1HE v^Rnsir
SCHOOL
The Varnett Public School's personnel procedures
and job-related information for employees
2016-2017
EMPLOYEE HANDBOOK
The Varnett Public Schoor is dedicated to excellence
in all things.
Dr. Margaret Stroud Superintendent August 2016
VdRREir
SCHOOL
2016-2017 Board Members
Dr. Matthew Plummer
President
Dr. Edgardo Colon
Vice-President
Mr. Clarence White III
Secretary
Mrs. Marcia Johnson, Esq.
Member
Mr. Ward S. Gray
Member
Dr. Margaret Stroud
(Non-Voting Member)
Table of Contents PAGE{S) 1.
INTRODUCTION 1.1.
Welcome to The Vamett Public School
7
1.2.
About this Employee Handbook
8
1.3.
About The Varnett Public School
8
History Update
8
Governance
9
1.4.
2.
Board of Directors
9
Mission Statement
9
1.6.
Core Beliefs
9
1.7.
Vision Statement
10
1.8.
Educational Goals
11
1.9.
Acknowledgment of Receipt of Employee Handbook
STARTING YOUR JOB
2.2.
2.3. 2.4.
4.
8
1.5.
2.1.
3.
7
Accuracy of information Employment Application & Required Documentation Criminal History Background Checks New Employee Orientation
REPORTING TO WORK
12 12 12 13 13
13
3.1.
Official The Varnett Public School Office Hours
13
3.2.
Regular Work Schedules
13
3.3.
Attendance
14
3.4.
Employee Absences
14
TIME AWAY FROM WORK/LEAVES OF ABSENCE 4.1.
Leave Policy and Procedures
15
4.2.
Leave Terms and Conditions
16
Terms:
16
Immediate Family Family Emergency Workday
16
16
Year
16
Conditions:
16
Absence From Duty Request Notice Of Early Return To Work Responsibility Of Employee Recording Of Leave Taken
16
16
16 16 17
Medical Certification
17
Health Care Provider
17
ih:
VARnsir
MHOOL
Excellence Is Expected
Employee Handbook 2016-2017 - Board Approved September 12.2016
Page 1 of 38
PAGE(S}
4.3.
Conditions - continued:
1:
Certification Of Long-Term Illness
1
Medical Release
1
Failure To Return To Work
1
Employee Reinstatement Restricted Duty Availability
1" 18 18
Donation Of Leave
18
Types of Leaves and Absences Family or Medical Leave Act (FMLA) / Family Medical Leave of Absence (FMLA) Eligible Employees
18 18 19
Service member FMLA Leave
19
Leave Eligibility and Duration
20
Veterans
20
Family Medical Leave
20
Local Personal Leave
20
Maternity Leave
20
Combined Leave For Spouses
20
Rate Of Accrual For Local Personal Leave
21
Adoption Leave Hardship Leave Temporary Disability Leave
21 21 21
Education Leave
21
Jury Duty Ottier Court Appearances
22 22
Short-Term Leave
22
Long-Term Leave
22
Other Absences
22
Intermittent Leave
22
Workers' Compensation Workers'Compensation Insurance
22 23
4.4. 4.5.
Workers' Compensation Benefits Compensatory Time Holidays & School Breaks - See School Calendar Appendix B
24 24 24
4.7.
Vacation/Local Personal Paid Leave/Sick Leave
25
Vacation Leave
25
Accumulation
25
Requests for use of Vacation Leave Compensation for unused Vacation Leave Forfeited Vacation Days
25 26 26
tHE vdiinsir
SCHOOL
Excellence Is Expected
Employee Handbook 2016-2017 - Board Approved September 12,2016
Page 2 of 38
Table of Contents PAGE(S)
5.
4.8. Bereavement Leave
26
4.9. Military Leave Of Absence
26
COMPENSATION AND BENEFITS
27
5.1. Salaries and Wages 5.2. Payroil 5.3. Direct Deposit 5.4. Mistake in Payroll or Expense Reimbursement 5.5. Hours Woi1ol
Excellence Is Expected
Employee Handbook 2016-2017 - Board Approved September 12, 2016
Page 11 of 38
2.
STARTING YOUR JOB
2.1. Accuracy of Infomiation The Vamett Public School relies upon the accuracy of information contained in the employment application, as well as the accuracy of other information presented throughout the hiring process and employment. Employees are expected to provide truthful and accurate information in connection with their employment at The Vamett Public School.
Any falsification or misrepresentation in connection with application materials, or during the course of employment, is a serious offense and may lead to discharge from employment or nonselection of an applicant. 2.2. Employment Application & Required Documentation
New employees are required to complete and submit the following documentation: Copy of Driver's License Copy of Social Security Card/Passport Copy of Service Record Official Transcripts Application Criminal History Authorization Fonn Fingerprint Applicant Information Form W-4 Form 1-9 Form SSA-1945 Form
Sexual Harassment Policy Form Substance Abuse Policy Form Direct Deposit Form
Wage Deduction Authorization Agreement Form Ethnicity and Race Reporting Guidance Form Emergency Contact Form Attendance History Form Employee Handbook Acknowledgment Form Release of Personal Information Form
Confidentiality Agreement Form Benefit Enrollment Forms
Worker's Compensation Acknowledgement Form All forms may be found on The Vamett Public School website at www.varnett.orq
Current employees may be required to update or execute any of the above documentation. Any employee who falls or refuses to complete the above documentation or to provide The Vamett Public School with requested documentation may be subject to discipline, up to and Including discharge from employment.
IHS
VAimeir
>CM001
Excellence Is Expected
Employee Handbook 2016-2017 - Board Approved September 12, 2016
Page 12 of 38
2.3. Criminal Background Checks A person may not be employed or serve as a teacher, substitute teacher, librarian, educational aide, administrator, or counselor unless the person has been approved by the Texas Education Agency following a review of the person's National Criminal History Record Information. Each individual serving or expected to serve in the aforementioned roles will be expected to comply and submit the necessary information for the background check.
Additionally, other employees and contractors subject to criminal background checks wll be required to comply and submit the necessary Information for the background check. 2.4. New Employee Orientation
During the first few weeks of employment, an employee must attend an orientation that will include the following subject areas: a.
A review of this personnel Handbook;
b.
A tour of the campus;
c.
Receipt of credentials necessary for parking, access to the school building, keys (if applicable), and other materials as appropriate;
d.
Prevention techniques for, and recognition, of sexual abuse and other maltreatment of children.
3.
REPORTING TO WORK
3.1. The Official Varnett Public School Office Hours
Standard hours of operation in the administrative office areas are from 7:30 a.m. until 4:30 p.m. Students are in session from 8:00 a.m. until 3:15 p.m.
3.2. Regular Work Schedules
The Varnett Public School has a standard workweek of forty (40) hours per week, excluding time off for lunch or other personal breaks. Scheduled hours for employees may vary from department to department.
All full-time, non-exempt employees generally work a Monday through Friday schedule of forty (40) hours divided into (5) eight-hour workdays unless a different schedule Is approved in writing by the employee's supervisor.
Exempt employees are expected to work the hours necessary to complete their assigned work to the satisfaction of their supervisor without regard to scheduled hours and without expectation of additional compensation.
All employees are expected to be at work during The Varnett Public School's official office hours unless otherwise required or approved by the employee's supervisor.
IHS VARnsnr
>CHOOL
Excellence Is Expected
Employee Handbook 2016-2017 - Board Approved September 12, 2016
Page 13 of 38
3.3. Attendance
The Varnett Public School employees are expected to be reliable and punctual in reporting for work each scheduled day. If an employee will be late to work or is unable to work as scheduled, the employee should notify his or her supervisor in advance as soon as possible. There will be no approval of absences during the 90-day probation period for new hires.
Poor attendance and/or repeated tardiness are disruptive to the operations of The Varnett Public School and may lead to disciplinary action, up to and Including discharge from employment. 3.4. Employee Absences
When it is necessary for an employee to be absent the procedures listed below must be followed;
1. All employees are expected to report anticipated absences to their respective campus director/supervisor as soon as possible.
2. Contact your campus director/supervisor to report an absence no later than 8 p.m. of the preceding day. If this is not possible, notification must be made to your campus director/supervisor before 6 a.m. on the day of the absence. Campus directors/supervisors will provide emergency contact Information to employees during employee orientation.
3. Upon returning to work, the employee must clock in and complete an Absence/Leave Request Form documenting the absence along with appropriate documentation that may be related to the absence. The employee must submit the completed absence/leave request form to the campus director/supervisor.
IHE
VARnEV
SCHOOL
Excellence Is Expected
Employee Handbook 2016-2017 - Board Approved September 12, 2016
Page 14 of 38
Classroom teachers are required to have a substitute folder readily accessible. This folder \mII be kept by the schools' instructional coaches and will be updated as needed. The folder should contain the following at all times: •
Lesson plans;
•
Alternative activities, if needed;
• • •
Seating charts - if applicable; Class rosters; Discipline plan;
•
Fire drill and disaster routes;
•
Name and room number of a staff member to answer questions; also, names of helpful students; and Special instructions unique to your location or subject area.
•
4. TIME AWAY FROM WORK/LEAVES OF ABSENCE
The Vamett Public School recognizes there will be occasions when an Illness or other personal events may result In an unscheduled absence. As such. The Varnett Public School has a leave policy. 4.1. Leave Policy and Procedures
It is the policy of The Vamett Public School to provide opportunities for employees to take leave under appropriate conditions. The Varnett Public School recognizes a variety of circumstances where leave may be appropriate. An employee who qualifies for leave must follow the procedures below.
To request a leave of absence, the employee must submit an Absence from Duty Request Form to the supervisor. The form must provide the appropriate information that may include: 1. The type of leave that is being requested; 2. The period of time requested;
3. Where appropriate, (e.g. sick leave. Family Medical Leave, Disability Leave) a written statement from an attending physician on official letterhead outlining the nature of the illness and anticipated recovery time;
4. Adoption documents from the appropriate Adoption Agency; and 5. Official military duty assignment documents.
The request for leave is to be submitted to the supervisor at least two (2) weeks prior to the date the leave is requested. In the event circumstances will not permit a leave request two weeks in advance, the request must be made as soon as feasible. No action will be taken until documentation for Absence From Duty requests has been submitted.
Please note that all requests must be in writing; no verbal requests or mentioning of an Absence From Duty Requests in casual conversation will be accepted. Leave of absences taken any time after April 15 through June 30 must be approved by the supervisor/director and Superintendent. Local personal leave days may not be combined with a school holiday.
1HE
Vdansir
XHOOL
Excellence Is Expected
Employee Handbook 2016-2017 - Board Approved September 12, 2016
Rage 15 of 38
An "Absence from Duty" request that has been denied may be appealed in accordance with The Varnett Public School Grievance Policy and Procedures. Local personal leave days may not be combined with school holidays. See Section 8. Grievance Procedures. 4.2. Leave Terms and Conditions Terms:
Immediate Family- For the purposes of family leave, the term "immediate family" includes; 1. Spouse or partner; 2. Son or daughter, Including a biological, adopted, or foster child; a stepchild; a legal ward; or a child for whom the employee stands in loco parentis\ 3. Parent, step-parent, parent-in-law or another Individual who stands in ioco parentis to the employee; 4. Sibling, step-sibling, sibling-in-law, son-in-law, or daughter-in-law; 5. Grandparent and grandchild; and 6. Any person who may be residing in the employee's household at the time of Illness or death if such person is treated by the employee as a member of the employee's family.
