutions. These records will be either education records or treatment records under FERPA, both of which are excluded from coverage under the HIPAA Privacy Rule, even if the school is a HIPAA covered entity. See the exceptions at paragraphs (2)(i) and (2)(ii) to the definition of “protected health information” at 45 CFR § 160.103. The term “education records” is broadly defined under FERPA to mean those records that are: (1) directly related to a student and (2) maintained by an educational agency or institution or by a party acting for the agency or institution. See 34 CFR § 99.3, “Education records.” “Treatment records” under FERPA, as they are commonly called, are: records on a student who is eighteen years of age or older, or is attending an institution of postsecondary education, which are made or maintained by a physician, psychiatrist, psychologist, or other recognized professional or paraprofessional acting in his professional or paraprofessional capacity, or assisting in that capacity, and which are made, maintained, or used only in connection with the provision of treatment to the student, and are not available to anyone other than persons providing such treatment, except that such records
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can be personally reviewed by a physician or other appropriate professional of the student’s choice. See 20 U.S.C. § 1232g(a)(4)(B)(iv); 34 CFR § 99.3, “Education records.” For example, treatment records would include health or medical records that a university psychologist maintains only in connection with the provision of treatment to an eligible student, and health or medical records that the campus health center or clinic maintains only in connection with the provision of treatment to an eligible student. (Treatment records also would include health or medical records on an eligible student in high school if the records otherwise meet the above definition.) “Treatment records” are excluded from the definition of “education records” under FERPA. However, it is important to note, that a school may disclose an eligible student’s treatment records for purposes other than the student’s treatment provided that the records are disclosed under one of the exceptions to written consent under 34 CFR § 99.31(a) or with the student’s written consent under 34 CFR § 99.30. If a school discloses an eligible student’s treatment records for purposes other than treatment, the treatment records are no longer excluded from the definition of “education records” and are subject to all other FERPA requirements, including the right of the eligible student to inspect and review the records. While the health records of students at postsecondary institutions may be subject to FERPA, if the institution is a HIPAA covered entity and provides health care to nonstudents, the individually identifiable health information of the clinic’s nonstudent patients is subject to the HIPAA Privacy Rule. Thus, for example, postsecondary institutions that are subject to both HIPAA and FERPA and that operate clinics open to staff, or the public, or both (including family members of students) are required to comply with FERPA with respect to the health records of their student patients, and with the HIPAA Privacy Rule with respect to the health records of their nonstudent patients. 8.
Under FERPA, may an eligible student inspect and review his or her “treatment records”?
Under FERPA, treatment records, by definition, are not available to anyone other than professionals providing treatment to the student, or to physicians or other appropriate professionals of the student’s choice. However, this does not prevent an educational institution from allowing a student to inspect and review such records. If the institution chooses to do so, though, such records are no longer excluded from the definition of “education records” and are subject to all other FERPA requirements. 9.
Under FERPA, may an eligible student’s treatment records be shared with parties other than treating professionals?
As explained previously, treatment records, by definition, are not available to anyone other than professionals providing treatment to the student, or to physicians or other appropriate professionals of the student’s choice. However, this does not prevent an educational institution from using or disclosing these records for other purposes or with other parties. If the institution chooses to do so, a disclosure may be made to any party with a prior written consent from the eligible student (see 34 CFR § 99.30) or under any of the disclosures permitted without consent in 34 CFR § 99.31 of FERPA.
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For example, a university physician treating an eligible student might determine that treatment records should be disclosed to the student’s parents. This disclosure may be made if the eligible student is claimed as a dependent for federal income tax purposes (see 34 CFR § 99.31(a)(8)). If the eligible student is not claimed as a dependent, the disclosure may be made to parents, as well as other appropriate parties, if the disclosure is in connection with a health or safety emergency. See 34 CFR §§ 99.31(a)(10) and 99.36. Once the records are disclosed under one of the exceptions to FERPA’s general consent requirement, the treatment records are no longer excluded from the definition of “education records” and are subject to all other FERPA requirements as “education records” under FERPA. 10.
Under what circumstances does FERPA permit an eligible student’s treatment records to be disclosed to a third-party health care provider for treatment?
An eligible student’s treatment records may be shared with health care professionals who are providing treatment to the student, including health care professionals who are not part of or not acting on behalf of the educational institution (i.e., third-party health care provider), as long as the information is being disclosed only for the purpose of providing treatment to the student. In addition, an eligible student’s treatment records may be disclosed to a third-party health care provider when the student has requested that his or her records be “reviewed by a physician or other appropriate professional of the student’s choice.” See 20 U.S.C. § 1232g(a)(4)(B)(iv). In either of these situations, if the treatment records are disclosed to a third-party health care provider that is a HIPAA covered entity, the records would become subject to the HIPAA Privacy Rule. The records at the educational institution continue to be treatment records under FERPA, so long as the records are only disclosed by the institution for treatment purposes to a health care provider or to the student’s physician or other appropriate professional requested by the student. If the disclosure is for purposes other than treatment, an eligible student’s treatment record only may be disclosed to a third party as an “education record,” that is, with the prior written consent of the eligible student or if one of the exceptions to FERPA’s general consent requirement is met. See 34 CFR § 99.31. For example, if a university is served with a court order requiring the disclosure of the mental health records of a student maintained as treatment records at the campus clinic, the university may disclose the records to comply with the court order in accordance with the provisions of § 99.31(a)(9) of the FERPA regulations. However, the mental health records that the university disclosed for non-treatment purposes are no longer excluded from the definition of “education records” and are subject to all other FERPA requirements as “education records” under FERPA. 11.
Are all student records maintained by a health clinic run by a postsecondary institution considered “treatment records” under FERPA?
Not all records on eligible students that are maintained by a college- or university-run health clinic are treatment records under FERPA because many such records are not made, maintained, or used only in connection with the treatment of a student. For example, billing records that a college- or university-run health clinic maintains on a student are “education records” under FERPA, the disclosure of which would require prior written consent from the eligible student unless an exception applies. See 34 CFR § 99.30. In addition, records relating to treatment that are shared with persons other than professionals providing treatment to the student are “education records” under FERPA. Thus, to the extent a health clinic has shared a student’s treatment information with 8
persons and for purposes other than for treatment, such information is an “education record,” not a treatment record under FERPA. 12.
Does FERPA or HIPAA apply to records on students who are patients at a university hospital?
Patient records maintained by a hospital affiliated with a university that is subject to FERPA are not typically “education records” or “treatment records” under FERPA because university hospitals generally do not provide health care services to students on behalf of the educational institution. Rather, these hospitals provide such services without regard to the person’s status as a student and not on behalf of a university. Thus, assuming the hospital is a HIPAA covered entity, these records are subject to all of the HIPAA rules, including the HIPAA Privacy Rule. However, in a situation where a hospital does run the student health clinic on behalf of a university, the clinic records on students would be subject to FERPA, either as “education records” or “treatment records,” and not subject to the HIPAA Privacy Rule. 13.
Where the HIPAA Privacy Rule applies, does it permit a health care provider to disclose protected health information (PHI) about a patient to law enforcement, family members, or others if the provider believes the patient presents a serious danger to self or others?
The HIPAA Privacy Rule permits a covered entity to disclose PHI, including psychotherapy notes, when the covered entity has a good faith belief that the disclosure: (1) is necessary to prevent or lessen a serious and imminent threat to the health or safety of the patient or others and (2) is to a person(s) reasonably able to prevent or lessen the threat. This may include, depending on the circumstances, disclosure to law enforcement, family members, the target of the threat, or others who the covered entity has a good faith belief can mitigate the threat. The disclosure also must be consistent with applicable law and standards of ethical conduct. See 45 CFR § 164.512(j)(1)(i). For example, consistent with other law and ethical standards, a mental health provider whose teenage patient has made a credible threat to inflict serious and imminent bodily harm on one or more fellow students may alert law enforcement, a parent or other family member, school administrators or campus police, or others the provider believes may be able to prevent or lessen the chance of harm. In such cases, the covered entity is presumed to have acted in good faith where its belief is based upon the covered entity’s actual knowledge (i.e., based on the covered entity’s own interaction with the patient) or in reliance on a credible representation by a person with apparent knowledge or authority (i.e., based on a credible report from a family member or other person). See 45 CFR § 164.512(j)(4). For threats or concerns that do not rise to the level of “serious and imminent,” other HIPAA Privacy Rule provisions may apply to permit the disclosure of PHI. For example, covered entities generally may disclose PHI about a minor child to the minor’s personal representative (e.g., a parent or legal guardian), consistent with state or other laws. See 45 CFR § 164.502(b). 14.
Does FERPA permit a postsecondary institution to disclose a student’s treatment records or education records to law enforcement, the student’s parents, or others if the institution believes the student presents a serious danger to self or others?
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An eligible student’s education records and treatment records (which are considered education records if used or made available for any purpose other than the eligible student’s treatment) may be disclosed, without consent, if the disclosure meets one of the exceptions to FERPA’s general consent rule. See 34 CFR § 99.31. One of the permitted disclosures is to appropriate parties, which may include law enforcement or parents of a student, in connection with an emergency if knowledge of the information is necessary to protect the health or safety of the student or other individuals. See 34 CFR §§ 99.31(a)(10) and 99.36. There are other exceptions that apply to disclosing information to parents of eligible students that are discussed on the “Safe Schools & FERPA” Web page, as well as other information that should be helpful to school officials, at: http://www.ed.gov/policy/gen/guid/fpco/ferpa/safeschools/index.html/. 15.
Are the health records of an individual who is both a student and an employee of a university at which the person receives health care subject to the privacy provisions of FERPA or those of HIPAA?
The individual’s health records would be considered “education records” protected under FERPA and, thus, excluded from coverage under the HIPAA Privacy Rule. FERPA defines “education records” as records that are directly related to a student and maintained by an educational agency or institution or by a party acting for the agency or institution. 34 CFR § 99.3 (“education records”). While FERPA excludes from this definition certain records relating to employees of the educational institution, to fall within this exclusion, such records must, among other things, relate exclusively to the individual in his or her capacity as an employee, such as records that were created in connection with health services that are available only to employees. Thus, the health or medical records that are maintained by a university as part of its provision of health care to a student who is also an employee of a university are covered by FERPA and not the HIPAA Privacy Rule. 16.
Can a postsecondary institution be a “hybrid entity” under the HIPAA Privacy Rule?
