HUMAN RESOURCES ORIENTATION CHECKLIST EMPLOYEE NAME: Position:
DATE OF HIRE:
Introductory Period Notice Employee Handbook Acknowledgement Confidentiality and Access Agreement HIPPA Notification Social Media Acknowledgement Confidentiality Statement for Computer Passwords and Acceptable Internet Usage Bloodborne Pathogens Training Record Hepatitis B Notification EFT Authorization W-4 Social Security Notification Employee Injury Plan Arbitration for Employee Injury Claims I-9 Staff Emergency Contact Form Automobile Insurance Coverage Health Coverage Notification Security Release Form
*Any document not on the list is for the employee to keep.*
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) and agree to its terms. Employee’s Signature
Date
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
Confidentiality and Access Agreement I am currently an employee for Trinity Charter Schools. Because of the nature of my position, I may have access to certain sensitive student records and/or employee information. This Confidentiality and Access Agreement will remain in effect regardless of my position or location of employment with Trinity Charter Schools. _______ (initial) I understand that any unauthorized disclosure of confidential information regarding students is prohibited as provided in the federal Family Educational Rights and Privacy Act of 1974 (FERPA), 20 U.S.C. 1232 eg. seq. and in the federal regulations found in 34 CFR Part 99. FERPA is specifically incorporated into the Texas Public Information Act (formerly known as the Open Records Act). It is listed as an exception to records that are subject to disclosures to the public. I hereby affirm that any student data of which I have knowledge will be kept strictly confidential, and I will not disclose any student’s confidential information to anyone other than a District employee with a legitimate educational need to know. I understand that any unauthorized disclosure of confidential information regarding employees is prohibited in accordance with 19 TAC 247.2, Code of Ethics and Standard Practices for Texas Educators. In addition, I understand that any conversations among staff are confidential and are to be protected. _______ (initial) I will not repeat any sensitive information I may overhear regarding a student or staff member to any member of the public without proper authorization. I understand that any data or reports that I may generate are confidential and the data are to be protected. I understand that transmitting or providing TCS data outside of our network is a breach of this agreement and may be a safety or identity threat to students and staff. I will not distribute to any unauthorized person any data or reports that I have access to or may generate using confidential TCS data. I hereby agree that failure to abide by the requirements of this agreement may lead to the immediate revocation of my employment with TCS. ______ (initial) I understand that any intentional, knowing, or negligent release of confidential student and/or employee information to unauthorized persons may also subject me to a legal cause of action for violation of an individual’s civil rights in addition to state or federal criminal penalties. I hereby waive, release and discharge TCS, its trustees, officers and employees from any claim, demand or cause of action arising out of my negligent use or misuse of confidential student or employee information. I agree to hold the TCS harmless from any and all liability that the district may incur, including without limitation, damages of every kind and nature and out-of-pocket costs and legal expenses, incurred by reason of my negligence or misuse of confidential student or employee information.
_____________________________ Printed Name of Employee Signature of Employee
_____________________________ ________________________ Date Signed
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
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 TRSActiveCare, 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.
Social Media Acknowledgment I understand that information listed on my application is true and correct and that any false information could lead to termination of my employment. Do you have legal actions from the past or other matters that may be embarrassing to the school district or yourself that should be disclosed at this time?
If yes, explain__________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________
____________________________ Printed Name of Employee
____________________________ Signature of Employee
____________________________ Date Signed
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 and 4.35 Employee Internet Safety. 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 use the internet for educational purposes only and understand it is my responsibility to monitor student internet activity to prevent students from accessing inappropriate internet websites.
I will not sign another person in under my password and let them have access to my computer.
Employee’s Signature
Date
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.
What You Need to Know 1
What is hepatitis B?
2
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: • loss of appetite • diarrhea and vomiting • tiredness • jaundice (yellow skin or eyes) • 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
Hojas de Informacián Sobre Vacunas están disponibles en Español y en muchos otros idiomas. Visite http://www.immunize.org/vis
• 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.
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.
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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 developmentally 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. • 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. 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.
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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. • Anyone who has had a life-threatening allergic reaction to a previous dose of hepatitis B vaccine should not get another dose. • Anyone who is moderately or severely ill when a dose of vaccine is scheduled should probably wait until they recover before getting the vaccine. 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.