Family Emergency - The term "family emergency" shall be limited to natural disasters and lifethreatening situations involving the employee or a member of the employee's immediate family. Workday - A "workday" means the number of hours per day equivalent to the employee's work assignment, whether full-time or part-time. If the employee transfers to a position with different hourly requirements, the leave is not adjusted, and future accumulations of leave will be based on the current assignment.
Year - For the purpose of this policy, unless otherwise noted, a "year" means the employee's assigned instructional year. Conditions:
Absence/Leave Request Form- An Absence from Duty Request Form Is required for leave. The absence from duty Is a record established to track and maintain an employee's leave status. The absence can be paid or non-paid and can also be discretionary (foreseen absence) or nondiscretlonary (unforeseen absence).
Notice Of Early Return To Work - An employee who wants to return to work priorto the "return to wor1< date" on the approved Absence/Leave Request Form shall notify the Superintendent before a "return to work" date Is permitted.
Responsibility Of Employee - The employee shall submit leave request forms, return to duty form from an appropriate entity, and related leave of absence documentation to Human Resources before the employee is allowed to return to work.
IHE vonnEir
SCHOOL
Excellence is Expected
Employee Handbook 2016-2017 - Board Approved September 12, 2016
Page 16 of 38
Recording Of Leave Taken - Except for employees who are receiving workers' compensation wage benefits and are on FMLA, employees shall use all local personal/vacation time. Leave is recorded in work days, except in accordance with provisions for Intermittent leave under the Family and Medical Leave Act, Employees shall be charged leave for all leave taken. The Business Office shall monitor and accurately report an employee's use of leave time. Medical Certification - An employee absent three or more consecutive days due to illness shall require certification of a health care provider, either prior to or on the day he/she return to work. Health Care Provider - Medical certification shall be made by a health care provider as defined by the Family and Medical Leave Act. Certification Of Long-Term Illness - Upon request for a long-term leave of absence for an employee's serious health condition or for that of an immediate family member, the employee should provide medical certification of the disability or illness at a minimum of 30-day Intervals when he or she is:
1. In a temporary disability leave status only, or 2. In FMLAi and has exceeded the date of disability assigned by his or her physician.
An employee's failure to provide proper notice and required documentation for an extension of the leave may result in denial of a leave request. Medical Release - An employee's request to return to work shall be accompanied by written medical certification of the employee's ability to perform essential job functions immediately upon return to duty. This certification must be provided to the supervisor and Human Resources prior to the first day of returning to work. An employee cannot provide a certificate on the same day that he or she returns to work. Failure To Return To Work - An employee's failure to return from maximum available longterm leave may result in his or her termination of employment. In the event a contract employee falls to return to active duty as soon as he or she is released by the physician to perform regular duties, and the employee is not on an approved FMLA or Temporary Disability Extended Leave and has not requested a release from his or her contract, he or she may be subject to termination. In the event a non-contract employee fails to return to active duty as soon as he or she is released by the physician to perform regular duties, and the employee is not on an approved FMLA or temporary disability extended leave, the employee may be deemed to have resigned his or her position with The Varnett Public School and to have waived any and all rights to further employment by The Varnett Public School.
Employee Reinstatement - Ail employees of The Varnett Public School are subject to assignment by the Superintendent. Therefore, an employee returning from any type of absence or leave may be assigned to a different position, just as an employee not on leave. However, when possible to meet the educational needs of The Varnett Public School's students, efforts shall be made to return the employee to the same school and position held by the employee before the leave. If the educational needs of The Varnett Public School do not allow such an
assignment, a suitable assignment w/iil be made subject to availability. The Varnett Public School shall meet return to work provisions found in the various leave laws. The employee's pay and benefits shall resume or continue as specified in the policy under which the employee's leave was granted. An employee returning from leave shall be entitled to return no later than the start of the next school year after making a written request to The Varnett Public School to return. An employee's reinstatement may be delayed until the start of the next school year If the employee's leave ends within the last reporting period or within the last six weeks of school. 1HS VdRHEir
XHOOL
Excellence Is Expected
Employee Handbook 2016-2017 - Board Approved September 12, 2016
Page 17 of 38
Restricted Duty - If a physician recommends restricted duty, the Superintendent may approve the employee's return to duty subject to the availability of a position allowing designated restrictions. An employee assigned to restricted duty who refuses to accept the assignment may be subject to termination of his or her employment. Availability - Should the employee cease to be employed by The Varnett Public School prior to the end of his or her calendar year, leave earned will be prorated based on actual days employed. Any leave days used but not earned shall be deducted from the employee's final paycheck. Employees who resign shall forfeit all local personal days.
Donation Of Leave - Employees may not donate unused leave to another employee. 4.3. Types of Leaves and Absences Family or Medical Leave Act (FMLA)
1. The Varnett Public School is required to comply with the Federal Family Medical Leave Act (FMLA) of 1993.
2. The FMLA entitles eligible employees to take up to 12 weeks of paid or unpaid, jobprotected leave in a 12-month period based on the employee's anniversary hire date for:
• •
The birth or placement of a child for adoption or foster care. To care for an immediate family member (spouse, child, or parent) with a
•
To take medical leave when the employee is unable to work because of
serious health condition. his/her own serious health condition.
•
To take leave pursuant to military eligibility.
3. The Varnett Public School resen/es the right to designate FMLA leave as needed to
any eligible employee and to require employees to use first all available paid time off as qualifying FMLA time toward the 12-week limit.
4. For more information see Appendix A of this Employee Handbook or contact Human Resources at 713-667-4051.
IHs
VARnST
SCHOOL
Excellence Is Expected
Employee Handbook 2016-2017 - Board Approved September 12, 2016
Page 18 of 38
Eligible Employees
In order to be eligible for FMLA, an employee must have worked for Varnett for at least one year and have completed 1,250 hours over the 12 months prior to the commencement of the leave. The 12-month period during which an eligible employee may take up to 12 weeks of unpaid leave will be calculated using the eligible employee's service anniversary date. An eligible employee who wishes to take FMLA must provide his/her supervisor with 30 days advance notice when the leave is foreseeable. At the time of the request, the employee may complete a "Family Medical Leave information/Request Form." Once FMLA is approved by the Superintendent, the employee will receive an information packet containing the full policy, forms, rights and duties of the FMLA for both the employee and the school. In most cases, the eligible employee must submit medical certification to support a request for leave. Health and dental benefits will continue during the FMLA provided the employee makes his/her regular, monthly contributions to the plan. Failure to pay premiums may result in a lapse of coverage. Contact the Business Office for specific details on continuing benefits while on leave.
Employees returning from FMLA within the 12-week period will be restored to their original job, or to an equivalent job with equivalent pay and benefits in accordance with their contract with The Varnett Public School.
Employees returning from a medical FMLA are required to present medical certification of fitness for duty. Failure to provide a medical certificate of fitness for duty may result in a denial of job reinstatement until medical certificate release is provided. FMLA may be taken in increments as small as one hour.
Employees may not earn additional paid time offwhile on FMLA.
Contact Human Resources for the complete policy on the Family and Medical Leave Act and for a full explanation of your rights. FMLA will always begin with paid time off until ail available paid time is used. After exhausting paid FMLA leave, non-paid FMLA leave will continue until the conclusion of the protected 12-week time limit. Following the conclusion of protected leave, the employer will decide whether non-FMLA leave should apply. The medical Certification of Health Care Provider serves as a "doctor's note" to certify the
reason and expected duration of the extended medical leave in writing. All requests for medical leaves must be accompanied by a doctor's statement verifying the employee's total disability and estimated date of return to work. Further, the Varnett requires written medical verification of the employee's ability to resume work and a list of restrictions that would directly relate to his/her ability to perform the job. Service Member FMLA Leave
FMLA entitles eligible employees to take leave for a covered family member's service in the Armed Forces.
1HI
VABHEir
SCHOOL
Excellence Is Expected
Employee Handbook2016-2017-Board Approved September 12, 2016
Rage 19 of 38
Leave Eligibility and Duration
Eligible employees may take service member leave for either (or both) of the following reasons: • A "qualifying exigenc/ arising out of a covered family member's active duty or call to active duty in the Armed Forces.
Leave Duration: Up to 12 workweeks of leave during any 12-month period. • To care for a covered family member ("next of kin") who has incurred an injury or illness in the line of duty while on active duty in the Armed Forces provided that such injury or illness may render the family member medically unfit to perform duties of the member's office, grade, rank or rating. Leave Duration: Up to 26 workweeks of leave during a single 12-month period. (Leave may not exceed 26 weeks in a single 12-month period when it is combined with other FMLA-qualifying leave).
Veterans - The FfylLA extends military caregiver leave to close family members of veterans who were members of the Armed Forces (including the National Guard or Reserves) at any time within five (5) years preceding the date on which the veteran undergoes medical treatment, recuperation, or therapy.
Service member FMLA runs concurrently with other leave entitlements provided under federal, state and local law.
Family Medical Leave - For purposes of an employee's entitlement to family and medical leave, the 12-month period shall be measured forward from the day an individual employee's first family and medical leave begin. The total number of months and hours worked for The Varnett Public School shall be calculated by using the last 12 months prior to the requested date of leave. Family medical leave shall be used in accordance with procedures found in Employee Handbook.
Local 1. 2. 3. 4.
Personal Leave - Local personal leave may be used for the following: Illness of the employee; Illness of a member of the employee's immediate family; Death in the employee's immediate family; and Maternity leave.
Maternity Leave - Maternity leave is defined as a personal illness/disability. The leave period for maternity/disability leave is twelve (12) calendar weeks following the birth of a child if an employee qualifies for FMLA and six (6) calendar weeks for employees who qualify for temporary disability only, unless otherwise documented by a physician.
An employee absent from work must notify his or her supervisor at the beginning of each workday or as soon as possible thereafter.
Combined Leave For Spouses • If both spouses are employed by The Varnett Public School, combined family and medical leave for the birth, adoption, or placement of a child, or to care for a parent with a serious health condition, may be limited to a combined total of 12 weeks as determined by the needs of The Varnett Public School.
1HS
VARnEir
XHOOL
Excellence Is Expected
Employee Handbook2016-2017-Board Approved September 12, 2016
Page 20of 38
Rate Of Accrual For Local Personal Leave - Each employee working for a full school year Is entitled to local personal leave, in equivalent workdays, of five (5) days per year as mandated by law. This local personal leave may not accumulate from year to year. Each person regularly employed for a partial year shall earn local personal leave, in equivalent workdays, prorated based on the first day of employment, up to the maximum of five workdays per year. Local personal leave days may not be combined w/ith a school holiday or utilized prior to the week of standardized testing. Adoption Leave - Employees qualifying for FMLA leave are permitted twelve (12) calendar weeks of adoption leave following the adoption of a child. Employees not qualifying for FMLA, but rather for temporary disability only, are permitted six (6) calendar weeks of leave following the adoption of a child. Hardship Leave - Employees \Mth no paid/personal or FMLA leave available may apply for a hardship leave of absence without pay. The hardship leave may be granted for an extended absence that is in the best interest of the employee and the school. Leave of absence without pay may not exceed 90 days for professional and paraprofesslonal employees and 60 days for auxiliary staff. Employees shall only earn leave based on actual days worked per their employment calendar. Employees needing a hardship leave for more than the maximum number of days may apply for a one-time extension not to exceed 60 days. Employees on leave without pay may continue to participate in The Varnett Public School's group insurance programs but must pay for the coverage.