Yes. A postsecondary institution that is a HIPAA covered entity may have health information to which the Privacy Rule may apply not only in the health records of nonstudents in the health clinic, but also in records maintained by other components of the institution that are not education records or treatment records under FERPA, such as in a law enforcement unit or research department. In such cases, the institution, as a HIPAA covered entity, has the option of becoming a “hybrid entity” and, thus, having the HIPAA Privacy Rule apply only to its health care unit. The school can achieve hybrid entity status by designating the health unit as its “health care component.” As a hybrid entity, any individually identifiable health information maintained by other components of the university (i.e., outside of the health care component), such as a law enforcement unit, or a research department, would not be subject to the HIPAA Privacy Rule, notwithstanding that these components of the institution might maintain records that are not “education records” or treatment records under FERPA. To become a hybrid entity, the covered entity must designate and include in its health care component all components that would meet the definition of a covered entity if those components were separate legal entities. (A covered entity may have more than one health care component.) However, the hybrid entity is not permitted to include in its health care component other types of components that do not perform the covered functions of the covered entity or components that do 10
not perform support activities for the components performing covered functions. That is, components that do not perform health plan, health care provider, or health care clearinghouse functions and components that do not perform activities in support of these functions (as would a business associate of a separate legal entity) may not be included in a health care component. Within the hybrid entity, most of the HIPAA Privacy Rule requirements apply only to the health care component, although the hybrid entity retains certain oversight, compliance, and enforcement obligations. See 45 CFR § 164.105 of the Privacy Rule for more information. VI.
Conclusion
The HIPAA Privacy Rule specifically excludes from its coverage those records that are protected by FERPA. When making determinations as to whether personally identifiable information from student health records maintained by the educational agency or institution may be disclosed, school officials at institutions subject to FERPA should refer to FERPA and its requirements. While the educational agency or institution has the responsibility to make the initial, case-by-case determination of whether a disclosure meets the requirements of FERPA, the Department of Education’s Family Policy Compliance Office is available to offer technical assistance to school officials in making such determinations. For quick, informal responses to routine questions about FERPA, school officials may e-mail the Department at
[email protected]. For more formal technical assistance on the information provided in this guidance in particular or FERPA in general, please contact the Family Policy Compliance Office at the following address: Family Policy Compliance Office U.S. Department of Education 400 Maryland Ave. S.W. Washington, D.C. 20202-8520 You may also find additional information and guidance on the Department’s Web site at: http://www.ed.gov/policy/gen/guid/fpco/index.html. For more information on the HIPAA Privacy Rule, please visit the Department of Health and Human Services’ HIPAA Privacy Rule Web site at: http://www.hhs.gov/ocr/hipaa/. The Web site offers a wide range of helpful information about the HIPAA Privacy Rule, including the full text of the Privacy Rule, a HIPAA Privacy Rule summary, over 200 frequently asked questions, and both consumer and covered entity fact sheets. In addition, if you would like to submit additional questions not covered by this guidance document or suggestions for purposes of informing future guidance, please send an e-mail to
[email protected] and
[email protected].
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From: Administration To: All New Hires Ref: HIPPA Privacy Attached are training materials concerning privacy and the Health Insurance Portability and Accountability Act (HIPAA). Health information, medical or insurance related is confidential and protected by Federal Law, the HIPAA Act. Our clients’ information, as well as your own personal information, is only to be used to provide health care and payment of health care operations. Please read the attached HIPAA training materials for an explanation of how you can protect the privacy of health information.
I, _______________________________, have read the training materials and understand (Print name) the agency’s HIPAA rules and regulations.
Signature _________________________________
Date_____________
8305 Cross Park Dr. Austin, TX 78754 512-459-1000, FAX 877-705-2447
TRINITY CHARTER SCHOOL CONFIDENTIALITY AGREEMENT Employees, volunteers, interns and/or subcontractors who work in or with programs and facilities operated by Trinity Charter School (TCS) need and will have access to personal information about clients/students/families. Federal and state laws require that TCS carefully guard all private information. By signing this agreement, you agree to abide by the following conditions and requirements: I will only use private information about clients/students/families as needed to fulfill my assigned job or service. I agree to access and use only the minimum amount of information necessary. I will not seek access to information I do not need. Health information, medical or insurance related is confidential and protected by Federal Law, the HIPAA Act. Our client/student/family information, as well as your own personal information, is confidential and should not be discussed with anyone. I will not disclose this information to others, especially those outside the school. I will not discuss private information unless it is required to conduct my job task. I will not gossip about or inappropriately discuss client/student/family information. I will not sell any client/student/family information. I will not remove client/student/family information in any form from a school. I understand that failure to meet the above standards may constitute grounds for discharge or cancellation of subcontract. I have received a signed copy of this agreement.
__________________________ ________________________ Employee/Volunteer/Sub-contractor Date
__________________________________ Program or Location
__________________________________ TCS Staff Witness
CONFIDENTIALITY STATEMENT FOR COMPUTER PASSWORDS
I have read, understand and will comply with the provisions of Personnel Policy 4.29 – Computer & Information Systems management and 4.36 – Employee Acceptable use. Regarding the use of computer passwords:
I will not use a password, access a file, or retrieve any stored information, unless authorized to do so.
I will not disclose my password to any other person.
I will not sign another person in under my password and let them have access to my computer.
______________________________ Employee’s Signature
_____________ Date
08/14
Trinity Charter School Bloodborne Pathogens Exposure Control Plan Training Record Upon completion of this Trinity Charter School training program, the employee will understand:
Chapter 96. Bloodborne Pathogen Control; OSHA Bloodborne Pathogen Final Rule; A general explanation on of the epidemiology and symptoms of bloodborne disease An explanation of the modes of transmission of bloodborne pathogens An explanation of the Trinity Charter School Exposure Control Plan and where to obtain a copy
An explanation of procedures which might cause exposure to blood or other potentially infectious materials An explanation of the control methods, which are used at the facility to control exposure to blood or other potential infectious materials. An explanation of personal protective equipment available at the facility An explanation of Trinity Charter School hepatitis B vaccine program, information on the HBV vaccine, including its efficacy, safety, and the benefits of being vaccinated. An explanation of procedures to follow in an emergency involving blood or other potentially infectious materials. An explanation of procedures to follow in an exposure incident occurs. An explanation of post exposure evaluation and follow up. An explanation of signs and labels used at the facility. An opportunity to ask question of the individual conducting the training. I have participated in the Trinity Charter School training program on Bloodborne Pathogens and have met the above state objectives. Employee Signature _____________________________________________ Date: __________________ One copy to employee One signed copy to school district HR Office
Bloodborne Pathogens Exposure Control Plan Copies of Plan
Nurse’s Office Principal’s Office Central Office, Risk Management Coordinator
Work Area Practices
No eating, drinking, applying cosmetics, or handling contact lenses Food or beverages are not to be kept in the refrigerators, on shelves or counter tops where blood or OPIM might be present Wear gloves when it is reasonably anticipated that you will have contact with blood or OPIM Wash your hands immediately after the removal of gloves Employees exposed to human bites should wear long sleeved clothing Removing all garments that are penetrated with blood immediately. These garments are to be placed in a plastic bag. Mouth pipetting/suctioning of blood is prohibited. Always conduct procedures in a manner to minimize splashing, spraying, splattering.
What do I do
If I see a blood spill in the hall or on the playground? Do not touch. Secure the area. Contact the custodian. If I see broken glass or a needle in the trashcan? Do not touch. Secure the area. Contact the custodian. If a student in my class gets a bloody nose? Hand the student tissues, Instruct them to hold the tissues to their nose and pinch. In the case of severe injury involving blood….. Use clothing, towels, or anything else to create a barrier in order to place pressure on the wound.
One copy to employee One signed copy to school district HR Office
HEPATITIS B VACCINE ACCEPTANCE/DECLINATION FORM ACCEPTANCE: I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of being infected by bloodborne pathogens, including Human Immunodeficiency Virus (HIV) and Hepatitis B Virus (HBV). This is to certify that I have been informed about the symptoms and the hazards associated with these viruses, as well as the modes of transmission of bloodborne pathogens. I have been given the opportunity to be vaccinated with Hepatitis B vaccine, at no charge to myself. In addition, I have received information regarding the Hepatitis B (HBV) vaccine. Based on the training I have received, I am making an informed decision to accept the Hepatitis B (HBV) vaccine. DECLINATION: I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring Hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with hepatitis B vaccine, at no charge to myself. However, I decline Hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring Hepatitis B, a serious disease. If in the future I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with Hepatitis B vaccine, I can receive the vaccination series at no charge to me. CHECK ONE: _____ I ACCEPT Hepatitis B vaccine inoculation: OR _____ I DECLINE Hepatitis B vaccine inoculation
________________________________ Employee’s Name ________________________________ Employee’s Signature
____________________ Date
________________________________ Witness Signature
____________________ Date
VACCINE INFORMATION STATEMENT
Hepatitis B Vaccine
Many Vaccine Information Statements are available in Spanish and other languages. See www.immunize.org/vis.
Hojas de Informacián Sobre Vacunas están disponibles en Español y en muchos otros idiomas. Visite http://www.immunize.org/vis
What You Need to Know 1
What is hepatitis B?
Hepatitis B is a serious infection that affects the liver. It is caused by the hepatitis B virus. • In 2009, about 38,000 people became infected with hepatitis B. • Each year about 2,000 to 4,000 people die in the United States from cirrhosis or liver cancer caused by hepatitis B. Hepatitis B can cause: Acute (short-term) illness. This can lead to: • diarrhea and vomiting • loss of appetite • jaundice (yellow skin or eyes) • tiredness • pain in muscles, joints, and stomach Acute illness, with symptoms, is more common among adults. Children who become infected usually do not have symptoms. Chronic (long-term) infection. Some people go on to develop chronic hepatitis B infection. Most of them do not have symptoms, but the infection is still very serious, and can lead to: • liver damage (cirrhosis) • liver cancer • death
Chronic infection is more common among infants and children than among adults. People who are chronically infected can spread hepatitis B virus to others, even if they don’t look or feel sick. Up to 1.4 million people in the United States may have chronic hepatitis B infection.
Hepatitis B virus is easily spread through contact with the blood or other body fluids of an infected person. People can also be infected from contact with a contaminated object, where the virus can live for up to 7 days. • A baby whose mother is infected can be infected at birth; • Children, adolescents, and adults can become infected by: - contact with blood and body fluids through breaks in the skin such as bites, cuts, or sores; - contact with objects that have blood or body fluids on them such as toothbrushes, razors, or monitoring and treatment devices for diabetes; - having unprotected sex with an infected person;
- sharing needles when injecting drugs;
- being stuck with a used needle.
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Hepatitis B vaccine: Why get vaccinated?