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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. Some mild problems have been reported: • Soreness where the shot was given (up to about 1 person in 4). • Temperature of 99.9°F or higher (up to about 1 person in 15).
Severe problems are extremely rare. Severe allergic reactions are believed to occur about once in 1.1 million doses. 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.
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What if there is a moderate or severe reaction?
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. VAERS does not provide medical advice.
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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.
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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)
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:
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:
Bank Transit Number:
Zip: (Attach copy of VOIDED check or savings deposit slip)
Bank Account Number: Employee Name (Printed): Employee Signature: Employee ID Number:
_ Date: 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
5/2012
Form SSA-1945 (12-2004)
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. /12
Form SSA-1945 (12-2004)
Solutions
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August 3, 2012 RE: Casa Gracia ERISA amendment To Whom It May Concern: The changes listed below have been approved for the Casa Gracia ERISA plan.
AMENDMENT NUMBER ONE TO CASA GRACIA EMPLOYEE OCCUPATIONAL INJURY BENEFIT PLAN Effective August 15,2012, the Casa Gracia of the South, Inc. Employee Injury Benefit Plan (the "Plan") is amended as follows:
3.3 Medical Determinations and Treatment Medical Benefits are payable only for Covered Medical Expense for Medical Care directly relating to treatment of an Occurrence.
(a) The first Covered Medical Expense must be incurred within 30 days of the day of the Occurrence causing the Occupational Injury. (b) No further amount shall be considered a Covered Medical Expense if the Participant does not receive medical treatment from an Approved Provider (or scheduled treatment with an Approved Provider has not been approved by the Claims Administrator) for a period of more than 60 days. This subsection (b), however, shall not apply to any Covered Medical Expense for testing and any follow up vaccination with respect to an Occurrence that involves a potential occupational exposure to a blood borne pathogen. (c) Medical benefits shall be paid by the Employer directly to an Approved Provider, or to the Participant as reimbursement for such medical care which the Participant has already paid an Approved Provider.
Combined Group 14785 Preston Rd. Suite 350 Dallas, TX 75254 Ph. 2 14-295- 1600 Fax 214-295-1700 Tol l Free: 800-275-6900 www .combinedgroup.com
COMtiiNED
GKOliP
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'l'llill Simplify
4.2 Non-Covered Injuries The plan specifically excludes any Pre-existing Condition and degenerative conditions. "Definitions"
Pre-existing Condition means an Injury caused by or diagnosed to be the aggravation or re-injury of a prior condition or Injury including degenerative conditions (such as osteoarthritis, arthritis, or any other degenerative process of the joints, bones, tendons or ligaments). The plan does not cover, and therefore will not pay for any Pre-existing Condition. All other terms and conditions in the Agreement shall remain unchanged and in full force and effect. Executed this 3rd day of August, 2012 to be effective August 15, 2012.
Combined Group 14785 Preston Rd. Suite 350 Da l las. TX 75254 Toll Free: 800-275-6900 www .combinedgroup.com
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
TCS Employee Injury Benefit Plan Information RESPONSIBILITY
TCS is committed to providing all employees with a safe and healthful work environment. Safety is paramount in all work efforts. There is no justification for performing work related tasks in an unsafe manner. It is the responsibility of all employees to attend in-service safety training, observe safety rules and report safety violations. Employees are encouraged to make suggestions that would improve safety. ACCIDENT /INCIDENT REPORTING
Any employee who witnesses, discovers or is involved in a workplace accident or incident, no matter how minor, must report it to his/her supervisor immediately and no later than the end of his or her shift. An Accident Report will be completed, by the employee involved and his/her supervisor, within 24 hours of when the accident/incident occurred. MEDICAL RELEASE
Whenever a situation arises where the physical condition of an employee may be in question, a written medical release from a physician must be provided by the employee before the employee can begin work or return to work. Any work limitations noted on the medical release will be adhered to strictly (see Limited Duty section below). LIMITED DUTY
Employees injured on the job will return to work on a temporary basis on limited duty as soon as the attending physician has provided a written medical release. Duties will be tailored to fit the employee's medical condition. All restrictions on the medical release will be adhered to strictly. Direct care facility employees on limited duty will normally be assigned to the day shift due to limited supervision and staffing at night. Limited duty is provided only for employees injured on the job. NON-SUBSCRIBER TO WORKERS' COMPENSATION- TEXAS ONLY
TCS does not subscribe to Workers' Compensation Insurance for its services located in the State of Texas. Each accident/incident will be judged on its own merit. Safety Plan Benefits (see below) should never be called, and are not to be construed as, Workers Compensation by any Texas employee ofTCS. Any payment made by TCS in connection with an alleged job related accident/incident is made with the definite understanding that such payment in no way constitutes an admission of liability on the part ofTCS. OCCUPATIONAL BENEFIT PLAN BENEFITS- TEXAS ONLY
Medical and salary benefits may be paid for an employee who is unable to work due to an injury which is sustained on the job, provided: • • •
The injury is reported immediately to the supervisor (no later than the end of his/her shift) and an Accident Report is completed within 24 hours of when the injury occurred. A physician designated by TCS prescribes the treatments or requires the employee to miss work. The employee follows all of the physician's orders for limitation of activities and makes all recommended medical appointments.