Temporary Disability Leave - The maximum length of temporary disability leave for auxiliary personnel shall be 60 calendar days. The maximum length of temporary disability leave for all other employees shall be 180 calendar days. Recertlfication is required at 30-day intervals. Temporary disability leave shall run concurrently with FMLA and/or workers' compensation. If a temporary disability is foreseen, then the request for temporary disability leave must be completed 30 days in advance. If the temporary disability is unforeseen, then the request must be submitted as soon as possible. If an employee does not return to work after twelve (12) weeks of FMLA leave, all benefits will be terminated. Employees may continue to participate in The Varnett Public School's group Insurance programs during their twelve (12) weeks of leave, but must pay their portion of those benefits. Education Leave - Contract employees may be granted a one-year, unpaid leave of absence for advanced academic preparation after completion of five (5) consecutive years of employment with The Varnett Public School. Leave shall be granted only to employees in the first year of a four-year term contractual status. Approval shall be recommended to the Board if the employee meets the criteria and has been recommended by his or her campus director. Exempt non-contract employees may be granted a one-year, unpaid leave of absence for advanced academic preparation after completion of five (5) consecutive years of employment with The Varnett Public School. Approval shall be recommended to the Board if the employee meets the criteria and has been recommended by his or her supen/isor and approved by the Superintendent. Non-exempt employees may be granted a one-year, unpaid leave of absence for advanced academic preparation after completion of five (5) consecutive years of employment with The Varnett Public School. Upon completion of the one-year absence, the employee is expected to work for The Varnett Public School for at least one year (equivalent to the employee's assigned calendar year). To be eligible for a paraprofesslonal leave of absence at least one of the following criteria must be met:
IHE
VAiinET
XHOOL
Excellence Is Expected
Employee Handbook 2016-2017-Board Approved September 12, 2016
Page 21 of 38
1. The employee Is in the last year/semester of study. 2. The employee is seeking certification in the employee's current assigned position at The Varnett Public School or in an area that shall be serviceable to The Varnett Public School.
All Varnett-provided benefits shall cease when an employee is on leave without pay for ten (10) or more days during a calendar month. Employees may continue to participate in The Varnett Public School's group insurance programs but must pay for coverage. Jury Duty - An employee shall be granted leave with pay and without loss of accumulated leave for jury duty. The employee shall be required to present documentation of the service and shall be allowed to retain any compensation for this service. An employee who is subpoenaed to appear before a court shall be required to present documentation and shall not be required to use local personal leave.
Other Court Appearances - Absences for court appearances related to an employee's local personal business shall be deducted from the employee's local personal leave; or, if accrued leave time is not available, shall be taken by the employee as leave without pay.
Short-Term Leave - An employee may qualify for short-term leave in extraordinary circumstances, and where the employee is absent three (3) or fewer consecutive days and where the employee does not qualify for another leave under this employee handbook. If an employee is granted short-term leave, the employee must submit to his or her supen/isor an Absence from Duty Form immediately after returning to duty from short-term leave. The payroll office shall record short-term leave based on the information provided on the employee's Absence From Duty Request Form.
Long-Term Leave - An employee may qualify for short-term leave in extraordinary circumstances, and where the employee is absent for more than three (3)consecutive days and where the employee does not qualify for another leave as provided in this employee handbook. An employee who is eligible for long-term leave shall submit to his or her supervisor an Absence from Duty form and such medical or other certification documents, as appropriate, immediately after returning to duty from long-term leave. The business office shall record long-term leave based on the information provided on the employee's Absence from Duty form.
Other Absences • Any other leaves granted or days of absence shall result in a deduction of the daily rate of pay for each day of absence, unless othenwise provided. Intermittent Leave - Intermittent leave is permitted for the birth of the employee's child or the adoption or placement of a child with the employee.
Workers' Compensation - An employee absent because of a Job-related injury or illness shall be assigned to family and medical leave, if applicable. An employee eligible for workers' compensation wage benefits, and not on assault leave, shall indicate whether he or she chooses to:
ih:
VARner i6T
SCHOOL
Excellence is Expected
Employee Handbook 2016-2017 - Board Approved September 12, 2016
Page 22 of 38
1. Receive workers' compensation wage benefits; or 2. Use avaliable paid leave. Workers' compensation wage benefits shail begin when; a. Paid ieave is exhausted; or b. The empioyee elects to discontinue use of paid leave; or
0. Leave payments are less than the employee's pre-injury average weekly wage. Workers' Compensation Insurance Employees of The Vamett Public School are covered by workers' compensation insurance should they sustain an injury that arises out of and in the course and scope of employment of which compensation is payable under the applicable sections of the Texas Labor Code, Division of Workers' Compensation Rules and law. The Varnett Public School has established an Empioyee injury Benefit Plan, which is intended to conform to the requirements for an empioyee welfare benefit plan under the Empioyee Retirement Income Security Act of 1974, as amended ("ERISA"). The Varnett Public School has coverage for its employees under the Texas Workers' Compensation Act and has established a separate empioyee injury benefit plan.
Employees injured on the Job must immediateiv report the injury or accident to their supervisor/campus director even if they do not seek medical treatment. The supervisor/campus director will notify the Human Resources representative for your location and provide the empioyee with the information to complete and submit a First Report of injury, if medical attention is required, the empioyee will be directed to go to a Varnetl-designated medical facility/provider. The medical provider will call the human resources representative for your work location before treatment to verify that the injury/iilness is Job-related; therefore, it is
imperative that the supervisor/campus director notify human resources in a timely manner. The doctor's bill and medical expenses will be paid for Job-related injuries. Additionally, indemnity compensation will be paid after the employee's absence exceeds five (5) calendar days. If an empioyee is injured, he/she has responsibilities, including but not limited to, the following: o
inform the supervisor/campus director of the injury immediately;
o
Seek medical treatment, if necessary;
o
Ensure human resources receives a copy of the medical statement; and
o Keep supervisor/campus director and human resources informed of status of the injury.
When retuming to work, the empioyee must have a Return-to-Duty Release Form from his/her doctor and must provide this release to human resources. Human resources will review the medical release vwth the Superintendent to determine if the return is permitted. The empioyee will not be allowed to work until clearance is approved.
IHE
VARnEir
SCHOOL
Excellence Is Expected
Employee Handbook 2016-2017 - Board Approved September 12, 2016
Page 23 of 38
If an injured employee is out for more than 9 calendar days due to the injury, the employee must contact the human resources representative for his/her work location regarding Absence from Duty options. Employees who have questions concerning their rights or responsibilities under Workers' Compensation should contact the human resources representative for the employee's work location. Employees who are unabie to work because of a work-related Injury will be notified of their rights and responsibilities under Texas Labor Code. Workers' Compensation Benefits
An employee absent from duty because of a job-related Illness or injury may be eligible for workers' compensation weekly Income benefits if the absence exceeds five (5) calendar days. An employee receiving workers' compensation wage benefits for a job-related Illness or injury may choose to use local personal leave or any other paid leave benefits. An employee choosing to use paid leave will not receive workers' compensation weekly income benefits until ail paid leave is exhausted or to the extent that paid leave does not equal the preillness or Injury wage. If the use of paid leave is not elected, then the employee will receive only workers' compensation wage benefits for any absence resulting from a work-related illness or injury, which may not equal his or her pre-lllness or pre-injury wage. 4.4. Compensatory Time
Compensatory time Is time earned by working outside of your normal work hours. Only twelve month salaried employees may be eligible to earn compensatory time. Time worked outside normal work hours (including holidays) will qualify as compensatory time if prior written authority was granted by the supervisor/campus director and approved by the Superintendent,
Compensatory time is earned only at the discretion and approval of the Superintendent. If employees volunteer to work outside their normal work hours or they come to work on Saturdays or Sundays, it will not be considered compensatory time without prior written approval from the Superintendent. Compensatory time is calculated at 1 V2 times the normal rate. Compensatory time must be used during the month earned. Failure to do so will result in a loss of time.
4.5. Holidays &School Breaks - See School Calendar Appendix B Please reference the work day calendar for the days that employees are required to attend. The Varnett Public School will be closed during the following recognized holidays; Labor Day Fall Holiday Thanksgiving c. d. Dr. Martin Luther King Day Spring Holiday e. f. Memorial Day a.
b.
September 5, 2016 October 12, 2016 November21-25, 2016 January 16, 2017 April 14, 2017
May 29, 2017
IHE vaansir
SCHOOL
Excellence Is Expected
Employee Handbook 2016-2017 - Board Approved September 12, 2016
Page 24 of 38
Additionally, during the following dates, The Varnett Public School will be closed for school break:
a. Winter Break b. Spring Break c. Summer Break
December 19, 2016 - January 2, 2017 March 13-17, 2017 July 3, 2017 - July 14, 2017 Twelve-month employees must use 5 days of vacation time.
4.7. Vacation/Local Personal Leave Vacation Leave
The Varnett Public School provides Vacation Leave to all eligible employees and requires employees to plan for its use in advance. Accumulation
Eligible employees will be given vacation time at the beginning of the school year based on the following schedule. If an employee terminates during the school year all leave will be prorated based on the actual days works. a.
One (1) week paid vacation after employment.
b.
Two (2) weeks paid vacation after first twelve (12) months of employment.
c.
Three (3) weeks paid vacation after five (5) years of employment.
d.
Four (4) weeks paid vacation after ten (10) years of employment.
e.
Five (5) weeks paid vacation after fifteen (15) years of employment.
For new employees, vacation leave will be prorated based on the actual number of days worked if the employee terminates during the year.
Employees may accrue a maximum of 25 vacation days and cannot be carried over between school years.
Requests for use of Vacation Leave
Requests for Vacation Leave should be submitted in vwiting to the supervisor at least two weeks in advance. Requests are approved at the discretion of the supervisor.
When possible, requests for vacation will be granted as requested by employees. However, employees must bear in mind that operating the school requires an adequate number of trained staff at all times. In order to maintain quality education services, knowledgeable employees must be In key areas whenever the school is open. This must be kept in mind when scheduling vacations and this can mean that a request for vacation will be denied if it would cause insufficient staffing of the school.
-iHe VAiniBir
XHOOL
Excellence Is Expected
Employee Handbook 2016-2017 - Board Approved September 12, 2016
Page 25 of 38
To request vacation leave, the employee must submit a completed Request for Leave form to the supervisor at least tw/o (2) weeks prior to the date the vacation is requested. In the event, circumstances will not permit a vacation request at least two weeks In advance, the request must be made as soon as feasible.
Compensation for unused Vacation Leave
Employees will not be paid for unused Vacation Leave except at the time of termination of employment. When an official holiday occurs during a vacation, that day is not charged against vacation time. Sickness during vacation may be taken as local personal days if verified by a doctor's certificate. (Please see Holidays for guidance concerning the use or accrual of vacation leave during closed or open holidays.)