Hepatitis B vaccine can prevent hepatitis B, and the serious consequences of hepatitis B infection, including liver cancer and cirrhosis. Hepatitis B vaccine may be given by itself or in the same shot with other vaccines. Routine hepatitis B vaccination was recommended for some U.S. adults and children beginning in 1982, and for all children in 1991. Since 1990, new hepatitis B infections among children and adolescents have dropped by more than 95% – and by 75% in other age groups. Vaccination gives long-term protection from hepatitis B infection, possibly lifelong.
3
Who should get hepatitis B vaccine and when?
Children and Adolescents • Babies normally get 3 doses of hepatitis B vaccine: 1st Dose: Birth 2nd Dose: 1-2 months of age 3rd Dose: 6-18 months of age Some babies might get 4 doses, for example, if a combination vaccine containing hepatitis B is used. (This is a single shot containing several vaccines.) The extra dose is not harmful. • Anyone through 18 years of age who didn’t get the vaccine when they were younger should also be vaccinated. Adults • All unvaccinated adults at risk for hepatitis B infection should be vaccinated. This includes: - sex partners of people infected with hepatitis B, - men who have sex with men, - people who inject street drugs, - people with more than one sex partner, - people with chronic liver or kidney disease, - people under 60 years of age with diabetes, - people with jobs that expose them to human blood or other body fluids,
- household contacts of people infected with hepatitis B, - residents and staff in institutions for the developmen- tally disabled, - kidney dialysis patients, - people who travel to countries where hepatitis B is common, - people with HIV infection.
• Other people may be encouraged by their doctor to get hepatitis B vaccine; for example, adults 60 and older with diabetes. Anyone else who wants to be protected from hepatitis B infection may get the vaccine.
Adults getting hepatitis B vaccine should get 3 doses — with the second dose given 4 weeks after the first and the third dose 5 months after the second. Your doctor can tell you about other dosing schedules that might be used in certain circumstances.
Who should not get hepatitis B vaccine?
• Anyone with a life-threatening allergy to yeast, or to any other component of the vaccine, should not get hepatitis B vaccine. Tell your doctor if you have any severe allergies.
What should I look for? • Any unusual condition, such as a high fever or unusual behavior. Signs of a serious allergic reaction can include difficulty breathing, hoarseness or wheezing, hives, paleness, weakness, a fast heart beat or dizziness. What should I do? • Call a doctor, or get the person to a doctor right away. • Tell your doctor what happened, the date and time it happened, and when the vaccination was given. • Ask your doctor, nurse, or health department to report the reaction by filing a Vaccine Adverse Event Reporting System (VAERS) form. Or you can file this report through the VAERS web site at www.vaers.hhs.gov, or by calling 1-800-822-7967.
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• Anyone who is moderately or severely ill when a dose of vaccine is scheduled should probably wait until they recover before getting the vaccine.
The National Vaccine Injury Compensation Program
The National Vaccine Injury Compensation Program (VICP) was created in 1986. Persons who believe they may have been injured by a vaccine can learn about the program and about filing a claim by calling 1-800-338-2382 or visiting the VICP website at www.hrsa.gov/vaccinecompensation.
Your doctor can give you more information about these precautions. Note: You might be asked to wait 28 days before donating blood after getting hepatitis B vaccine. This is because the screening test could mistake vaccine in the bloodstream (which is not infectious) for hepatitis B infection.
8
What are the risks from hepatitis B vaccine?
Hepatitis B is a very safe vaccine. Most people do not have any problems with it. The vaccine contains non-infectious material, and cannot cause hepatitis B infection.
How can I learn more?
• Ask your doctor They can give you the vaccine package insert or suggest other sources of information. • Call your local or state health department. • Contact the Centers for Disease Control and Prevention (CDC): - Call 1-800-232-4636 (1-800-CDC-INFO) or - Visit CDC’s website at www.cdc.gov/vaccines
Vaccine Information Statement (Interim)
Some mild problems have been reported: • Soreness where the shot was given (up to about 1 person in 4).
What if there is a moderate or severe reaction?
VAERS does not provide medical advice.
• Anyone who has had a life-threatening allergic reaction to a previous dose of hepatitis B vaccine should not get another dose.
5
A vaccine, like any medicine, could cause a serious reaction. But the risk of a vaccine causing serious harm, or death, is extremely small. More than 100 million people in the United States have been vaccinated with hepatitis B vaccine.
6
• Pregnant women who are at risk for one of the reasons stated above should be vaccinated. Other pregnant women who want protection may be vaccinated.
4
Severe problems are extremely rare. Severe allergic reactions are believed to occur about once in 1.1 million doses.
• Temperature of 99.9°F or higher (up to about 1 person in 15).
Hepatitis B Vaccine 2/2/2012 42 U.S.C. § 300aa-26
Office Use Only
HIV/AIDS and the Workplace
What you should know about HIV, AIDS and the workplace: • HIV is the virus that causes AIDS, a disease that destroys a person’s immune system. • There are only a few ways that a person can be infected with HIV - most of which don’t involve work related situations. • It is easy to protect yourself from being infected with HIV, both in your personal life and in workplace settings. Some general information about HIV/AIDS: Acquired Immune Deficiency Syndrome (AIDS) is the final stage of an infection caused by the Human Immunodeficiency Virus (HIV). HIV attacks the body’s immune system, hurting the body’s ability to fight off diseases and other infections. There is no cure for HIV infection or AIDS. There are also no clear symptoms of HIV infection, although some people may have flu-like symptoms for a few days after they are infected with HIV. But, even if an infected person has no symptoms, feels, and looks healthy, he or she can still pass the virus to others. HIV is spread from person to person in the following body fluids: • blood • semen • vaginal secretions • breast milk HIV is NOT spread through the environment; it is a very fragile blood-borne virus. HIV-infected persons do not pose a threat to co-workers or clients during casual, day-to-day activities and contacts. You CANNOT be infected with HIV through: • handshakes
• dishes, utensils, or food
• hugs or casual touching
• sneezing or coughing
• close working conditions
• air
• telephones, office equipment, or furniture
• water
• sinks, toilets, or showers
• insects
There are only a few ways for a person to come in contact with HIV: • by having sex, either anal, oral, or vaginal, without the use of a condom; • by sharing needles, syringes, and other instruments that break the skin, such as tattoo and/or ear/body piercing needles; • from an HIV-infected mother to her baby during pregnancy, birth, or breastfeeding; and • by coming in contact with HIV-infected blood either through an open wound or through a blood transfusion. Risks from transfusions, however, are now very low because of blood-screening, which started in 1985. -OVER-
HIV/STD FACTS HIV/STD FACTS HIV/STD FACTS HIV/STD FACTS HIV/STD FACTS HIV/STD FACTS HIV/STD FACTS HIV/STD FACTS
You may be wondering what HIV and AIDS could have to do with your job and workplace. Well, it depends on the type of work you do. Some people, like health care workers, have to deal with HIV and AIDS every day. Most of us, though, don’t need to give much thought to HIV or AIDS when it comes to our jobs. And that makes a lot of sense, because HIV is not spread through the type of casual day-to-day contact that most of us have with other people in our jobs. On the other hand, it does make sense to be familiar with HIV and AIDS for our own personal health, as well as with the situations that might come up at work that do involve HIV and AIDS.
HIV/AIDS and the Workplace As you can see from the information on the last page, most of the behaviors that pass HIV from one person to another do not occur in the workplace. The only way that most people in the average workplace could be exposed to HIV would be if they had an open wound and someone else’s infected blood entered their body through that broken skin. How to avoid HIV infection in the workplace: It is easy to avoid being exposed to HIV and other blood-borne diseases by using good personal hygiene and common sense at all times: • keep broken skin covered with a clean, dry bandage; • avoid direct contact with blood spills; • wear gloves to clean spills that contain visible blood; and • clean blood spills with an appropriate disinfectant or 1:10 solution of freshly mixed household bleach and water. After cleanup, wash hands thoroughly with soap and running water. Ways to reduce your risk for HIV infection in your personal life: • Do not have sex (abstain) • Delay having sex until you are in a faithful relationship with one person who you know does not have HIV. • If you choose not to abstain from sex or to limit sex to one faithful, uninfected partner, then always use a latex condom every time you have sex (oral, anal, or vaginal). If used correctly and every time you have sex, latex condoms can provide protection against HIV and other sexually transmitted diseases (STDs). • If you have a drug habit, do not share needles or syringes. If you can’t stop sharing needles/syringes, clean them with bleach and then rinse them with water between every use. Also, do not share any other type of needles, such as tattoo and ear/body piercing needles. • The best thing for your health is to stop using drugs. If you need help to stop using, call the National Drug Abuse Hotline at 1-800-662-4357. If you work with someone who has HIV and/or AIDS: If you have a cold, flu or other virus, remember that people with HIV or AIDS do not have a healthy immune system. They are more likely to become ill from a virus that a healthy person’s body could easily fight. Remember, too, that people with HIV or AIDS are just like anyone else living with a disease: they need caring, support, and understanding.
For HIV/STD testing locations in Texas, call: 2-1-1 For other HIV/STD questions, call: 1 (800) CDC-INFO (English/Español) 1 (888) 232-6348 (TTY) For more information, go to: www.dshs.state.tx.us/hivstd
DSHS TB/HIV/STD Unit DSHS Stock E4-148 Revised 10/2007
HIV/STD FACTS HIV/STD FACTS HIV/STD FACTS HIV/STD FACTS HIV/STD FACTS HIV/STD FACTS HIV/STD FACTS HIV/STD FACTS
How HIV/AIDS affects you in your workplace:
Trinity Charter School 2014-2015
Payroll Understanding Your Paycheck
Salaried and Exempt from Overtime Your paycheck is processed based on your annual salary and number of days worked. You will receive the same gross amount each bi-weekly pay period. If the employee begins their employment after the start of the school year, their gross amount is prorated based on the number of days worked.
Example: Annual Salary $40,000.00yr; 26 pay periods $40,000.00/26 = $1,538.46 Bi-weekly
Non-Exempt - Eligible for Overtime Non-exempt employees will be paid at a bi-weekly rate calculated by annualizing their hourly rate and dividing it by the pay periods.