Employees who have or cause an accident/incident on the job which is determined to be due to their intoxication, use of illegal drugs, self inflicted injury, horseplay or any other safety violation are not eligible for Safety Plan benefits. Employees who are released for full or limited duty are not eligible for Safety Plan benefits unless they resume working.
CASA GRACIA DBA TRINITY CHARTER SCHOOL EMPLOYEE INJURY BENEFIT PLAN Benefits Schedule COMPANY INFORMATION: 1. Company Name : Casa Gracia DBA Trinity Charter School 2. Address : 8305 Cross Park Drive, Austin, TX 78754 3. Telephone Number : 512-459-1000 4. Federal Tax J.D. Number: 74-1109745 5. Nam e and Telephone Number of Contact Person for Employee Questions: Sheila Wad ley: 512-706-7542 6. N arne and Address of Agent for Service of Legal Process : Sheila Wadley, 8305 Cross Park Drive, Austin, TX 78754 7. Plan Number: BENEFIT LIMITS 8. Effective for Injury Occurrence On or After: 02/02/11 9. Maximum Coverage Period: 156 weeks 10. Total Disability Benefits: a. ·Waiting Period: 5 days* b. Percentage of Pre-I njury Pay: 85% lost time/85% light duty (90% for employees earning less than $8.50/hr) c. Maximum Weekly Di sability Benefit Amount: $700* *Participants may receive a higher percentage of pay or be subject to a shorter waiting period or higher maximum weekly amount pursuant to a payroll practice adopted by the Company and any Participa ting Employers. Contact the person in Item 5 above regarding availability (if any). 11. Death or Dismemberment Benefit Limit : $150,000 12. Combined Limits for All Benefits : a. Maximum Any One Employee Per Occurrence: $2,000,000 b. Maximum All Employees Per Occurrence : $25,000,000 c. Annual Aggregate: $25,000,000 Please see the official Plan Docum ent for other benefit limitations and exclusions. SIGNATURE AND DATE: The Company hereby adopts this Plan by signatur e of its authorized representative.
(Signature a d
le)
Date
CASA GRACIA DBA TRINITY CHARTER SCHOOL EMPLOYEE INJURY BENEFIT PLAN
& ARBITRATION PROGRAM
RECEIPT AND ARBITRATION ACKNOWLEDGMENT RECEIPT OF MATERIALS. By my signature below, I acknowledge that I have received and read (or had the
opportunity to read) the Benefit Plan Information, Benefits Schedule, Summary Plan Description (the "SPD") for the Employee Injury Benefit Plan, and Mutual Agreement To Arbitrate Claims, effective 02/02/2009. ARBITRATION. I acknowledge that this includes a mandatory company policy requiring that certain claims
or disputes (that cannot otherwise be resolved between the Company and me) must be submitted to an arbitrator, rather than a judge and jury in court. I understand that by receiving this Mutual Agreement To Arbitrate Claims and becoming employed (or continuing my employment) with the Company at any time on or after 02/02/2009, I am accepting and agreeing to comply with these arbitration requirements. I understand that the Company is also accepting and agreeing to comply with these arbitration requirements. All covered claims brought by my spouse, children, parents, estate, successors and assigns are also subject to this Mutual Agreement To Arbitrate Claims, and any decision of an arbitrator will be final and binding on such persons and the Company.
x Employee's Signature
Date
Print Employee's Name
Employee's Social Security No.