Forfeited Vacation Days Vacation days not taken within the year starting with the anniversary date and ending one year later are forfeited at the end of the year.
Vacation time is important and staff certainly earn and desen/e the vacation time coming to them. Requests for vacation time will be honored but must be balanced against adequately staffing the schools in order to best serve the public.
Please note that all requests for vacation must be In writing; no verbal requests or mentioning of a vacation in casual conversation will be accepted. 4.8. Bereavement Leave
In the event that a full-time employee experiences the death of an immediate family member. The Varnett Public School will provide up to three (3) days of paid time off. Days will be deducted from your personal leave balance. An employee may request to use additional vacation or local personal paid leave time if the employee has such leave available. 1. Spouse or partner;
2. Son or daughter, Including a biological, adopted, or foster child; a stepchild; a legal ward; or a child for whom the employee stands in loco parentis',
3. Parent, step-parent, parent-in-law, or another individual who stands in loco parentis to the employee;
4. Sibling, step-sibling, sibling-in-law, son-in-law, or daughter-in-law; 5. Grandparent and grandchild; and
6. Any person who may be residing in the employee's household at the time of Illness or death if such person is treated by the employee as a member of the employee's family. 4.9. Military Leave Of Absence
The Varnett Public School is committed to protecting the employment rights of employees serving In the uniformed services who must be absent due to military leave. The Varnett Public School will comply with applicable state and federal laws regarding an employee's absence due to service in the uniformed services.
-IHS VARnn*
SCHOOL
Excellence is Expected
Employee Handbook 2016-2017 - Board Approved September 12,2016
Page 26 of 38
5. COMPENSATION AND BENEFITS
5.1. Salaries and Wages
Employees are paid in accordance with administrative guidelines and salary schedules. The Vamett Public School's salary schedules are reviewed by the Superintendent each year. Salary schedules are adjusted as data dictate and budgets allow. The Board of Directors approves salary schedules on an annual basis. All Varnett positions are classified as either exempt or nonexempt according to federal law. Professional employees and academic administrators are generally classified as exempt and are paid on a salary basis regardless of the number of hours worked. Exempt employees are not entitled to overtime compensation. Employees classified as nonexempt are paid on a salary based on an hourly wage. Nonexempt employees are not allowed to work beyond 40 hours within a work week. If nonexempt employees are approved by the Superintendent to work beyond 40 hours a week, they will receive overtime pay at time and half. The workweek is defined as Monday through Sunday. 5.2. Payroll
Employees are compensated based upon a Board-approved pay schedule that may be amended by the Board from time to time. All employees of The Varnett Public School participate in the Texas Teacher Retirement System in lieu of paying into the Social Security retirement system. However, Medicare contributions remain a deduction each pay period.
Payroll occurs on a semi-monthly basis and is distributed to all employees on the 15'^ and 30". Paid salary begins on the date defined in the Employment Letter of Agreement and continues until a salary amendment has been approved by the Board of Directors, unless an employee is terminated or resigns.
Employees absent due to an Illness on either payroll check date will receive their employee
checks through direct deposit on the 30". If an employee designates someone to pick up his or her payroll check, the designated person must bring a hand-written letter with the employee's signature along with the deslgnee's picture ID. The ID must either be a driver's license or DPS identification card.
Work performed from the 1®* of the month through the 15" of the current month will be paid on the 30" day of the current month; work performed from the 16" through the last working day of the month will be paid on the 15" of the following month. 5.3. Direct Deposit
Direct deposit is The Varnett Public School's preferred method of payment for all employees paid by The Varnett Public School. Direct deposit enables The Varnett Public School to facilitate the distribution of pay to employees in a safe, secure, and timely manner. To enroll in direct deposit an employee must complete the required paperwork with Human Resources.
IH: VdRDEir
SCHOOL
Excellence Is Expected
Employee Handbook 2016-2017 - Board Approved September 12.2016
Page 27 of 38
5.4. Mistake In Payroll or Expense Reimbursement
Employees are required to immediately notify their supervisor in the event of a suspected mistake in their payroll or expense reimbursement. Failure to report an overpayment in payroll or in an expense reimbursement may result in disciplinary action. Correction pay will t)e paid the very next payday following the date of the discovery of the error. 5.5. Hours Worked; Exempt Employees
All exempt employees who are compensated on a salary rather than hourly basis are paid their salary for all hours worked during the work week, regardless of the actual number of hours worked.
5.6. Hours Worked; Non-Exempt Employees
Non-exempt employees will be paid at the rate of 1.5 times their regular hourly rate of pay for all time worked in excess of 40 hours in any one workweek. Overtime is never at the employee's discretion. An employee may work overtime only after receiving authorization from the employee's supervisor. Working overtime without prior authorization may result in disciplinary action.
A non-exempt employee is never permitted to work "off the clock". While all hours will be compensated appropriately, an employee's failure to report hours accurately whether too low or too high is cause for disciplinary action. Employees should immediately report to the Business
Office any effort by a supervisor to participate, encourage, or even permit an employee to work "off the clock" In violation of this overtime provision. 5.7. Attendance Records
Employee attendance records must be kept complete and accurate. They are maintained by the Business Office. Attendance records are subject to unannounced revie\ws to ensure proper use.
Falsification of time records Is a serious offense and may lead to disciplinary action, up to and Including discharge from employment. 5.8 Compensatory Time
Compensatory time Is regular time earned by working outside of normal work hours. Only twelve-month salaried employees may be eligible to earn compensatory time. Time worked outside normal work hours (including holidays) will qualify as compensatory time if prior written authoritywas granted by the supervisor/campus director and approved by the Superintendent. Compensatory time is earned only at the discretion and approval of the Superintendent. If employees volunteer to work outside their normal work hours or they come to work on Saturdays or Sundays, it will not be considered compensatory time without prior written approval from the Superintendent. Compensatory time must be used during the month earned. Failure to do so will result in a loss of time. 5.9 Medical/Health Benefits
Medical insurance benefits are available to all employees during the annual open enrollment period and during the first 30 days of employment. Supplemental benefits are available to all new employees. These benefits include participation in group dental, other voluntary plans, and options to participate in a retirement plan, and health insurance for family members. IHs
Vditnair
SCHOOL
Excellence Is Expected
Employee Handbook 2016-2017 - Board Approved September 12,2016
Page 28 of 38
The Varnett Public School will contribute a flat amount towards the cost of the coverage for medical insurance for all employees who work 35 full-time hours. However, all employees must
pay the remaining cost of medical insurance benefits. Other medical/health benefits are available to all full-time employees at the employee's expense. 5.10. Local Personal Day Benefits
All employees, except positions designated by the Board of Directors, are provided 5 local personal days per year. Employees that do not work the full year will have their leave prorated based on the actual number of days worked per their employment calendar. The school does not transfer personal days from other schools or carry forward unused days from the previous year unless otherwise provided by the Board of Directors. An employee may have no more than three (3) personal days per semester and they may not be taken immediately before or after a holiday or vacation. Also, personal days may not be taken during staff development days,
or between August 1*' and September 15"^ and during the months of May and June. All personal days taken by the Instructional staff must be taken prior to April
and after
September IS"'. Any persona! leave taken during this time frame must have approval from the Superintendent. All employees will be governed by the following conditions:
1. Accept 5 days of personal leave benefits with the understanding that your performance evaluation and salary increases will include a review of your attendance record during each scholastic year;
2. Accept the condition that no payment will be received for local personal leave taken beyond the annual 5 days of personal/sick leave benefit.
3. Personal time taken during staff development days, or between August 1*' and September 15"'and during the month of May and June must have the prior written approval of the Superintendent.
The procedure for taking a personal day is to contact your campus director or supervisor by telephone prior to 6:00 a.m. the day you will be absent. When possible, contact your campus director/supervisor to report an absence no later than 8:00 p.m. of the preceding day. Employees are expected to contact their campus director or supervisor each and every day they are absent. Leaving messages on the voice mall or with other employees is not acceptable. Unauthorized leave will not be tolerated and any employee violating this policy can be suspended without pay or terminated from employment.
5.11. Travel Expense Reimbursements Before an employee incurs travel expenses related to The Varnett Public School business, the employee must submit a travel request form for approval of the campus director/supervisor. Mileage for use of an employee's personal car will be reimbursed at the rate of reimbursement approved by the Board of Directors. Employees who select amounts and exceed above federal guideline amounts and board approved rates must have prior approval by the Superintendent. Travel expenses from approved travel must be Itemized and detailed on The Varnett Public School travel reimbursement form. Taxes and tips cannot be reimbursed with state or local school funds. To be reimbursed, all original receipts for travel expenses must be included with the reimbursement form and submitted to the employee's supervisor. 5.12. Deductions In Pay -ms ViiRnsir
5CHOOL
Excellence Is Expected
Employee Handbook 2016-2017 - Board Approved September 12, 2016
Page 29 of 38
The Vamett Public School will only deduct wages from an employee's pay under circumstances that are allowable under state and federal law. Additionally, any wages that an employee has requested and authorized in writing will be deducted. If there is a deduction that has been made that the employee believes is in error, the employee should immediately contact the Business Office. Retaliation against an employee who has questioned what he/she believes may be an incorrect deduction In pay is prohibited. 6. NON-DISCRIMINATION & ANTI-HARASSMENT 6.1. Non-Discrimination
The Varnett Public School does not discriminate against any employee or applicant for employment because of race, color, religion, sex, national origin, age. disability, military status, sexual orientation, gender identity, genetic information, or any other class, characteristic or activity protected under state and federal law. Employment decisions will be made on the basis of each applicant's job qualifications, experience and abilities. 6.2. Reasonable Accommodation
In the event an employee needs to request a reasonable accommodation or a variance in The Varnett Public School's stated policies and/or procedures due to the employee's disability, as defined by the Americans with Disabilities Act, or the employee's sincerely held religious belief, the employee should notify his or her supervisor and/or the Business Office. 6.3. Anti-Harassment
The Varnett Public School is committed to creating and maintaining a work environment free of all forms of unlawful harassment The Varnett Public School does not discriminate against
any employee or applicant for employment because of race, color, religion, sex. national origin, age. disability, military status, sexual orientation, gender identity, genetic information, or any other class, characteristic or activity protected under state and federal law. Employment decisions will be made on the basis of each applicant's job qualifications, experience and abilities.
Harassment based on any of the aforementioned protected classes may include, but is not limited to, many different types of actions: verbal (e.g. derogatory comment), physical (e.g. assault), or visual (e.g. internet materials). Sexual harassment does not have to be of a sexual nature, however, and can include offensive remarks about a person's sex. Both victim and harasser can be either a woman or a man. and the victim and harasser can be the same sex.