Example: Hourly Rate $12hr; 26 pay periods $12.00*1520 = $18,240yr $18,240yr/26 = $701.54 Bi-weekly
Non-exempt means that you are eligible for overtime pay; therefore you are required to submit a “Request for Overtime” form (see attached) for the actual hours worked. You will receive your bi-weekly amount plus any overtime reported. Overtime; however, MUST have prior approval. If an employee works less than the 80 hours for the bi-weekly pay, adjustments will be made. How is Overtime Calculated? Overtime is calculated for any hours actually worked over 40 in a single work week. Overtime does not include any days taken off in which you used any type of leave. Example #1: Jane worked 36 hours in the office and 5 hours on the bus for a total of 41 hours for the week. She will be paid for 1 hour of overtime. Example #2: Jane worked 30 hours in the office and 5 hours on the bus, but used 6 hours of sick leave. She will receive pay for 41 total hours, but at her regular rate of pay. Timesheet Reporting Periods Any additions, changes or deletions that need to be made to a particular staff member needs to be received by the Payroll Department the Thursday before the pay period ends. For example: Pay Period 1 is: 8/13/12 – 8/26/12. All paperwork needs to be received by NOON Thursday, 8/23/12. This date is subject to change if a holiday interrupts normal processing time. All backup paperwork, i.e., Time Corrections, Overtime and Time Off forms, to a particular pay period must be received in the Payroll Department the Monday after the pay period ends. For example: Pay Period 1 is: 8/13/12 – 8/26/12. All backup paperwork must be received by NOON Monday, 8/27/12. (see attached forms) PLEASE MAKE COPIES AND USE THE ATTACHED FORMS FOR THE 2013-2014 SCHOOL YEAR. 2|Page
When is Pay Day? Pay dates and reporting periods are determined at the beginning of each school year and based on the new school calendar (see attached Pay Date Table Main form). When and Where can Pay Checks be Picked up? Pay checks are separated by the Payroll Department at Central Office based on campus. The Payroll Department then will Fed-X each campuses checks on the Monday before the actual pay day on Tuesday. If there is a change in address, notify the Payroll Department immediately with an “Address Change“ form (see attached). Can I Get a Copy of my Pay Check(s) or W-2? Employees may get copies of their paychecks or W-2; however, please allow 10 days for processing. It is encouraged that each employee keep copies for future reference. Employees may access their patrol and employee data on TXEIS employee access at http://txeishost.net/employeeaccess/app/login
How does Direct Deposit work and Where do I Sign Up? We encourage employees to sign up for direct deposit if you haven’t done so already. This form is only required for your initial sign-up OR if you need to make changes to your current account information. Your pay will be deposited into the same account each month unless you let us know it should be changed. You cannot split your pay into separate accounts. Please complete the authorization form and submit to the Payroll Department (see attached forms). Taxes…How are They Calculated and How can I Adjust my Withholding Amounts? If you would like to check your tax withholdings or need help with questions about your personal tax status, please refer to the IRS website www.irs.gov or the Department of Revenue’s website www.dor.state.nc.us. Or contact your CPA. They can provide helpful information that the Payroll Department cannot. What is my Employee ID Number? Where Can I Find it? When Should I Use it? Each employee is assigned a unique 6-digit TCS ID number when hired. It usually starts with 000000 and then 3 digits following that. This number will be used instead of your Social Security Number. This ID number was assigned to help secure your personal information from any threat of misuse and identity theft. When filling out certain forms, you may be required to put your ID number so please remember it. If you do forget, you can contact the Payroll Department and they can tell you what your ID number is. If you have any questions, please feel free to contact the Payroll Department: Trinity Charter School Dawn Haney 8305 Crosspark Drive Austin, TX 78754 512-706-7566 3|Page
Attachments
4|Page
ADDRESS CHANGE FORM Employee Information **Form Must be Returned to the Business Office Before the End of the Pay Period in Which it Occurred**
Employee Name:
Campus:
Position:
Old Address:
New Address:
____________________________________ ____________________________________
____________________________________ ____________________________________
Effective Date: ____________________________________
Required Signature
Employee Signature:
Date:
Office Use Only
☐ Employee Folder ☐ Aetna
☐ HRB
☐ TxEIS
☐ Mid-Tex Benefits Cooperative Rev: 07/14
Time Correction Form 2014-2015 (ONE FORM PER PAY PERIOD)
**APPROVED Time Correction Form(s) must be returned to the Payroll Department the Monday after the pay period ends in which the time correction(s) occurred**
Employee Name:
Campus:
Changes: Date:
In:
Out:
Date:
In:
Out:
Date:
In:
Out:
Date:
In:
Out:
Date:
In:
Out:
Date:
In:
Out:
Date:
In:
Out:
Date:
In:
Out:
Reason for Missed Punch(es):
Employee Signature:
Date:
Principal/Supervisor Signature:
Date:
Rev: 7/14
Electronic Funds Transfer Authorization Form I authorize Trinity Charter School to initiate electronic funds transfer credits to my: _____Checking Account
_____Savings Account
I understand this authorization will remain in effect until I request its termination in writing. (Cancellation form on Page 2) ***PLEASE CONFIRM THE ACH ROUTING NUMBER AND ACCOUNT NUMBER WITH YOUR BANKING INSTITUTION FOR PROPER PROCESSING OF YOUR FUNDS*** Bank Name:
_________________________________________________________________
Branch:
_________________________________________________________________
Bank Phone #:_________________________________________________________________ City:
____________________________
State: ___________ Zip:
_________________
Bank Transit Number: ____________________________ (Attach copy of VOIDED check or savings deposit slip)
Bank Account Number:
____________________________
Employee Name (Printed):
_____________________________________________________
Employee Signature: _________________________________________ Date: ___________ Employee ID Number:_______________________ Campus:
_______________________
Instructions for Direct Deposit: 1. Please verify checking/savings account number; 2. Make sure you sign and list your Employee ID Number on the form; and 3. Attach a VOIDED check for Checking or a VOIDED Deposit Slip for Savings.
Direct deposit should begin one month after you have returned this form. Direct deposits will be for the entire check amount – no partials please.
5/2012
Electronic Funds Transfer Cancellation Form Please cancel my electronic funds transfer credits to my:
_____Checking Account
_____Savings Account
Employee Name:
_________________________________________
Employee ID #:
_________________________________________
Campus:
_________________________________________
Effective Date:
_________________________________________
_________________________________ Employee Signature
____________________________ Date
5/2012
Time Correction Form 2014-2015 (ONE FORM PER PAY PERIOD)
**APPROVED Time Correction Form(s) must be returned to the Payroll Department the Monday after the pay period ends in which the time correction(s) occurred**
Employee Name:
Campus:
Changes: Date:
In:
Out:
Date:
In:
Out:
Date:
In:
Out:
Date:
In:
Out:
Date:
In:
Out:
Date:
In:
Out:
Date:
In:
Out:
Date:
In:
Out:
Reason for Missed Punch(es):
Employee Signature:
Date:
Principal/Supervisor Signature:
Date:
Rev: 7/14
2014‐2015 Campus Employee Work Calendar FEBRUARY 2015
AUGUST 2014 S M T W T F S 1 3
4
5
6
7
LEGEND
2
8
9
10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Student/Staff Holiday (unless it is a specified In‐Service day)
First/Last day of classes
(Unless more than 2 make‐up days required)
1
2
3
SEPTEMBER 2014 1
2
3
4
5
6
8
9
10 11 12 13
14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Work Schedule 190 195 206 210 220
8
9
10 11 12 13 14
5
6
7
3
4
Start
End
8/18/2014 8/11/2014 8/11/2014 8/11/2014 8/11/2014
6/9/2015 6/9/2015 6/24/2015 6/30/2015 7/15/2015
S M T W T F S 1
2
3
8
9
10 11 12 13 14
8
9
10 11
4
5
6
7
15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
APRIL 2015 S M T W T F S 5
Paydate
7
MARCH 2015
Bad Weather Make‐Up Day
S M T W T F S 2
6
22 23 24 25 26 27 28
OCTOBER 2014 1
5
Full Day All Staff In‐service
*School in session only if needed
S M T W T F S
4
15 16 17 18 19 20 21
(7:30 a.m. ‐ 3:30 pm)
31
7
S M T W T F S
Pay Period Start
Pay Period End
6
7
1
2
3
4
8
9
10 11
12 13 14 15 16 17 18 19 20 21 22 23 24 25
12 13 14 15 16 17 18
======
======
======
19 20 21 22 23 24 25
9/2/2014
8/11/2014
8/24/2014
26 27 28 29 30 31
9/16/2014
8/25/2014
9/7/2014
MAY 2015
9/30/2014
9/8/2014
9/21/2014
S M T W T F S
10/14/2014
9/22/2014
10/5/2014
NOVEMBER 2014
26 27 28 29 30
1
2
8
9
S M T W T F S
10/28/2014
10/6/2014
10/19/2014
3
1
11/11/2014
10/20/2014
11/2/2014
10 11 12 13 14 15 16
4
5
6
7
4
5
6
7
2
3
8
11/25/2014
11/3/2014
11/16/2014
17 18 19 20 21 22 23
9
10 11 12 13 14 15
11/17/2014 12/1/2014 12/15/2014
11/30/2014 12/14/2014 12/28/2014
31
23 24 25 26 27 28 29
12/9/2014 12/23/2014 1/6/2015
30
1/20/2015
12/29/2014
1/11/2015
JUNE 2015
2/3/2015
1/12/2015
1/25/2015
S M T W T F S
DECEMBER 2014
2/17/2015
1/26/2015
2/8/2015
S M T W T F S
3/3/2015
2/9/2015
2/22/2015
7 8 9 10+ 11+ 12 13 14 15 16 17 18 19 20
16 17 18 19 20 21 22
24 25 26 27 28 29 30
1
2
3
4
5
6
1
2
3
6
3/17/2015
2/23/2015
3/8/2015
8
9
10 11 12 13
3/31/2015
3/9/2015
3/22/2015
21 22 23 24 25 26 27
14 15 16 17 18 19 20
4/14/2015
3/23/2015
4/5/2015
28 29 30
21 22 23 24 25 26 27
4/28/2015
4/6/2015
4/19/2015
28 29 30 31
5/12/2015
4/20/2015
5/3/2015
JULY 2015
5/26/2015
5/4/2015
5/17/2015
S M T W T F S
JANUARY 2015
6/9/2015
5/18/2015
5/31/2015
S M T W T F S
6/23/2015
6/1/2015
6/14/2015
5
7
4
5
6
7
1
2
3
8
9
10 11
4
1
2
3
7/7/2015
6/15/2015
6/28/2015
12 13 14 15 16 17 18
8
9
10
6/29/2015 7/13/2015
7/12/2015 7/26/2015
19 20 21 22 23 24 25
11 12 13 14 15 16 17
7/21/2015 8/4/2015
18 19 20 21 22 23 24
8/18/2015
7/27/2015
8/9/2015
4
5
6
7
25 26 27 28 29 30 31 09/30/14 & 3/31/15 = No h/c taken out
26 27 28 29 30 31
Electronic Funds Transfer Authorization Form I authorize Trinity Charter School to initiate electronic funds transfer credits to my: _____Checking Account
_____Savings Account
I understand this authorization will remain in effect until I request its termination in writing. (Cancellation form on Page 2) ***PLEASE CONFIRM THE ACH ROUTING NUMBER AND ACCOUNT NUMBER WITH YOUR BANKING INSTITUTION FOR PROPER PROCESSING OF YOUR FUNDS*** Bank Name:
_________________________________________________________________
Branch:
_________________________________________________________________
Bank Phone #:_________________________________________________________________ City:
____________________________
State: ___________ Zip:
_________________
Bank Transit Number: ____________________________ (Attach copy of VOIDED check or savings deposit slip)
Bank Account Number:
____________________________
Employee Name (Printed):
_____________________________________________________
Employee Signature: _________________________________________ Date: ___________ Employee ID Number:_______________________ Campus:
_______________________
Instructions for Direct Deposit: 1. Please verify checking/savings account number; 2. Make sure you sign and list your Employee ID Number on the form; and 3. Attach a VOIDED check for Checking or a VOIDED Deposit Slip for Savings.