Employee's Work Location
Department
*A copy ofthe Employee Injury Benefit Plan can be located on the LSS intranet or with your facility HR rep
Employment Eligibility Verification
USC IS
Form l-9
Department of Homeland Security
OMB No. 1615-004 7 Ex pires 03/ 3 l/ 20 16
U.S. Citizenship and Immigration Services
...START HERE. Read instructions carefully before completing this form. The instructions must be available during completion of this form. ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) they will accept from an employee . The refusal to hire an individual because the documentation presented has a future expiration date may also constitute illegal discrimination .
Section 1. Employee Information and Attestation
(Employees must complete and sign Section 1 of Form 1-9 no later than the first day of employment, but not before accepting a job offer) Last Name (Family Name)
First Name (Given Name)
Address (Street Number and Name)
Date of Birth (mm/dd/yyyy)
Apt. Number
U.S. Social Security Number
Middle Initial Other Names Used (if any)
City or Town
State
E-mail Address
Zip Code
Telephone Number
I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form. I attest, under penalty of perjury, that Iam (check one of the following):
D A citizen of the United States 0 A noncitizen national of the United States (See instructions)
D A lawful permanent resident (Alien Registration Number/USC IS Number): D An alien authorized to work until (expiration date, if applicable , mm/dd/yyyy)
_ . Some aliens may write "N/A" in this field .
(See instructions) For aliens authorized to work, provide your Alien Registration Number/ USCIS Number OR Form 1-94 Admission Number : 1. Alien Registration Number/USCIS Number:
_ 3-D Barcode Do Not Write in This Space
OR 2. Form 1-94 Admission Number:
_
If you obtained your admission number from CBP in connection with your arrival in the United States, include the following: Foreign Passport Number:----------------------Country of Issuance: ------------------------Some aliens may write "N/A" on the Foreign Passport Number and Country of Issuance fields. (See instructions) Signature of Employee :
Date (mm/ dd/ yyyy):
Preparer and/or Translator Certification (To be completed and signed if Section 1 is prepared by a person other than the employee.) Iattest, under penalty of perjury, that I have assisted in the completion of this form and that to the best of my knowledge the information is true and correct.
I
Signature of Preparer or Translator :
Last Name (Family Name)
A ddress (Street Number and Name)
Date (mmldd/yyyy):
First Name (Given Name)
City or Town
State
Zip Code
Employer Completes Next Page Form 1-9 03/08/ 1 3 N
Page 7 of9
Section 2. Employer or Authorized Representative Review and Verification (Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee 's first day of employment . You must physically examine one document from List A OR examine a combination of one document from List Band one document from List C as listed on the "Lists of Acceptable Documents" on the next page of this form. For each document you review, record the following information : document title, issuing authority, document number, and expiration date, if any.) Employee Last Name, First Name and Middle Initial from Section 1:
List A
OR
AND
List B
Identity and Employment Authorization
Identity
List C Employment Authorization
Document Title:
Document Title :
Document Title:
Issuing Authority :
Issuing Authority :
Issuing Authority :
Document Number:
Document Number:
Document Number:
Ex piration Date (if any)( mmlddlyyyy) :
Expiration Date (if any)(mmldd/yyyy) :
Expiration Date (if any)(mmlddlyyyy):
Document Title : Issuing Authority: Document Number: Expiration Date (if any)(mmlddlyyyy) : 3-D Barcode Do Not Write in This Space
Document Title: Issuing Authority : Document Number: Expiration Date (if any)( mmlddlyyyy) :
Certification I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee , (2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the employee is authorized to work in the United States. The employee's first day of employment (mmldd/yyyy)' Signature of Employer or Authorized Representative
Last Name (Family Name)
(See instructions for exemptions.) Date (mmlddlyyy y)
First Name (Given Name)
Title of Employer or Authorized Representative
Employer's Business or Organization Name
Employer's Business or Organization Address (Street Number and Name) City or Town
State
Zip Code
I Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.) A . New Name (if applicable) Last Name (Family Name) First Name (Given Name)
J B. Date of Rehire (if applicable) (mmldd/yyyy) :
Middle Initial
C. If employee's previous grant of employment authorization has expired, provide the information for the document from List A or List C the employee
presented that establishes current employment authorization in the space provided below. Document Title:
Document Number:
Expiration Date (if any)(mmldd/yyyy):
I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented document(s) , the document(s) I have examined appear to be genuine and to relate to the individual. Signature of Employer or Authorized Representative:
Form 1-9 03108113 N
Date (mmlddlyyyy) :
Print Name of Employer or Authorized Representative:
Page 8 of9
LISTS OF ACCEPTABLE DOCUMENTS All documents must be UNEXPIRED Employees may present one selection from List A or a combination of one selection from List 8 and one selection from List C.