The harasser can be the victim's supervisor, a supervisor in another area, a co-worker, or someone who is not an employee of the employer. 6.4. Reporting Discrimination and/or Harassment
This section applies to both incidents of harassment and discrimination. Employees should promptly report an incident of discrimination or harassment to the employee's immediate supervisor. If the alleged harasser is the employee's supervisor, a manager, or even one of the individuals designated to receive harassment reports, the employee does not have to directly report the incident to that individual, but instead must notify the Business Office in order to ensure that the matter is promptly and appropriately addressed. The employee should not assume that witnesses to the incident will know the conduct Is IHE
VARHET
SCHOOL
Excellence Is Expected
Employee Handbook 2016-2017- Board Approved September 12. 2016
Page 30 of 38
unwelcomed; an employee should not rely on a witness to report the conduct of the employee. Informing the harasser that the conduct is unwelcomed is not a report of harassment since the harasser may not self-report the violation to management or the business office. Any supervisor/manager who receives information indicating a concern about harassment or discrimination must report it to the business office, even if the information comes from someone other than the target of the harassment or discrimination, or even if the person expressing the concern indicates that he/she does not wish to have the harassment or discrimination reported. The Varnett Public School will promptly investigate any report and take appropriate remedial action. If the harassment or discrimination continues, the employee must immediately report the incident so that the matter can be reopened and addressed.
Retaliation for reporting what an employee believes to be harassing or discriminatory conduct or for participating in an investigation of alleged harassment or discrimination is prohibited. Any retaliation should be reported according to the same procedures as reporting discrimination or harassment.
Any employee engaging in any type of discrimination, harassment, and/or retaliation will be subject to disciplinary action, up to and including discharge. Any supervisor who has knowledge of such behavior yet takes no action to report it is subject to disciplinary action, up to and including discharge. 7. EMPLOYMENT STANDARDS
7.1.
Expected Employee Conduct
All employees are expected to:
Meet established expectations of job performance: Comply with attendance policies; Be responsible in the performance of job duties; Be efficient;
Respect the personal and property rights of all individuals one comes In contact with during the course of The Varnett Public School business; Follow job instructions; Maintain a courteous and professional demeanor; and Be on time.
Employees who do not adhere to these standards are subject to disciplinary action, up to and including discharge.
IHs
VdRnST
»a400L
Excellence Is Expected
Employee Handbook 2016-2017 - Board Approved September 12, 2016
Page 31 of 38
7.2. Violence in the Workplace
The Varnett Public School is committed to providing a safe workplace that is free from violence or threats of violence. Any and all acts of violence in the workplace are prohibited and subject to disciplinary action, up to and including discharge. Additionally, any and all threats of violence, direct or indirect, serious or said in jest, are prohibited. All threats will be taken seriously and are subject to disciplinary action, up to and including discharge. Employees concemed about family violence being brought into the workplace or onto the work parking lot are encouraged to notify their supervisor or the Business Office.
Any employee who receives a protective or restraining order that lists The Varnett Public School as a protected area is required to provide the Business Office with a copy of the order and information requested by The Varnett Public School to identify the individual subject to the order. 7.3. Drug-Free Workplace
The Varnett Public School Is committed to maintaining a drug-free work environment and each employee is responsible for the maintenance of such an environment. The unlawful manufacture, distribution, possession, or use of a controlled substance (i.e. drugs) and/or the use of alcohol or tobacco in the workplace, or while conducting The Varnett Public School business, are prohibited.
Additionally, an employee must notify The Varnett Public School of any criminal drug statute conviction for a violation occurring in the workplace, or while conducting The Varnett Public School business, no later than five (5) days after such conviction. A report of a conviction must be sent to the Superintendent of Schools.
Violation ofthis policy may lead to disciplinary action, up to and including discharge. The Varnett Public School may ask an employee to submit to a drug or alcohol test whenever it reasonably believes that the employee may be under the influence of drugs or alcohol at the work place In violation of this Drug-Free Workplace policy, including, but not limited to the
following circumstances: evidence of drugs or alcohol on or about the employee's person or in the employee's vicinity; unusual, bizarre or erratic conduct that suggests the employee is impaired by, or under the influence of, drugs or alcohol; or an on-the-job accident or Injury under circumstances that suggest the possible use or Influence of drugs or alcohol in the injury. All VPS employees are subject to random drug testing at any time.
Nothing in this policy prohibits, or in any way limits, the lawful use of prescription or nonprescription drugs. However, an employee must Inform his/her immediate supervisor if he/she is using a prescription or nonprescription drug which could impair work performance or pose a risk of harm to the employee, to others, or to property. It is the employee's responsibility to determine from his or her physicfan(s) if the medication can impair work performance or pose such a risk. If the lawful use of lawful prescription or nonprescription drugs does limit or otherwise impair the employee's ability to perform the essential functions of his or her position or otherwise creates a safety risk, the Business Office will meet with the employee to determine whether a reasonable accommodation Is available.
-IHE
VAanEir
school
Excellence Is Expected
Employee Handbook 2016-2017 - Board Approved September 12,2016
Page 32 of 38
7.4. Suspicious Behavior
Employees are encouraged to report any suspicious behavior observed at school or at any school-related or school-sponsored activity. Strangers or former employees walking unaccompanied In areas not generally open to the public should be pointed out to a supervisor. 7.5. Former Employees
Former employees may not enter areas that are not open to the public after they are no longer employed by The Varnett Public School. 7.6. Employee Dress Code
Employee dress should be neat and clean and appropriate for a professional appearance. While shoes must be worn at all times, house shoes (e.g. slippers) and flip-flops are not allowed. Denim jeans are allowed on Fridays if worn with either a white shirt, school spirit shirt, Varnett polo shirt and a Varnett blazer or sweater. Tennis shoes may be worn on Fridays with jeans. Jeans must be free from holes and frays. Dress days for employees are Mondays and Wednesdays. Varnett employees must wear the approved Varnett jacket or cardigan sweater on these days. If an employee Is unsure of the appropriateness of a particular item of clothing, the employee should choose not to wear it. Shorts, capris and leggings are not allowed. An administrator may require an employee to cover tattoos and/or remove facial jewelry. Additionally, because it is difficult to establish a specific dress-code standard, The Vamett Public School administrator may require an employee to change his or her dress/attire if it is in the administrator's best judgment that it is inappropriate.
Exceptions to the dress code may be considered in order to make reasonable accommodations for an employee's disability, as defined by the Americans with Disabilities Act, or an employee's sincerely held religious belief. 7.7.0utslde Employment
Employees of The Varnett Public School are expected to work solely for The Varnett Public School. Any outside employment, whether self-employment or working for another employer, should be immediately disclosed to and approved by the Superintendent. In some circumstances such outside employment may be permitted by The Varnett Public School. However, The Varnett Public School retains the right to review and evaluate each situation on an individual basis.
7.8. Employee Monitoring
Employees do not have an expectation of privacy In any work areas (e.g. offices, desks, file cabinets, etc.) or in any The Varnett Public School property, either owned or leased. Work areas and The Varnett Public School property are subject to search at any time ifthere is reasonable suspicion. Any of the following may be monitored if they occur during business hours and/or on school property: phone calls, voice-mail, e-mail (work and personal), and internet activity.
-IHe VARnsir
XHOOL
Excellence Is Expected
Employee Handbook 2016-2017 - Board Approved September 12, 2016
Page 33 of 38
7.9. Audio & Video Recordings
An employee is prohibited from making any audio or video recording while acting in the course and scope of their employment or while on school property vwthout the written consent of all parties subject to the recording. School functions such as athletic activities or performances are exempt from this prohibition. 7.10. Office Dating
Employees who are in administration/management/supervisory roles are prohibited from dating any employee over whom they have direct or indirect supervision. Also, individuals who work within the Business Office are prohibited from dating any The Varnett Public School employee. If two employees are involved in a dating relationship it will be presumed by The Varnett Public School that the relationship is welcomed by both parties unless one or the other notifies The Varnett Public School to the contrary. Public displays of affection and favoritism in the course of employment are prohibited. Conduct that occurs during a disagreement or following a termination of the relationship must not violate The Varnett Public School's harassment policy. 7.11. Workplace Investigations
There are instances when The Varnett Public School may wish to investigate personnel matters. Employees are required to cooperate in any Investigation. Refusal to participate, or actions taken to compromise the effectiveness of any investigation, may result in termination. If the employee is instructed not to discuss the matter being investigated, failure to abide by this instruction may also result in termination. This restriction excludes the employee's privileged communications with his or her own private legal counsel. 7.12. Updated/Current Employee Information
Employees are required to regularly update; • • • • •
A change in home address or telephone number; A change in marital status or in the number of dependents; A change of insurance beneficiary; A change in the number of exemptions claimed for income tax purposes; The driving record or status of an employee's driver's license. If the employee operates any The Varnett Public School vehicle or operates his or her owi vehicle for workrelated duties, not including driving to and from work; A legal change of name; and The Public Information Act form indicating whether certain personal information may be released to the public.
• •
Updates should be made by the Human Resources representative for the employee's work location.
IHb
VARHEir
SCHOOL
Excellenceis Expected
Employee Handbook 2016-2017- Board Approved September 12, 2016
Page 34 of 38
7.13. Allowable Uses of The Varnett Public School Property
Employees may use The Varnett Public School property only for a purpose that is consistent with applicable law and to implement a program that is described in The Varnett Public School's charter.
Employees of The Varnett Public School may use local telephone service, celluiar phones, electronic mail, Internet connections, or social media for incidental personal use under the following conditions:
•
Such incidental personal use must not result in any direct cost paid with state funds. If this does happen, the employee who caused the direct cost to be incurred by The Varnett Public School must reimburse The Varnett Public School;
•
Such incidental personal use must not impede the functions of The Varnett Public
•
The use of The Varnett Public School property for private commercial purposes is
School;
strictly prohibited; and
• •
Only incidental amounts of an employee's time for personal matters, comparable to reasonable coffee breaks during the day, are authorized under this section. Ceil phone usage is not permitted during instructional time. Employees may use cell phones, during lunch breaks, before and after school or in emergency situations.
An employee may be required to compensate The Varnett Public School for any damage and/or destruction the employee causes to The Varnett Public School property.
A violation(s) of this section may result in disciplinary action, up to and including discharge. 7.14. Computer and Internet Use
With the exception of the incidental personal use described herein, access and use of The Varnett Public School's computers, computer networks, electronic mail, and the Internet are only for educational and administrative purposes. The access to material that is obscene, child pornography, or harmful to minors is prohibited. Failure to comply with this section may result in disciplinary action, up to and including termination. 7.15. Administration of Medication to Students
All employees, agents, and volunteers are prohibited from administering any medication to a student unless expressly authorized by The Varnett Public School. 7.16. Reporting Child Abuse/Child Neglect
An employee, volunteer, or agent who believes a child has been adversely affected by physical, sexual, or mental abuse or neglect must make a report vwthin 48 hours of first suspecting such abuse or neglect. The report must be made to law enforcement or the Department of Family and Child Protective Services.
IHS
vAiniBir
SCHOOL
Excellence Is Expected
Employee Handbook 2016-2017-Board Approved September 12.2016
Page 35 of 38
7.17.Traffic Violations
If an employee, during the course of The Varnett Public School business, receives a traffic violation, the employee will be personally liable for any expenses Incurred from that violation. If during the course of transporting a student(s) an employee receives a traffic violation, that employee is subject to disciplinary action, up to and including discharge. 7.18. Time Clock
All employees, except administrators, must clock In upon arrival and clock out before you leave the campus on a dally basis. If you are not on your campus at the end of the day you are to sign time sheets at that location. Be reminded that employees are not to stand in line at the time
clock waiting on time. Clock In/out as you arrive/leave at the time clock. 8. GRIEVANCE PROCEDURES
Employees who have a complaint about their terms or conditions of work are encouraged to resolve their concerns informally with their supervisors at the lowest level possible, if the employee is not satisfied with the outcome of the informal resolution, then the employee may file a formal complaint according to the procedures below.