Direct deposit should begin one month after you have returned this form. Direct deposits will be for the entire check amount – no partials please.
5/2012
Electronic Funds Transfer Cancellation Form Please cancel my electronic funds transfer credits to my:
_____Checking Account
_____Savings Account
Employee Name:
_________________________________________
Employee ID #:
_________________________________________
Campus:
_________________________________________
Effective Date:
_________________________________________
_________________________________ Employee Signature
____________________________ Date
5/2012
Statement Concerning Your Employment in a Job Not Covered by Social Security Employee Name
Employee ID#
Employer Name
Employer ID#
Your earnings from this job are not covered under Social Security. When you retire, or if you become disabled, you may receive a pension based on earnings from this job. If you do, and you are also entitled to a benefit from Social Security based on either your own work or the work of your husband or wife, or former husband or wife, your pension may affect the amount of the Social Security benefit you receive. Your Medicare benefits, however, will not be affected. Under the Social Security law, there are two ways your Social Security benefit amount may be affected. Windfall Elimination Provision Under the Windfall Elimination Provision, your Social Security retirement or disability benefit is figured using a modified formula when you are also entitled to a pension from a job where you did not pay Social Security tax. As a result, you will receive a lower Social Security benefit than if you were not entitled to a pension from this job. For example, if you are age 62 in 2005, the maximum monthly reduction in your Social Security benefit as a result of this provision is $313.50. This amount is updated annually. This provision reduces, but does not totally eliminate, your Social Security benefit. For additional information, please refer to Social Security Publication, “Windfall Elimination Provision.” Government Pension Offset Provision Under the Government Pension Offset Provision, any Social Security spouse or widow(er) benefit to which you become entitled will be offset if you also receive a Federal, State or local government pension based on work where you did not pay Social Security tax. The offset reduces the amount of your Social Security spouse or widow(er) benefit by two-thirds of the amount of your pension. For example, if you get a monthly pension of $600 based on earnings that are not covered under Social Security, two-thirds of that amount, $400, is used to offset your Social Security spouse or widow(er) benefit. If you are eligible for a $500 widow(er) benefit, you will receive $100 per month from Social Security ($500 - $400=$100). Even if your pension is high enough to totally offset your spouse or widow(er) Social Security benefit, you are still eligible for Medicare at age 65. For additional information, please refer to Social Security Publication, “Government Pension Offset.” For More Information Social Security publications and additional information, including information about exceptions to each provision, are available at www.socialsecurity.gov. You may also call toll free 1-800-772-1213, or for the deaf or hard of hearing call the TTY number 1-800-325-0778, or contact your local Social Security office. I certify that I have received Form SSA-1945 that contains information about the possible effects of the Windfall Elimination Provision and the Government Pension Offset Provision on my potential future Social Security benefits.
Signature of Employee
Form SSA-1945 (12-2004)
Date
Information about Social Security Form SSA-1945 Statement Concerning Your Employment in a Job Not Covered by Social Security New legislation [Section 419(c) of Public Law 108-203, the Social Security Protection Act of 2004] requires State and local government employers to provide a statement to employees hired January 1, 2005 or later in a job not covered under Social Security. The statement explains how a pension from that job could affect future Social Security benefits to which they may become entitled. Form SSA-1945, Statement Concerning Your Employment in a Job Not Covered by Social Security, is the document that employers should use to meet the requirements of the law. The SSA-1945 explains the potential effects of two provisions in the Social Security law for workers who also receive a pension based on their work in a job not covered by Social Security. The Windfall Elimination Provision can affect the amount of a worker’s Social Security retirement or disability benefit. The Government Pension Offset Provision can affect a Social Security benefit received as a spouse or an ex-spouse. Employers must: • Give the statement to the employee prior to the start of employment; • Get the employee’s signature on the form; and • Submit a copy of the signed form to the pension paying agency. Social Security will not be setting any additional guidelines for the use of this form. Copies of the SSA-1945 are available online at the Social Security website, www.socialsecurity.gov/form1945. Paper copies can be requested by email at