LIST A Documents that Establish Both Identity and Employment Authorization
LIST B
LIST C
Documents that Establish Identity AND
OR
1. U.S. Passport or U.S. Passport Card 2. Permanent Resident Card or Alien Registration Receipt Card (Form 1-551)
3. Foreign passport that contains a temporary 1-551 stamp or temporary 1-551 printed notation on a machinereadable immigrant visa
4. Employment Authorization Document that contains a photograph (Form 1-766)
Documents that Establish Employment Authorization
1. Driver's license or ID card issued by a State or outlying possession of the United States provided it contains a photograph or information such as name, date of birth, gender , height, eye color, and address 2. ID card issued by federal, state or local government agencies or entities, provided it contains a photograph or information such as name, date of birth, gender , height, eye color , and address
3. SchooiiD card with a photograph 5. For a nonimmigrant alien authorized to work for a specific employer because of his or her status :
4. Voter's registration card 5. U.S. Military card or draft record
a. Foreign passport ; and b. Form 1-94 or Form I-94A that has the following : (1) The same name as the passport ; and (2) An endorsement of the alien's nonimmigrant status as long as that period of endorsement has ' not yet expired and the proposed employment is not in ' conflict with any restrictions or limitations identified on the form . 6. Passport from the Federated States of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with Form 1-94 or Form 1-94A indicating nonimmigrant admission under the Compact of Free Association Between the United States and the FSM or RMI
6. Military dependent's ID card 7. U.S. Coast Guard Merchant Mariner Card
1. A Social Security Account Number card, unless the card includes one of the following restrictions: (1) NOT VALID FOR EMPLOYMENT (2) VALID FOR WORK ONLY WITH INS AUTHORIZATION (3) VALID FOR WORK ONLY WITH DHS AUTHORIZATION 2. Certification of Birth Abroad issued by the Department of State (Form FS-545)
3. Certification of Report of Birth issued by the Department of State (Form DS-1350)
4. Original or certified copy of birth certificate issued by a State, county , municipal authority . or territory of the United States bearing an official seal
8. Native American tribal document
5. Native American tribal document
9. Driver's license issued by a Canadian government authority
6. U.S. Citizen ID Card (Form 1-197)
For persons under age 18 who are unable to present a document listed above:
7. Identification Card for Use of Resident Citizen in the United States (Form 1-179)
8. Employment authorization 10. School record or report card
document issued by the Department of Homeland Security
11. Clinic, doctor , or hospital record 12. Day-care or nursery school record
Illustrations of many of these documents appear in Part 8 of the Handbook for Employers (M-274). Refer to Section 2 of the instructions, titled "Employer or Authorized Representative Review and Verification," for more information about acceptable receipts.
Fonn I-9 03/08/1 3 N
Page 9 of 9
Staff Emergency Contact Form For 2015-2016 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
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 the first day of my official start date or the first day following the month after hire. This also serves as your receipt that TCS offered you coverage on this day signed below.
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
DATE RETURNED
BADGE Desk #: File cabinet #:
Keys ‐ Room #:
OTHER ITEMS: (i.e., uniforms, calling card, equipment, etc. Radio/headset: Computer: Desktop
Laptop
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
Employee’s Signature
Date
Date
Supervisor’s Signature
Supervisor’s Signature
Date
Date