With the exception of a complaint against the Superintendent, each complaint must initially be brought at the lowest level of review, at the campus director review level. If the complaint is against the campus director, then the complaint may be initially brought at the Superintendent level.
8.1. Campus Director/Supervisor Review of Complaint
Where an employee has a complaint or concern regarding the terms or conditions of work, the individual shall first bring the complaint or concem In writing to the appropriate campus director or to the employee's direct supervisor If the employee does not work on a school campus. The complaint must be brought within 15 school days of the date that the complainant knew or should have known of the alleged harm. The complaint must be specific, and where possible suggest a resolution. The campus director/supervisor must hear the complaint, attempt to remedy the complaint in the best interest of the affected parties, and document the outcome. The campus director/supervisor must respond to the complainant and issue a final decision in writing within 10 days of the campus director's/supervisor's receipt of the complaint. 8.2. Superintendent Review of Complaint If the complainant is not satisfied with the final decision of the campus director/supervisor, then the Individual may file a written appeal to the Superintendent. This written appeal shall be filed with the Superintendent's office within 10 days of the individual's receipt of the final decision from the campus director/supervisor. The complaint shall Include a copy of the prior written complaint along with a copy of the final decision of the campus director/ supervisor. A copy of the appeal shall also be delivered to the campus directors/supervisor. The appeal and a possible suggestion for resolution must be specific. The complaint shall not Include any new issues or complaints unrelated in the original complaint.
The Superintendent, or the Superintendent's designee, shall respond to the complaint and issue a final decision In writing within 15 days of receipt of the written appeal. IKS
vdiinEir
SCHOOL
Excellence Is Expected Employee Handbook 2016-2017 - Board Approved September 12, 2016
Page 36 of 38
8.3. Board of Directors Review of Complaint
If the complainant is not satisfied with the Superintendent's final decision, then the individual may appeal the complaint in writing to the Board of Directors within 10 days of receiving the Superintendent's final decision. The complaint shall be directed to the President of the Board, and shall include a copy of the written complaint to the Superintendent along with a copy of the Superintendent's final decision. A copy of this appeal shall also be delivered to the Superintendent.
The President of the Board, at the next regular meeting of the Board, shall provide a copy of the
complaint record to all board members. The Board's decision shall be decided on a review of the record developed at the Superintendent's level. Any action of the Board of Directors regarding the complaint shall be taken in compliance with the Texas Open Meeting Act.
A complaint against a Superintendent shall begin at this level of review and shall follow the complaint process in accordance with this policy section andtheTexas Open Meetings Act. The failure of the Board of Directors to act on a complaint has the effect of upholding the Superintendent's decision. 9. DISCIPLINE
In an effort to correct employee misconduct at the earliest stage possible. The Varnett Public School administration may implement a stair-step disciplinary procedure. Such procedure may
begin first with a verbal warning. The next offense would proceed to a written warning; the next step Is a suspension; followed by termination of employment.
Though The Varnett Public School may utilize such stair-step disciplinary procedures. The Varnett Public School reserves the right to skip any or all steps and immediately discharge the employee.
The stair-step disciplinary procedure does not forfeit the at-will status of its employees and The Varnett Public School preserves the at-will nature of the employment relationship. Accordingly, discharge may be initiated by The Varnett Public School at any time, with or without cause, and with or without notice.
10. SEPARATION FROM EMPLOYMENT
10.1. Resignation
An employee is expected, but not required, to give as much advance notice as possible regarding the resignation from The Varnett Public School. Typically, two (2) weeks (10 business days) Is considered sufficient notice time. The Varnett Public School requests that employees submit their resignation in writing to their supervisor; the writing should include the employee's anticipated last work day.
The Varnett Public School reserves the right to require the employee to resign immediately rather than work during the notice period.
1HS
VArtllBH' rfh. >CHOOL Excellence Is Expected
Employee Handbook 2016-2017 - Board Approved September 12, 2016
Page 37 of 38
10.2. Discharge
In an effort to reduce the risk of employee violence or vandalism, upon an employee's discharge
from employment. The Varnett Public School administration may request that an employee leave the facility immediately upon separation from employment. If accompanied by a Varnett Public School administrator, the employee will be permitted to gather his/her personal belongings before being escorted to the exit.
The exiting employee Is prohibited from taking any Varnett Public School property or Information with him/her; the employee is not to retain in hard copy or soft copy any Varnett Public School information. The Varnett Public School reserves the right to examine any boxes, briefcases, or other receptacle of an exiting employee to ensure these rules are being followed. An exiting employee who has been discharged Is not to return to the premises of The Varnett Public School without prior written approval from the Business Office or the Director of the school campus.
-|HS
VAfinEir
SCHOOL
Excellence Is Expected
Employee Handbook 2016-2017-Board Approved September 12, 2016
Page 38of38
The Varnett Public School
Appendix A Human Resource Documents
Forms, Calendars and Contact Information 1. Calendars a. Teachers, Nurses, Librarians & Food Service b. Other Support Staff c. Administration d. Absence From Duty Form Submittal and Payroll Schedule 2. Absence from Duty Form 3. Personnel Demographic/ Benefit Change Form 4. W-4 5. Time Sheet Form 6. Administration Time Sheet (Sample) 7. Compensatory Time Form 8. Family and Medical Leave Act Form (FMLA) 9. Exit Interview Form
Ø Please request and submit all forms to Human Resources.
Updated and Revised Forms can be found at www.varnett.org
IHc SCHOOL
VARnEir
2016-2017 Academic Calendar
September 2016
August 2016 Su Mo Tu Wo Th 1
2
8
7
9
3
4
10 11
Fr Sa 5
Su Mo Tu Wo Th
16 16 17 18 19
21
22
28
29 30 31
20
23 24 25 28 27
6
4
12 13
14
Fr Sa
1
6
11
8
9
26
Fr Sa
Su Mo Tu Wo Th
10
22 23 24
27
29
30
2
3
6
5
4
7
6
8
13 14 IS
10 11
9
7
13 14
Ft
3
2
1
1
20 21 28
Su Mo Tu Wo Th
3
12 13 14 15 16 17
18 19 25
7
2
November 2016
Octobor 2016
5
4
8
9
10 11
12
IS
16
17 18
19 26
16 17 18 19 20 21 22
20
a a a BB
27 28 29
27
28
23
25 26
24
Sa
29 30
30 31
Su
MoItu
5
4
11
We Th
7
6
12 13 14
8
Fr Sa
Su Mo Tu Wo Th
2
3
1
2
3
9
10
8
9
10
15 16 17
15
24
22
23
24
^ 31
29
30
31
i
18
251^^
2
3
4
5
6
9
10 11
12 13
16
17 18
19
23
24
25
26
20 27
Fr Sa
Su Mo Tu We Th
Fr
7
21 28
18 19
20
21
12 13 14 15 16 17 IB
25
27
28
19
20
21
26
27
28
26
2
6
3
4
7
Fr Sa 5
6
Su Mo Tu
24
25
23
27
29
30
12 13
22
21
22
23
24
25
27
IB
19
31
5
25
26
24
29 days
Thanksgiving
November 21-25.2016
Oct 03 - Nov 04
Winter Break
DecemberlO, 2016-January 2. 2017
MLKDay
January 18, 2017
Nov07 - Dec 16 Jan 03-Febl7
24 days 25 days 33 days
Spring Break Spring Holiday
March 13-17, 2017
Feb20-Apr 7
April 14, 2017
Apr 10-May 26
3
4
10 11
16 17 23
24
30
31
5
School bus drivers report to work
30 days 34 days
August 08-17.2016 May 30, 2017-June 2. 2017 TEACHER PREPARATION DAY
First day of school Last day of Isl semester First day of 2rv] semester Last day of seho^ Last day for teachers
August 22.2016 December 16, 2016
Januarys,2017 May 26.2017 June 2.2017
August 18-19.2016 January 2,2017
Fr
Sa
7
8
14
15 22
28
29
26
26
27
October 7.2016 November 11. 2016
January 06. 2017 February 22,2017 April12. 2017 May 26, 2017
175 instructional Days - Monday • Friday
SIGNIFICANT DATES
31
18 19 20 21
PROFESSIONAL DEVELOPMENT DAYS August 06,2016 August 08,2016 August 16,2016
6
12 13
School Hours: 8:00 a.m. - 3:15 p.m
All instructional staff report to work All cafeteria staff report to work
30
1
April 14, 2017 May 30, 2017 STAFF REPORTING DAYS
18
22 23 24 26
Root>rt Card Datoa
Aug 22 - Sept 30
MAKE-UP DAYS/BAO WEATHER DAYS
11
Su Mo Tu Wo Th
6 CYCLES
September S. 2016 October 12,2016
Fall Holld^
10
28 29
2
22
11
9
27
9
21
4
20
8
26
10
28
13
4
21
9
20
12
17 18 19
3
20
16 17
6 IS
9 16
2
19
3
7
8 IS
7
1
a B B fl 1
2
30
Labor Day
6
5
Fr Sa
July 2017 Fr Sa
14
6
7 14
26
WelTh 1
8
10 11
22 23
10 11
June 2017
IS
30
9
14
5
Su Mo Tu Wo Th
4
13
1
29
8
3
11 12
Su Mo Tu Wo Tti
28
2
Fr Sa
7
5
Sa
29
1
March 2017
6
4
May 2017
April 2017 Su Mo Tu Wo Th
February 2017
January 2017
Docombor 2016
The Varnett School 191 Contract Days Teachers, instructional Aides, Ubrarlans, Nurses, Bus Drivers, Food Services FEBRUARY 2017
AUGUST 2016
^
1 7
8
14
1
15
71
fi
7
16
10
3
1
11
4
M
S
s
1
12
5
1 5
13
113 7
6
119
123 21
124
22
18
26
27
128 28
129
18
25
71
7
20
31
26
27
36
35
22
s
S
F
1
19
2
70
3
8
23
9
24
10
S
133 7
6
134
1
1
130
2
131 3
132 4
8
135
9
137
11
H
18
25
29
17
12
13
22
33
23
34 24
19
20
138 21
139
22
140
23
141 24
142
29
38
30
39
26
27
143 28
144
29
145
30
M6 31
147
32
28
37
21
W
H
H 17
16
21
15
136 10
28
15
K
2
3
40
4
5
F
T
42
18
APRIL 2017 S
S
T
M
S
F
T
W
_
1
1 41
S
16
H 14
27
T
F
T
W
T...
M
OCTOBER 2016 M
120
MARCH 20X7
T
W
19
18
25
118 14
20
14
?s
127
13
19
76
12
126 24
12
27
13
11
23
20
IS
r-" 6
125
10
26
T
5
18
19
SEPTEMBER 2016
4
11
122
9
31
M
117
121 17
14
17
4
116 10
25
16 30
112
16
18
79
111 3
9
8
17
2
115
13
23
no
120
17
n
s
T
8
7
7?