[email protected] or by fax at 410-965-2037. The request must include the name, complete address and telephone number of the employer. Forms will not be sent to a post office box. Also, if appropriate, include the name of the person to whom the forms are to be delivered. The forms are available in packages of 25. Please refer to Inventory Control Number (ICN) 276950 when ordering.
Form SSA-1945 (12-2004)
2014-2015 Payroll Information Sheet Name: _________________________________
Campus: ______________
Position: Pay Rate:
hourly/ daily
I have chosen the following pay schedule:
10 month schedule; 22 payments (only applicable to nonexempt working 190 or 195 per school year) 10 month schedule; 23 payments (only applicable to nonexempt working 206 per school year)
12 month schedule; 26 payments
I understand and agree that my employer, Trinity Charter School, will be annualizing my pay.
Employee Signature
Date
(Please Note: Schedule changes can only be made as a new hire or at the beginning of the school year.) 6/12
TCS Amendment to Non-Subscription, Employee Injury Plan By signing this, I acknowledge that I have received the information regarding the amendments to the employee injury plan that will go into effect on 8/15/12. I also understand that all information regarding the employee injury plan for TCS, to include the plan document, summary plan, new hire and arbitration information can be found on the LSS intranet under Risk Management or requested from my facility HR contact.
________________________________________ Name
________________________________________ Signature
________________________________________ Date
Staff Emergency Contact Form For 2014-2015 School Year
Employee Name: Employee ID #:
Emergency Contact Information: Contact Name: Relationship: Phone Number: Address:
Emergency Contact Information: Contact Name: Relationship: Phone Number: Address:
EMPLOYEE CERTIFICATION OF AUTOMOBILE INSURANCE COVERAGE Trinity Charter School requires that all employees using personally owned and company owned automobiles for agency business have the minimum automobile insurance required by the state in which they will be driving. Please complete the form below and return to the facility business office. THIS IS TO CERTIFY THAT I, ______________________________________________ (PRINT NAME) Check One ( )
Have the automobile coverage outlined above.
( )
Do not have the coverage outlined above and will not drive any personally owned or company owned automobile on agency business.
________________________________ Employee Signature _____________________________ Date 09/10
8/14
New Health Insurance Marketplace Coverage Options and Your Health Coverage
Form Approved OMB No. 1210-0149 (expires 1-31-201)
PART A: General Information ΈΙΖΟ͑ΜΖΪ͑ΡΒΣΥΤ͑ΠΗ͑ΥΙΖ͑ΙΖΒΝΥΙ͑ΔΒΣΖ͑ΝΒΨ͑ΥΒΜΖ͑ΖΗΗΖΔΥ͑ΚΟ͑ͣͥ͑͢͡͝ΥΙΖΣΖ͑ΨΚΝΝ͑ΓΖ͑Β͑ΟΖΨ͑ΨΒΪ͑ΥΠ͑ΓΦΪ͑ΙΖΒΝΥΙ͑ΚΟΤΦΣΒΟΔΖ:͑ΥΙΖ͑ΖΒΝΥΙ͑ ͺΟΤΦΣΒΟΔΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑͟΅Π͑ΒΤΤΚΤΥ͑ΪΠΦ͑ΒΤ͑ΪΠΦ͑ΖΧΒΝΦΒΥΖ͑ΠΡΥΚΠΟΤ͑ΗΠΣ͑ΪΠΦ͑ΒΟΕ͑ΪΠΦΣ͑ΗΒΞΚΝΪ͑͝ΥΙΚΤ͑ΟΠΥΚΔΖ͑ΡΣΠΧΚΕΖΤ͑ΤΠΞΖ͑ΓΒΤΚΔ͑ ΚΟΗΠΣΞΒΥΚΠΟ͑ΒΓΠΦΥ͑ΥΙΖ͑ΟΖΨ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΒΟΕ͑ΖΞΡΝΠΪΞΖΟΥνΓΒΤΖΕ͑ΙΖΒΝΥΙ͑ΔΠΧΖΣΒΘΖ͑ΠΗΗΖΣΖΕ͑ΓΪ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑͟ ͑
What is the Health Insurance Marketplace? ΅ΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΚΤ͑ΕΖΤΚΘΟΖΕ͑ΥΠ͑ΙΖΝΡ͑ΪΠΦ͑ΗΚΟΕ͑ΙΖΒΝΥΙ͑ΚΟΤΦΣΒΟΔΖ͑ΥΙΒΥ͑ΞΖΖΥΤ͑ΪΠΦΣ͑ΟΖΖΕΤ͑ΒΟΕ͑ΗΚΥΤ͑ΪΠΦΣ͑ΓΦΕΘΖΥ͑͟΅ΙΖ͑ ;ΒΣΜΖΥΡΝΒΔΖ͑ΠΗΗΖΣΤ͓͑ΠΟΖ͞ΤΥΠΡ͑ΤΙΠΡΡΚΟΘ͓͑ΥΠ͑ΗΚΟΕ͑ΒΟΕ͑ΔΠΞΡΒΣΖ͑ΡΣΚΧΒΥΖ͑ΙΖΒΝΥΙ͑ΚΟΤΦΣΒΟΔΖ͑ΠΡΥΚΠΟΤ͑͟ΊΠΦ͑ΞΒΪ͑ΒΝΤΠ͑ΓΖ͑ΖΝΚΘΚΓΝΖ͑ ΗΠΣ͑Β͑ΟΖΨ͑ΜΚΟΕ͑ΠΗ͑ΥΒΩ͑ΔΣΖΕΚΥ͑ΥΙΒΥ͑ΝΠΨΖΣΤ͑ΪΠΦΣ͑ΞΠΟΥΙΝΪ͑ΡΣΖΞΚΦΞ͑ΣΚΘΙΥ͑ΒΨΒΪ͑͟ΡΖΟ͑ΖΟΣΠΝΝΞΖΟΥ͑ΗΠΣ͑ΙΖΒΝΥΙ͑ΚΟΤΦΣΒΟΔΖ͑ ΔΠΧΖΣΒΘΖ͑ΥΙΣΠΦΘΙ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΓΖΘΚΟΤ͑ΚΟ͑ΔΥΠΓΖΣ͑ͣͤ͑͢͡ΗΠΣ͑ΔΠΧΖΣΒΘΖ͑ΤΥΒΣΥΚΟΘ͑ΒΤ͑ΖΒΣΝΪ͑ΒΤ͑ͻΒΟΦΒΣΪ͑͑ͣͥ͑͢͢͟͝͡
Can I Save Money on my Health Insurance Premiums in the Marketplace? ΊΠΦ͑ΞΒΪ͑ΦΒΝΚΗΪ͑ΥΠ͑ΤΒΧΖ͑ΞΠΟΖΪ͑ΒΟΕ͑ΝΠΨΖΣ͑ΪΠΦΣ͑ΞΠΟΥΙΝΪ͑ΡΣΖΞΚΦΞ͑͝ΓΦΥ͑ΠΟΝΪ͑ΚΗ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑ΕΠΖΤ͑ΟΠΥ͑ΠΗΗΖΣ͑ΔΠΧΖΣΒΘΖ͑͝ΠΣ͑ ΠΗΗΖΣΤ͑ΔΠΧΖΣΒΘΖ͑ΥΙΒΥ͑ΕΠΖΤΟ͘Υ͑ΞΖΖΥ͑ΔΖΣΥΒΚΟ͑ΤΥΒΟΕΒΣΕΤ͑͟΅ΙΖ͑ΤΒΧΚΟΘΤ͑ΠΟ͑ΪΠΦΣ͑ΡΣΖΞΚΦΞ͑ΥΙΒΥ͑ΪΠΦ͘ΣΖ͑ΖΝΚΘΚΓΝΖ͑ΗΠΣ͑ΕΖΡΖΟΕΤ͑ΠΟ͑ ΪΠΦΣ͑ΙΠΦΤΖΙΠΝΕ͑ΚΟΔΠΞΖ͑͟
Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace? ΊΖΤ͑͟ͺΗ͑ΪΠΦ͑ΙΒΧΖ͑ΒΟ͑ΠΗΗΖΣ͑ΠΗ͑ΙΖΒΝΥΙ͑ΔΠΧΖΣΒΘΖ͑ΗΣΠΞ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑ΥΙΒΥ͑ΞΖΖΥΤ͑ΔΖΣΥΒΚΟ͑ΤΥΒΟΕΒΣΕΤ͑͝ΪΠΦ͑ΨΚΝΝ͑ΟΠΥ͑ΓΖ͑ΖΝΚΘΚΓΝΖ͑ ΗΠΣ͑Β͑ΥΒΩ͑ΔΣΖΕΚΥ͑ΥΙΣΠΦΘΙ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΒΟΕ͑ΞΒΪ͑ΨΚΤΙ͑ΥΠ͑ΖΟΣΠΝΝ͑ΚΟ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͘Τ͑ΙΖΒΝΥΙ͑ΡΝΒΟ͑͟ΠΨΖΧΖΣ͑͝ΪΠΦ͑ΞΒΪ͑ΓΖ͑ ΖΝΚΘΚΓΝΖ͑ΗΠΣ͑Β͑ΥΒΩ͑ΔΣΖΕΚΥ͑ΥΙΒΥ͑ΝΠΨΖΣΤ͑ΪΠΦΣ͑ΞΠΟΥΙΝΪ͑ΡΣΖΞΚΦΞ͑͝ΠΣ͑Β͑ΣΖΕΦΔΥΚΠΟ͑ΚΟ͑ΔΖΣΥΒΚΟ͑ΔΠΤΥ͞ΤΙΒΣΚΟΘ͑ΚΗ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑ΕΠΖΤ͑ ΟΠΥ͑ΠΗΗΖΣ͑ΔΠΧΖΣΒΘΖ͑ΥΠ͑ΪΠΦ͑ΒΥ͑ΒΝΝ͑ΠΣ͑ΕΠΖΤ͑ΟΠΥ͑ΠΗΗΖΣ͑ΔΠΧΖΣΒΘΖ͑ΥΙΒΥ͑ΞΖΖΥΤ͑ΔΖΣΥΒΚΟ͑ΤΥΒΟΕΒΣΕΤ͑͟ͺΗ͑ΥΙΖ͑ΔΠΤΥ͑ΠΗ͑Β͑ΡΝΒΟ͑ΗΣΠΞ͑ΪΠΦΣ͑ ΖΞΡΝΠΪΖΣ͑ΥΙΒΥ͑ΨΠΦΝΕ͑ΔΠΧΖΣ͑ΪΠΦ͙͑ΒΟΕ͑ΟΠΥ͑ΒΟΪ͑ΠΥΙΖΣ͑ΞΖΞΓΖΣΤ͑ΠΗ͑ΪΠΦΣ͑ΗΒΞΚΝΪ͚͑ΚΤ͑ΞΠΣΖ͑ΥΙΒΟ͖͑ͪͦ͑͟ΠΗ͑ΪΠΦΣ͑ΙΠΦΤΖΙΠΝΕ͑ ΚΟΔΠΞΖ͑ΗΠΣ͑ΥΙΖ͑ΪΖΒΣ͑͝ΠΣ͑ΚΗ͑ΥΙΖ͑ΔΠΧΖΣΒΘΖ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑ΡΣΠΧΚΕΖΤ͑ΕΠΖΤ͑ΟΠΥ͑ΞΖΖΥ͑ΥΙΖ͓͑ΞΚΟΚΞΦΞ͑ΧΒΝΦΖ͓͑ΤΥΒΟΕΒΣΕ͑ΤΖΥ͑ΓΪ͑ΥΙΖ͑ ͲΗΗΠΣΕΒΓΝΖ͑ʹΒΣΖ͑ͲΔΥ͑͝ΪΠΦ͑ΞΒΪ͑ΓΖ͑ΖΝΚΘΚΓΝΖ͑ΗΠΣ͑Β͑ΥΒΩ͑ΔΣΖΕΚΥ͑͟͢ ͑ ͿΠΥΖͫ͑ͺΗ͑ΪΠΦ͑ΡΦΣΔΙΒΤΖ͑Β͑ΙΖΒΝΥΙ͑ΡΝΒΟ͑ΥΙΣΠΦΘΙ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΚΟΤΥΖΒΕ͑ΠΗ͑ΒΔΔΖΡΥΚΟΘ͑ΙΖΒΝΥΙ͑ΔΠΧΖΣΒΘΖ͑ΠΗΗΖΣΖΕ͑ΓΪ͑ΪΠΦΣ͑ ΖΞΡΝΠΪΖΣ͑͝ΥΙΖΟ͑ΪΠΦ͑ΞΒΪ͑ΝΠΤΖ͑ΥΙΖ͑ΖΞΡΝΠΪΖΣ͑ΔΠΟΥΣΚΓΦΥΚΠΟ͙͑ΚΗ͑ΒΟΪ͚͑ΥΠ͑ΥΙΖ͑ΖΞΡΝΠΪΖΣ͞ΠΗΗΖΣΖΕ͑ΔΠΧΖΣΒΘΖ͑͟ͲΝΤΠ͑͝ΥΙΚΤ͑ΖΞΡΝΠΪΖΣ͑ ΔΠΟΥΣΚΓΦΥΚΠΟ͑͞ΒΤ͑ΨΖΝΝ͑ΒΤ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΖ͑ΔΠΟΥΣΚΓΦΥΚΠΟ͑ΥΠ͑ΖΞΡΝΠΪΖΣ͞ΠΗΗΖΣΖΕ͑ΔΠΧΖΣΒΘΖ͑͞ΚΤ͑ΠΗΥΖΟ͑ΖΩΔΝΦΕΖΕ͑ΗΣΠΞ͑ΚΟΔΠΞΖ͑ΗΠΣ͑ ͷΖΕΖΣΒΝ͑ΒΟΕ͑΄ΥΒΥΖ͑ΚΟΔΠΞΖ͑ΥΒΩ͑ΡΦΣΡΠΤΖΤ͑͟ΊΠΦΣ͑ΡΒΪΞΖΟΥΤ͑ΗΠΣ͑ΔΠΧΖΣΒΘΖ͑ΥΙΣΠΦΘΙ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΒΣΖ͑ΞΒΕΖ͑ΠΟ͑ΒΟ͑ΒΗΥΖΣ͞ ΥΒΩ͑ΓΒΤΚΤ͑͟
͑ How Can I Get More Information? ͷΠΣ͑ΞΠΣΖ͑ΚΟΗΠΣΞΒΥΚΠΟ͑ΒΓΠΦΥ͑ΪΠΦΣ͑ΔΠΧΖΣΒΘΖ͑ΠΗΗΖΣΖΕ͑ΓΪ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑͝ΡΝΖΒΤΖ͑ΔΙΖΔΜ͑ΪΠΦΣ͑ΤΦΞΞΒΣΪ͑ΡΝΒΟ͑ΕΖΤΔΣΚΡΥΚΠΟ͑ΠΣ͑ Dawn Haney - Office Manager at
[email protected] or 512-706-7566 ΔΠΟΥΒΔΥ͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͟ ͑ ΅ΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΔΒΟ͑ΙΖΝΡ͑ΪΠΦ͑ΖΧΒΝΦΒΥΖ͑ΪΠΦΣ͑ΔΠΧΖΣΒΘΖ͑ΠΡΥΚΠΟΤ͑͝ΚΟΔΝΦΕΚΟΘ͑ΪΠΦΣ͑ΖΝΚΘΚΓΚΝΚΥΪ͑ΗΠΣ͑ΔΠΧΖΣΒΘΖ͑ΥΙΣΠΦΘΙ͑ΥΙΖ͑ ;ΒΣΜΖΥΡΝΒΔΖ͑ΒΟΕ͑ΚΥΤ͑ΔΠΤΥ͑͟ΝΖΒΤΖ͑ΧΚΤΚΥ͑ΖΒΝΥΙʹΒΣΖ͟ΘΠΧ͑ΗΠΣ͑ΞΠΣΖ͑ΚΟΗΠΣΞΒΥΚΠΟ͑͝ΚΟΔΝΦΕΚΟΘ͑ΒΟ͑ΠΟΝΚΟΖ͑ΒΡΡΝΚΔΒΥΚΠΟ͑ΗΠΣ͑ΙΖΒΝΥΙ͑ ΚΟΤΦΣΒΟΔΖ͑ΔΠΧΖΣΒΘΖ͑ΒΟΕ͑ΔΠΟΥΒΔΥ͑ΚΟΗΠΣΞΒΥΚΠΟ͑ΗΠΣ͑Β͑ΖΒΝΥΙ͑ͺΟΤΦΣΒΟΔΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΚΟ͑ΪΠΦΣ͑ΒΣΖΒ͑͟
͑͢ͲΟ͑ ΖΞΡΝΠΪΖΣ͞ΤΡΠΟΤΠΣΖΕ͑ ΙΖΒΝΥΙ͑ΡΝΒΟ͑ΞΖΖΥΤ͑ΥΙΖ͑ ͓ΞΚΟΚΞΦΞ͑ ΧΒΝΦΖ͑ΤΥΒΟΕΒΣΕ͓͑ ΚΗ͑ ΥΙΖ͑ΡΝΒΟ͘Τ͑ΤΙΒΣΖ͑ΠΗ͑ ΥΙΖ͑ΥΠΥΒΝ͑ΒΝΝΠΨΖΕ͑ΓΖΟΖΗΚΥ͑ΔΠΤΥΤ͑ΔΠΧΖΣΖΕ͑ ΓΪ͑ ΥΙΖ͑ΡΝΒΟ͑ΚΤ͑ ΟΠ͑ ΝΖΤΤ͑ΥΙΒΟ͑ͧ͑͡ΡΖΣΔΖΟΥ͑ΠΗ͑ ΤΦΔΙ͑ΔΠΤΥΤ͑͟
PART B: Information About Health Coverage Offered by Your Employer ΅ΙΚΤ͑ΤΖΔΥΚΠΟ͑ΔΠΟΥΒΚΟΤ͑ΚΟΗΠΣΞΒΥΚΠΟ͑ΒΓΠΦΥ͑ΒΟΪ͑ΙΖΒΝΥΙ͑ΔΠΧΖΣΒΘΖ͑ΠΗΗΖΣΖΕ͑ΓΪ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑͟ͺΗ͑ΪΠΦ͑ΕΖΔΚΕΖ͑ΥΠ͑ΔΠΞΡΝΖΥΖ͑ΒΟ͑ ΒΡΡΝΚΔΒΥΚΠΟ͑ΗΠΣ͑ΔΠΧΖΣΒΘΖ͑ΚΟ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑͝ΪΠΦ͑ΨΚΝΝ͑ΓΖ͑ΒΤΜΖΕ͑ΥΠ͑ΡΣΠΧΚΕΖ͑ΥΙΚΤ͑ΚΟΗΠΣΞΒΥΚΠΟ͑͟΅ΙΚΤ͑ΚΟΗΠΣΞΒΥΚΠΟ͑ΚΤ͑ΟΦΞΓΖΣΖΕ͑ ΥΠ͑ΔΠΣΣΖΤΡΠΟΕ͑ΥΠ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΒΡΡΝΚΔΒΥΚΠΟ͑͟ 3. Employer name
4. Employer Identification Number (EIN)
Casa Gracia DBA Trinity Charter School
742314606
5. Employer address
6. Employer phone number
8605 Cross Park Dr
512-706-7566
7. City
Austin
8. State
9. ZIP code
TX
78754
10. Who can we contact about employee health coverage at this job?
Dawn Haney 11. Phone number (if different from above)
͑
12. Email address
[email protected]
ΖΣΖ͑ΚΤ͑ΤΠΞΖ͑ΓΒΤΚΔ͑ΚΟΗΠΣΞΒΥΚΠΟ͑ΒΓΠΦΥ͑ΙΖΒΝΥΙ͑ΔΠΧΖΣΒΘΖ͑ΠΗΗΖΣΖΕ͑ΓΪ͑ΥΙΚΤ͑ΖΞΡΝΠΪΖΣͫ͑ x ͲΤ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑͝ΨΖ͑ΠΗΗΖΣ͑Β͑ΙΖΒΝΥΙ͑ΡΝΒΟ͑ΥΠͫ͑
ͲΝΝ͑ΖΞΡΝΠΪΖΖΤ͑͑͟ͶΝΚΘΚΓΝΖ͑ΖΞΡΝΠΪΖΖΤ͑ΒΣΖͫ͑ ͑ ͑ ͑ ͑ ͑ ✔
΄ΠΞΖ͑ΖΞΡΝΠΪΖΖΤ͑͟ͶΝΚΘΚΓΝΖ͑ΖΞΡΝΠΪΖΖΤ͑ΒΣΖͫ͑͑ ͑ ͑ Actively employed and making monthly contributions to TRS or regularly scheduled to work 10 or more ͑ hours per week. ͑ ͑ x ΈΚΥΙ͑ΣΖΤΡΖΔΥ͑ΥΠ͑ΕΖΡΖΟΕΖΟΥΤͫ͑ ✔
ΈΖ͑ΕΠ͑ΠΗΗΖΣ͑ΔΠΧΖΣΒΘΖ͑͟ͶΝΚΘΚΓΝΖ͑ΕΖΡΖΟΕΖΟΥΤ͑ΒΣΖͫ͑ ͑ Spouse (including common law spouse); Natural/adopted child, step-child, foster child, legal guardianship ͑ (under the age of 26); Other child (Under the age of 26 and unmarried); Grandchildren (under the age of 26)* ͑ *Must meet eligibility criteria specified in the eligible dependents section of the benefits handbook. ͑
ΈΖ͑ΕΠ͑ΟΠΥ͑ΠΗΗΖΣ͑ΔΠΧΖΣΒΘΖ͑͟ ͑
ͺΗ͑ΔΙΖΔΜΖΕ͑͝ΥΙΚΤ͑ΔΠΧΖΣΒΘΖ͑ΞΖΖΥΤ͑ΥΙΖ͑ΞΚΟΚΞΦΞ͑ΧΒΝΦΖ͑ΤΥΒΟΕΒΣΕ͑͝ΒΟΕ͑ΥΙΖ͑ΔΠΤΥ͑ΠΗ͑ΥΙΚΤ͑ΔΠΧΖΣΒΘΖ͑ΥΠ͑ΪΠΦ͑ΚΤ͑ΚΟΥΖΟΕΖΕ͑ ΥΠ͑ΓΖ͑ΒΗΗΠΣΕΒΓΝΖ͑͝ΓΒΤΖΕ͑ΠΟ͑ΖΞΡΝΠΪΖΖ͑ΨΒΘΖΤ͑͟ ͑ ͛͛͑ ͶΧΖΟ͑ΚΗ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑ΚΟΥΖΟΕΤ͑ΪΠΦΣ͑ΔΠΧΖΣΒΘΖ͑ΥΠ͑ΓΖ͑ΒΗΗΠΣΕΒΓΝΖ͑͝ΪΠΦ͑ΞΒΪ͑ΤΥΚΝΝ͑ΓΖ͑ΖΝΚΘΚΓΝΖ͑ΗΠΣ͑Β͑ΡΣΖΞΚΦΞ͑ ΕΚΤΔΠΦΟΥ͑ΥΙΣΠΦΘΙ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑͟΅ΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΨΚΝΝ͑ΦΤΖ͑ΪΠΦΣ͑ΙΠΦΤΖΙΠΝΕ͑ΚΟΔΠΞΖ͑͝ΒΝΠΟΘ͑ΨΚΥΙ͑ΠΥΙΖΣ͑ΗΒΔΥΠΣΤ͑͝ ΥΠ͑ΕΖΥΖΣΞΚΟΖ͑ΨΙΖΥΙΖΣ͑ΪΠΦ͑ΞΒΪ͑ΓΖ͑ΖΝΚΘΚΓΝΖ͑ΗΠΣ͑Β͑ΡΣΖΞΚΦΞ͑ΕΚΤΔΠΦΟΥ͑͟ͺΗ͑͝ΗΠΣ͑ΖΩΒΞΡΝΖ͑͝ΪΠΦΣ͑ΨΒΘΖΤ͑ΧΒΣΪ͑ΗΣΠΞ͑ ΨΖΖΜ͑ΥΠ͑ΨΖΖΜ͙͑ΡΖΣΙΒΡΤ͑ΪΠΦ͑ΒΣΖ͑ΒΟ͑ΙΠΦΣΝΪ͑ΖΞΡΝΠΪΖΖ͑ΠΣ͑ΪΠΦ͑ΨΠΣΜ͑ΠΟ͑Β͑ΔΠΞΞΚΤΤΚΠΟ͑ΓΒΤΚΤ͚͑͝ΚΗ͑ΪΠΦ͑ΒΣΖ͑ΟΖΨΝΪ͑ ΖΞΡΝΠΪΖΕ͑ΞΚΕ͞ΪΖΒΣ͑͝ΠΣ͑ΚΗ͑ΪΠΦ͑ΙΒΧΖ͑ΠΥΙΖΣ͑ΚΟΔΠΞΖ͑ΝΠΤΤΖΤ͑͝ΪΠΦ͑ΞΒΪ͑ΤΥΚΝΝ͑ΦΒΝΚΗΪ͑ΗΠΣ͑Β͑ΡΣΖΞΚΦΞ͑ΕΚΤΔΠΦΟΥ͑͟ ͑ ͺΗ͑ΪΠΦ͑ΕΖΔΚΕΖ͑ΥΠ͑ΤΙΠΡ͑ΗΠΣ͑ΔΠΧΖΣΒΘΖ͑ΚΟ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑͝ΖΒΝΥΙʹΒΣΖ͟ΘΠΧ ΨΚΝΝ͑ΘΦΚΕΖ͑ΪΠΦ͑ΥΙΣΠΦΘΙ͑ΥΙΖ ΡΣΠΔΖΤΤ͑͟ΖΣΖ͘Τ͑ΥΙΖ͑ ΖΞΡΝΠΪΖΣ͑ΚΟΗΠΣΞΒΥΚΠΟ͑ΪΠΦ͘ΝΝ͑ΖΟΥΖΣ͑ΨΙΖΟ͑ΪΠΦ͑ΧΚΤΚΥ͑ΖΒΝΥΙʹΒΣΖ͟ΘΠΧ͑ΥΠ͑ΗΚΟΕ͑ΠΦΥ͑ΚΗ͑ΪΠΦ͑ΔΒΟ͑ΘΖΥ͑Β͑ΥΒΩ͑ΔΣΖΕΚΥ͑ΥΠ͑ΝΠΨΖΣ͑ΪΠΦΣ͑ ΞΠΟΥΙΝΪ͑ΡΣΖΞΚΦΞΤ͑͟ ͑
΅ΙΖ͑ΚΟΗΠΣΞΒΥΚΠΟ͑ΓΖΝΠΨ͑ΔΠΣΣΖΤΡΠΟΕΤ͑ΥΠ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ͶΞΡΝΠΪΖΣ͑ʹΠΧΖΣΒΘΖ͑΅ΠΠΝ͑͑͟ʹΠΞΡΝΖΥΚΟΘ͑ΥΙΚΤ͑ΤΖΔΥΚΠΟ͑ΚΤ͑ΠΡΥΚΠΟΒΝ͑ΗΠΣ͑ ΖΞΡΝΠΪΖΣΤ͑͝ΓΦΥ͑ΨΚΝΝ͑ΙΖΝΡ͑ΖΟΤΦΣΖ͑ΖΞΡΝΠΪΖΖΤ͑ΦΟΕΖΣΤΥΒΟΕ͑ΥΙΖΚΣ͑ΔΠΧΖΣΒΘΖ͑ΔΙΠΚΔΖΤ͑͟ ͑ 13. Is the employee currently eligible for coverage offered by this employer, or will the employee be eligible in the next 3 months?