1
114
15
24
fs
W
T_
6
5
4
3
9
F
T
w
M
s
6
43
7
44
2
s
148 4
3
149
5
150
8
6
151 7
H
15
152
45 11
46
12
H
13
47
14
48
15
9
10
153 11
154
12
155
13
156 14
49
18
50
19
51
20
52
21
53
22
16
17
157 18
158
19
159
20
160 21
161
22
24
54
25
56
27
57
28
58
29
23
24
162 25
163
26
164
27
165 28
166
29
31
59
9
10
15
17
23 30
26
20
119
30
MAY 2017
NOVEMBER 2016
rr
M
T
W
S
F
T
1
60
2
61
3
62
4
63
S
5
T
M 1
F
T
W
167 2
163
3
169 4
170 5
S 171
6 13
6
7
64
8
65
9
66
10
67
11
68
12
7
8
172 9
173
10
174
11
175 12
176
13
14
69
15
70
16
71
17
72
18
73
19
14
15
177 16
178
17
179
18
ISO 19
181
20
H
23
H
24
H
26
21
22
182 23
183
24
184
25
185 26
186
27
75
30
76
28
29
187 30
188
31
189
20
21
H
22
27
28
74
29
H
25
17
DECEMBER 2016 M
S
T
W
JUNE 2017
T
1
F
1
123
77
2
S 78
3 10
M
s
T
W
F
T 1
190 2
S 1911 3
4
5
79
6
80
7
81
8
82
9
83
4
5
6
7
8
9
11
12
84
13
85
14
86
15
87
16
88 17
11
12
13
14
15
16
17
18
19
H
20
H
21
H
22
H
23
H
24
18
19
20
21
22
23
24
25
26
H
27
H
28
K
29
H
30
H
31
25
26
27
28
29
30
12
JANUARY 2017 S
M
T
W
1
2
89
3
90
4
8
9
94
10
95
11
15
16
M
17
22
23
:103 24
104
29
'30
losi 31
109
1
JULY 2017
T
F
_91 5 96
10
12
S
s
93
6
93
7
97
13
98
14
2
T
M
T
W
F
S 1
3
4
5
6
7
8
_99 18
100 19
:
20
102
21
9
10
11
12
13
17
15
25
ICS 26
:LOG 27
107
28
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
121 DAYS= 109
DAYS= TOTAL DAYS =
191
82
The Varnett School 201 Contract Days
Assistant Principal, Administrative AssisUnts, Instructional Facilitators, Parent Liaisons, Head Nurse FEBRUARY 2017
AUGUST 2016
m
s 1
7
1
;8
14 21 28
2
1
_6 9
15 22 29
11
16' 21
1m
1 w
fi—1
16 23 30
12
17
17
24 31
22
•j
18 18:
F 1S
5
4
8 11
10
7
i
25
5
w
n
6
4
5
K
r rn 1 6
11
12
30
13
18
19
3S
20
25
126
40
27
11 v\ 8
31
14
32
15
_36 21
37
22
28
42
29
41.
1
T
n1
wn
i
3 10
122' 11
118
7
119
8
120
9
121
19
_15
123
14
124
15
125
16
126 17
127
18
27
19
20
128
21
129
22
130
23
131
24
132
25
26
27
133
28
134
2o:
20
1
1
MARCH 2017 F
n
3
Z] W
1s [m n
s
1F
135
2
136 3
8
140
9
141
1s 137 4
24
2
28
9
29
10
5
53
16
34.
17
12
113
H
14
H
15
24
19
20
143
21
144
22
145
23
146
24
147
26
27
148
28
149
29
150
30
151131
152,
30
43
3
1T
1
21
44
6
7
138
139
H 16
10
H 17
142 11
H 18
2
3
9
10
_45 4 50
11
_S4 18
16
17
23
24
59
30
31
64
25
46
5
51
12
13
_5S 19
_S6 20 27
26
60
61
:6
n r rn
:n1 W
[m I]
s
14
53
15
57
21
98.
22 1
62
28 1
6
M
7
T
S
T
20
2
3
9
10
16
17
23
24
4
69
F
s
155
6
156
7
15sl 11
159
12
160
13
161
14
H
15
162
18
163
19
164
20
165
21
166
22
167
25
168
26
169
27
170
28
171
29
157
119
30
s
1
69
2
66
3
67
4
68
5
8
70
9
71
10
72
11
73
12
S
7
M
T 172
2
173
3
174
4
8
177
9
178
10
179 11
5
ISO
12
181
13
186
20
191
27
176
13
14
74
15
75
16
76
17
77
18
78
19
14
15
182
16
183 17
184
18
185
21
H
22
H
23
It
24
H
25
H
26
21
22
187
23
188
24
189
25
190
26
27
28
79
29
30
30
81
28
29
192
30
193
31
194
DECEMBER 2016
n Iw n
4
5
84
12
89
13
19
H
20
25
26
H 27
s 1M
T
JUNE 2017
1T
1
F
rnIm n ni
s
2
94 3
F
T
s
11
s:
I2
8
87
9
83 10
4
90
14
91
15
92
16
93 17
11
12
13
14
15
16
17
-Jli
21
H 22
M 23
H
24
18
. 19
20
21
22
23
24
H 28
H 29
H
30
H
31
25
!26
27
29
.30
It
If
S3,
3
1
12
197
198
JANUARY 2017
1
1W
Rf,
as
11
23
7
6
18
6
175
20
17
s
F
T
W
1
19
HjIm n
8
154
MAY 2017
T
W
18
1
_49 8
48 7
NOVEMBER 2016 s
25
APRIL 2017
... 11 47
4
13
_38 23
T
116
6
OCTOBER 2016
1 Mn
iisl 2
12
T
7
1 5
23
26
1s 1171
20
23
wn
!1 F
_10 13
SEPTEMBER 2016
1 Mn
1T
12
26
19
[M
W
7
199 8
28
2
196
3
200 9
201
10
195
JULY 2017
T
F
95 4
96 5
97 6
s
S
1M
It
I w
98 7
S 1
8
9
99 10
icc 11
101 12
102 13
103 14
2
3
4
6
7
8
15
16
H 17
lo-i 18
109 19
106 20
107 21
9
10
11
12
13
17
15
22
23
108 24
109 25
no 26
in 27
112 28
16
17
18
19
20
21
22
29
30
113 31
IM
23
24
25
26
27
28
29
30
31
121
1
1 OAYS=
K 5
1
114
DAYS= TOTAL DAYS =
201
87
The Varnett School 236 Contract Days
Administrators, Professionals, Communications Director, Technology Director, Technology Support, General Manager, Operations Manager, CFO, Food Services Manager, ESL Coordinator, Campus Director, Chief Academic Officer, instructional Coaches, Gifted and Talented Specialist, Data Analyst, SPED Coordinator, CFO, Business Office Staff, PEIMS, Clerks
FEBRUARY 2017
AUGUST 2016
m
s
7 14
1 W 1m
1
1
2
2
8
_6 9
7
15
ii! 16
21
' 22
16
23
28
29
21
30
m
fl 1 4 lie 8 11
3
17
12
_17 24
15
26
10
20
1 Mn
r rn
i
1
115
2
7
119! 8
120
9
121
10
122
20
12
13
123
14
124
15
125
16
126
17
127
18
27
19
20
12S
21
129
22
130' 23
131
24
132
25
26
27
133
28
134
n1 T 1
7
8
:•
n
3 3
5
10
6
7
3
9
141
10
142' 11
33
16
341 17
12
13
H
14
H 16
If 17
i]
39
24
19
20
143
21
144
22
145
23
146 24
147
30
44
26
27
143! 28
149
29
ISO
30
151
31
152
_31 14
18
20
_36 21
25
26
-10
27
29
43
27
42
21
138
r rn r rn
wn
K 15
H 18
n
s
[m
1W
T
s
_46 5
4
13
16
17
_S4 18
_S5 19
_56 20
24
59 64
25
60
26
_57 21 28
62
27
61
5
!5S
Jil 15
9
10
158
11
159
12
160' 13
_58 22 1
16
17
162
18
163
19
164
20
165
21
166
22
23
24
167
25
168
26
169'
27
170
28
171
29
3
12
31
154
14
11
23
4
52
10
30
153
7
3
45
3
48
2
1
2
6
9
8
29 1
63
i
20
6 13
IM
;7 14
20
21
27
!28
s
M
r 1T 69
1 8
74
IS
1|w 70
2 9
75
16
65
1T
11
73
12
17
77
18
78
19
24
H
25
H
26
10
76
H
23
H
29
80
30
81:
15
7:
71
H 22 79
1F
3
68' 5
3
S
17
F
Im
I
1
s:
2
53
5
84
6
85
7
86
8
87
9
88 10
11
12
89
13
90
14
91
IS
92
16
93
18
19
H
20
H
21
H
22
H
23
25
26
H
27
H
28
H
29
H
30
S
M
172
7
8
177
2 9
1
2
94
8
9
^ 10
3
95
4
109 11
14
15
182
21
2^
28
29
s
M
6
12
181
13
IBS
19
186
20
190
26
191
27
179
11
ISO
17
184
18
24
189
25
193! 31
194
174
178
10
16
183
187
23
188
192
30
S 176
175
3
T
5
I23
196
3
1
195
2
199
8
200
9
201
10
203 14
204
15
205
16
206
17
203
21
209
22
210
23
211
24
213
28
214
29
215
30
216
4
5
197
6
298
17
11
12
202
13
H
24
18
19
207
20
H
31
25
26
212
27
12
s
F
T
W
3
F
5
m [m r
98] 7
!