Yes (Continue) 13a. If the employee is not eligible today, including as a result of a waiting or probationary period, when is the employee eligible for coverage? (mm/dd/yyyy) (Continue) No (STOP and return this form to employee)
͑ 14. Does the employer offer a health plan that meets the minimum value standard*? Yes (Go to question 15) No (STOP and return form to employee) 15. For the lowest-cost plan that meets the minimum value standard* offered only to the employee (don't include family plans): If the employer has wellness programs, provide the premium that the employee would pay if he/ she received the maximum discount for any tobacco cessation programs, and didn't receive any other discounts based on wellness programs. a. How much would the employee have to pay in premiums for this plan? $ b. How often? Weekly Every 2 weeks Twice a month Monthly Quarterly Yearly ͺΗ͑ΥΙΖ͑ΡΝΒΟ͑ΪΖΒΣ͑ΨΚΝΝ͑ΖΟΕ͑ΤΠΠΟ͑ΒΟΕ͑ΪΠΦ͑ΜΟΠΨ͑ΥΙΒΥ͑ΥΙΖ͑ΙΖΒΝΥΙ͑ΡΝΒΟΤ͑ΠΗΗΖΣΖΕ͑ΨΚΝΝ͑ΔΙΒΟΘΖ͑͝ΘΠ͑ΥΠ͑ΦΖΤΥΚΠΟ͑ͧ͑͢͟ͺΗ͑ΪΠΦ͑ΕΠΟ͘Υ͑ ΜΟΠΨ͑͝΄΅͑ΒΟΕ͑ΣΖΥΦΣΟ͑ΗΠΣΞ͑ΥΠ͑ΖΞΡΝΠΪΖΖ͑͟ ͑ 16. What change will the employer make for the new plan year?
Employer won't offer health coverage
Employer will start offering health coverage to employees or change the premium for the lowest-cost plan available only to the employee that meets the minimum value standard.* (Premium should reflect the discount for wellness programs. See question 15.) a. How much would the employee have to pay in premiums for this plan? $ b. How often? Weekly Every 2 weeks Twice a month Monthly Quarterly Yearly
Ͳ͑חΟ͑ΖΞΡΝΠΪΖΣ͞ΤΡΠΟΤΠΣΖΕ͑ΙΖΒΝΥΙ͑ΡΝΒΟ͑ΞΖΖΥΤ͑ΥΙΖ͓͑ΞΚΟΚΞΦΞ͑ΧΒΝΦΖ͑ΤΥΒΟΕΒΣΕ͓͑ΚΗ͑ΥΙΖ͑ΡΝΒΟ͘Τ͑ΤΙΒΣΖ͑ΠΗ͑ΥΙΖ͑ΥΠΥΒΝ͑ΒΝΝΠΨΖΕ͑ΓΖΟΖΗΚΥ͑ΔΠΤΥΤ͑ΔΠΧΖΣΖΕ͑ΓΪ͑ ΥΙΖ͑ΡΝΒΟ͑ΚΤ͑ΟΠ͑ΝΖΤΤ͑ΥΙΒΟ͑ͧ͑͡ΡΖΣΔΖΟΥ͑ΠΗ͑ΤΦΔΙ͑ΔΠΤΥΤ͙͑΄ΖΔΥΚΠΟ͑ͤͧͳ͙Δ͚͙͚͙ͣʹ͚͙ΚΚ͚͑ΠΗ͑ΥΙΖ͑ͺΟΥΖΣΟΒΝ͑ΖΧΖΟΦΖ͑ʹΠΕΖ͑ΠΗ͚͑ͪͩͧ͑͢
NEW HEALTH INSURANCE MARKETPLACE COVERAGE OPTIONS AND YOUR HEALTH COVERAGE
RECEIPT OF ACKNOWLEDGMENT
By my signature below, I acknowledge that I have received a copy of the New Health Insurance Marketplace Coverage Notice. I also understand that it is my responsibility for further inquiry of eligibility and coverage requirements for health insurance coverage through the Marketplace, which begins in October 2013.
___________________________________ Employee Signature
Date
___________________________________ Print Employee Name
Employee Work Location
SECURITY RELEASE FORM The following items have been issued to
Employee Name:
Employee ID: Campus/Location: Position: *Upon termination of employment all items must be returned before issuance of the final pay check*
ASSET
ASSET I.D. (If applicable)
DATE ISSUED
BADGE Desk #: File cabinet #: Keys ‐ Room #:
OTHER ITEMS: (i.e., uniforms, calling card, equipment, etc. Radio/headset: Computer:
Desktop
Laptop
DATE RETURNED Cost to replace items not returned
$ $
Tablet
$ $ $ $ $
Phone: Monitor: Printer/Scanner:
I verify that I have received the items listed above. I understand that I will be responsible for reimbursing the agency for the costs of these items if they are not returned upon termination of employment.
I verify that the items listed above have been returned.
Employee’s Signature Date
Employee’s Signature Date
Supervisor’s Signature Date
Supervisor’s Signature Date
Revised 7/14
CAFETERIA PLAN (SECTION 125) ENROLLMENT FORM
EMPLOYEE NAME__________________________________________________ THIS FORM MUST BE COMPLETED BY ALL EMPLOYEES WHO SIGN UP FOR HEALTH INSURANCE. The Trinity Charter School EMPLOYEE CAFETERIA PLAN (SECTION 125) makes it possible for you to pay for health insurance with pre-tax dollars and reduce your taxes. CAUTION! You cannot change this agreement during the plan year unless you have a significant change in family status: marriage or divorce; death; birth or adoption; loss or gain of a job; change in full-time or part-time status by participant or spouse; unpaid leave of absence; significant change in health coverage attributable to spouse’s employment. To allow the change, written notice of a family status change must be submitted within 31 days of the change. Example: If you sign up for yourself and child on insurance, you may not drop the child from insurance later in the plan year unless there is a change in family status, as listed above. PRE TAX ELECTION: ( ) I want to participate in the Trinity Charter School EMPLOYEE CAFETERIA PLAN (SECTION 125) and agree to pay for the following plan with pre-tax dollars: Health Insurance Employee Only Employee & Child(ren) Employee & Spouse Employee & Family
I understand that this deduction election is for health insurance premiums only. My election will remain in force during the entire plan year, September 1 through August 31, unless I have a change in family status as defined in the plan contract or I change my election during open enrollment. Date
Signature of Employee
Date
Signature of Employer
AFTER TAX ELECTION: ( ) I understand the Trinity Charter School EMPLOYEE CAFETERIA PLAN (SECTION 125) and choose not to participate in the plan: Date
Signature of Employee
Date
Signature of Employer 08/12
To: FULL-TIME BENEFIT EMPLOYEES Re: Special Enrollee Notification
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires us to inform you of your rights to Special Enrollment under this plan when you and or your eligible dependents decline coverage during the initial enrollment period or discontinue current coverage. If you are declining coverage for yourself or your dependents (including your spouse) because of other health insurance coverage, you may in the future be able to enroll yourself and/or your dependents in this plan provided that you request coverage within 31 days after your other coverage ends. In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption or a court order, you may be able to enroll yourself and/or your dependents, provided that you request enrollment within 31 days after the marriage, birth, adoption, or placement for adoption or the court order. Employees who choose not to enroll when first eligible or do not meet the Special Enrollment criteria, will be considered Late Applicants. Late Applicants may apply for insurance only during the annual Open Enrollment period. I understand that to qualify as a Special Enrollee, I must notify the Plan Administrator within 31 days of: $
$
Termination of my/our current coverage as a result of exhausting of the maximum period of COBRA coverage or due to legal separation, divorce, death or termination of employment or reduction in the number of hours of employment; or A change in my family status as a result of a marriage, birth, adoption or placement for adoption of a child.
Employee’s Signature:
Date: 08/14
General Notice of Special Enrollment Rights and Preexisting Condition Exclusion Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), your group health plan is required to provide you this notice explaining your group health plan’s procedures for your special enrollment rights and imposing preexisting condition exclusions. • Your Special Enrollment Rights – If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance coverage, you may in the future be able to enroll yourself or your dependents in this plan, provided that you request enrollment within 31 days after your other coverage ends. In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents, provided that you request enrollment within 31days after the marriage, birth*, adoption, or placement for adoption. • Pre-existing Condition Exclusions – Under HIPAA, a “preexisting condition” is a condition for which medical advice, diagnosis, care, or treatment was recommended and received within the six-month period ending on the enrollment date in a health plan (the look-back period). Taking prescription medications during the look-back period constitutes receiving treatment. Your plan may deny benefits for a preexisting condition during a 12-month waiting period beginning on your enrollment date. (If you do not enroll in a timely manner, the maximum waiting period is 12 months from the date coverage begins.) A preexisting condition exclusion does not apply to a pregnancy or to a newborn child or adopted child under age 18 who becomes covered within 31 days of birth* or adoption. A genetic condition without advice, care, or treatment is not a preexisting condition. The existence of a preexisting condition will be determined using information obtained relating to an individual’s health status before his or her enrollment date. An individual’s enrollment date remains the same even if the individual changes benefit package options, as permitted by plan rules. The preexisting condition waiting period is reduced by any creditable coverage (prior coverage under various plans including, but not limited to, group health plans, individual health policies, Medicare, and Medicaid). You may obtain a certificate of creditable coverage from a prior plan sponsor or health insurance issuer. Should you disagree with the length of creditable coverage determined by TRS-ActiveCare, you have the right to appeal that determination and provide additional evidence of creditable coverage. For further information, contact your Benefits Administrator.
___________________________________ Employee Signature
____________________________ Date
*Special rules apply to newborns; refer to your TRS-ActiveCare Benefits booklet for more information.