101 12
ic:
13
103! 14
:
5
H 15
7
22
JULY 2017
T 96
8
F
4
173
JANUARY 2017 w
I61' 14
T
W
T
1
s
4
T
157
JUNE 2017
T
w
7
119
DECEMBER 2016 T
156
MAY 2017
4
66
6
30
NOVEMBER 2016
m
18
r
11 47
25
APRIL 2017
OCTOBER 2016
r rn 1
140
136
_38
13
35
Mn
8
139
4
2
_32 15
30
19
ni1
s
w
1
J7 22
12
28
1M n
9
11
•11
120
1
28
5
26
S
S 1
F
_24 2
1 6
11
MARCH 2017
4
M
117 4
lie
23
r-
3
6
23
W
1s
lie
5
SEPTEMBER 2016
m
1F
1T
W
T
6
s
JQ 13
19
K
ib! 25
31
22
5
_9 12
18
[m
s
97 6
IW
T
r rrr
s 1
2
3
217
4
H5
218
6
219
7
220
8 IS
15
16
H
17
104
18
105
19
106
20
107
21
9
10
221 11
222
12
223
13
224
17
225
22
23
108
24
109
25
110
26
111
27
112
28
16
17
226
18
227
19
228
20
229
21
230
22
29
30
113
31
114
23
24
231
25
232
26
233
27
234
28
235
29
30
31
236
21
1
120 DAYS= 122
OAYS= 114 TOTAL DAYS =
236
THE VARNETT PUBLIC SCHOOL ABSENCE FROM DUTY FORM SUBMITTAL AND PAYROLL SCHEUOLE
BEGINNING OF PAY PERIOD
9:00AM
If ISlh faBson Sat or Sun pay goes out the Friday _ l)efore^
LEAVE FORMS
PAYOATE
DUE from Csmpuccs to Builness Office t)y
2016-2017
END OF PAY PERIOD
2 working days aKer pay period TIME SHEETS / EXTRA DUTY FORM I EMPLOYEECHANGES
Tuesday. August 16, 2016 _
Wednesday. August 31. 2016
Friday, September 02. M16
Thursday. September 15^016
Thursday. September 15. 2016
Monday, September 19^2016
Friday, September 30,2016
_ FfkJjy.September 16.2016
Friday, September 30. 2016
Monday. October 03.2016
Friday, Oclober_14,2016
Saturday, O^ober 01.2016
Saturday, October 15.2016
Wednesday. October 19, 2016
Friday, October 28,2016
Saturday, October 31,201^
Thursday. Novernber 03^016
Tuesday. November 15, 2016
Thursday. November 17, 2016
VVednesday, November 30^2016
_ Thursday, September 01. 2016
Sunday. O^ber 16,2016
_Tue^y, November 01,201^ Wednesday, Njiyember 16.2016 Tuesday, DecemberOt, 201^
Tuesday. November 15. 2016
t
Wednesday. November30, 2^6
_
Thursday, December 15.2016
_Friday, December 02.2016
Tuesday, ^cembeMS. 2(^5
Thursday. December 1^2016
Wednesday. December 31.2015
Friday, December 16.2016
Saturday, December 31, 2016
Wednesday, January 0^ 2017
Friday. January 13, 2017
Sunday, Ja^aiy 01.2017
Sunday. January 15, 2017_
_Thursday. January 19. ^17
_MQnday. Jantjary 30, 2017
Monday, January 1^2017
Tuesday. January 31.2017
_Thutsda)[, Febru^ary 02.^17
Wednesday, February 01,2017
Wednesday. February IS. 2017
Thursday. February 16.2017
Wednesday, February 15. 2017 _
Friday, Febr^ry 17. 2017
Tuesday. February 28, 2017
Titesday, February 28. 2017
_ Thursday, March 02.2(^7
Wednesday, March 15.2017
Wednesday, March 01. 2017
VVednesd^March_^S. 2017
_
Thu^day. liflarch 1^2017
Friday. March 31.2017
TuMday, April 04. 2017
_^alurday^pii1 IS. 2017
Wednesday. April 19.2017
_
_ Mon^y, MayJS, 2017
Saturday. April 01.2017 _
Sunday. April 30. 2017 _
Wednesday. May 03.2017
Monday, May 01,2017
Monday, May 15,2017
Wednesday. May 17.2017
_
Tuesday. May 16.2017
Wednesday. May 31, 2017
Friday. Ji^ 02, 2017
_
Thursday,June 01,2017
Thursday. June 15. 2017
_
Friday. June 16, 2017
_
I
_
-
J
-
i
Thursday, March 30, 2017
Friday, Mardi 17,2017
Sunday. April 16,2017 _
_
_
Friday, April 14, 201^ Friday. April28.2011_
_
Tuesday, May 30.2017 _Thurs^y. Juiie 15.2017
Monday, June 19,2017
Friday^ June 30, 2017
_Ffldoy. Jurie 30. 2017
Tuesday. July 04.2017
Frj^y. JuJyU, 2qi7_
Saturday, ^ly OL2017
Saturday. July 15.2017
Wednesdayjuly 19, 2017
Sunday, July 16,_2^[)17
Monday. July 31.2017
Wednesday, August 02,2017
Tuesday. August 15,2017
Tuesday. August 01, 2017
Tuesday. August IS. 2017
Thursday, August 17.2017
Wednesday. Augijst 30.2017
_
Friday, July 28, 2011_
The Varnett Public School
Absence From Duty Form NOTE; You must submit requests for absences, other than sick leave, two days prior to thefirst day you will beabsent. Each employee must submit anabsence from duty report immediately after returning to duty when absent due tosickness. Please refer to the Employee Handbook for leave policies. Check One
Name
•(P) Personal •{JjJury Duty •{V) Vacation • (SjSchool Business
Oepartment/Campus
Reason for Absence
Date (s) 0 Absence
Please indicate
Half Day or Full Day (s)
n Personal illness or medical appointment is illness or Injury work-related? DYES G NO
n Personal Business
n Pamily and medical leave (care for anewborn child, placement of a child, quallfylns exigency, etc]
Q Jury Duty or subpoena (attach documents) n School Business
0 Military Duty Reason:
Employee Signature
Date
Manger Approval
•Approved
•Leave Without Pay
• Rejected Comments
Director/Supervisor Signature
Date
Superintendent Signature
Date
Varnett Public School PERSONNEL DEMOGRAPHIC/BENEFIT CHANGE FORM D.O.B.
Employee Name:
Facility:
• Name Change
Current Name:
• Address Change
New Address:,
New Name:
City, State Zip:. • Deduction
Change (See attached enrollment form(s)
•W-4
(See attached W-4 form)
•other Please specify
• Direct Deposit Change A copy of a voided check or printed ACH Fern from Bank Is REQUIRED. (See attached direct deposit form)
Comments:
Employee Signature.
Date:
The signature below by authorized personnel grants permission for WebSmartbyJR3 employees to input the information provided above into the HRand payroll system for processing. Approved by:
Printed Name of Authorized Person
Date
Signature of Authorized Person
Date
Varnett Public School
TIME SHEET
5025 South Willow Drive Houston TX 77035 713-723-4699
Please completely fill out and submit Time Sheet Form to Supervisor or Department Head iffor any reason you cannot clock in and/or out using the hand time clock.
Employee Name;
Title:
Employee Number:
Status:
Department;
Supervisor:
Date
Start Time
End Time
Active
Regular Hrs.
Overtime Mrs.
Weekly Totals
Employee signature:
Date:
Supervisor signature:
Date:
Total Mrs.
3CKIOOL
VARHEir
TIME SHEET
Title: Director
Campus: Southwest Supervisor: Superintendent of Schools TIME IN
TIMEOUT
DATE
NUM. OF DAYS
Jane Doe
8/10/2015
1
7 30 AM
4:30 PM
Jane Doe
8/11/2015
2
7 30 AM
4:30 PM
Jane Doe
8/12/2015 8/13/2015 8/14/2015
3
7 30 AM
4:30 PM
4
7 30 AM
4:30 PM
5
7 30 AM
4:30 PM
NAME
Jane Doe Jane Doe
Jane Doe
Employee Signature
Superintendent of Schools Supervisor Signature
8/17/2Q15 Date
8/17/2015 Date
THE VARNETT PUBLIC SCHOOL
REQUEST, AUTHORIZATION, AND REPORT OF COMPENSATORY TIME NAME;
LOCATION:
POSITION:
SUPERVISOR
SCHOOL YEAR:
COMPENSATORY TIME EARNED
COMPENSATORY TIME USED
MRS. WORKED DATE
BEYOND REG. SCHEDULED
DESCRIPTION
SUPERVISOR AUTHORIZATION
HRS
COMP
HOURS EARNED
DATE COMP
COMP HRS,
HRS. TAKEN
TAKEN
SUPERVISOR AUTHORIZATION
ACCUMULATIVE BALANCE*
BALANCE: FOR DISTRICT USE ONLY
EMPLOYEE'S SIGNATURE
DATE
CFO SIGNATURE
PAY DATE:
DR. MARGARET STROUD
DATE
Acct Code:
DATE
Employee Rights and Responsibilities Under the FMLA Basic Leave Entitlement
FMLA requires covered employers to provide up to 12 weeks of unpaid, job-protected leave to eligible employees for the following reasons:
• For incapacity due to pregnancy, prenatal medical care or child birth; • To care for the employee's child after birth, or placement for adoption or foster care; • To care for the employee's spouse, son or daughter, or parent, who has a serious health condition; or
• For a serious health condition that makes the employee unable to perform the employee's job. Military Family Leave Entitlements
"Qualifying Exigency" Leave for Families of Active Duty Members of the Armed Forces
Eligible employees with a spouse, son. daughter, or parent on active duty or call to active duty status in the Armed Forces may use their 12-week leave entitlement to address certain qualifying exigencies. Qualifying exigencies may Include attending certain military events, arranging for altematlve childcare, addressing certain financial and legal arrangements, attending certain counseling sessions, and attending post-deployment reintegration briehngs. Military Careglver Leave for Veterans and for Aggravated Illnesses or Injuries
FMLA also includes a special leave entitlement that permits eligible employees to take up to 26 weeks of leave to care for a covered service member or veteran during a single 12-month period. A "covered service member" is a current member of the Armed Forces, including a member of the National Guard or Reserves, who has a serious injury or Illness Incurred by the member in line of duty on active duty In the Armed Forces (or existed before the beginning of the member's active duty and was aggravated by service in line of duty on active duty in the Armed Forces), and that may render the member medically unfit to perform the duties of the member's office, grade, rank or rating. Since veterans do not have a current "office, grade, rank, or rating," the serious Injury or illness must be one "that manifested Itself before or after the member became a veteran."
The entitlement to take military careglver leave for the care of veterans extends only to family members of veterans when the veteran was a member of the Armed Forces at some point In the five (5) years preceding the date on v\^ich the veteran undergoes the medical treatment or receives the therapy that necessitates the leave. Benefits and Protections
During FMLA leave, the employer must maintain the employee's health coverage under any "group health plan"" on the same terms as if the employee had continued to work. Upon return from FMLA leave, most employees must be restored to their original or equivalent positions with equivalent pay, benefits, and other employment terms. Use of FMLA leave cannot result in the loss of any employment benefit that accrued prior to the start of an employee's leave.
Eligibility Requirements
Employees are eligible if they have worked for a covered employer for at least one year, for 1,250 hours over the previous 12 months, and if at least 60 employees are employed by the employer within 75 miles. Definition of Serious Health Condition
A serious health condition is an illness, injury, impairment, or physical or mental condition that invoives either an overnight stay in a medical care facility, or continuing treatment by a health care provider for a condition that either prevents the employee from performing the functions of the employee's job, or prevents the qualified family member from participating in school or other daily activities.
Subject to certain conditions, the continuing treatment requirement may be met by a period of incapacity of more than 3 consecutive calendar days combined with at least two (2) visits to a heaith care provider or one visit and a regimen of continuing treatment, or incapacity due to pregnancy, or incapacity due to a chronic condition. Other conditions may meet the definition of continuing treatment. Use of Leave
An employee does not need to use this leave entitlement in one block. Leave can be taken intermittently or on a reduced leave schedule when medically necessary. Employees must make reasonable efforts to schedule leave for planned medical treatment so as not to unduly disrupt the employer's operations. Leave due to qualifying exigencies may also be taken on an intermittent basis.
Substitution of Paid Leave for Unpaid Leave
Employees may choose or employers may require use of accrued paid leave \A^ile taking FMLA leave. In order to use paid leave for FMLA leave, employees must comply with the employer's normal paid leave policies. Employee Responsibilities
Employees must provide 30 days advance notice of the need to take FMLA leave when the need is foreseeable. When 30 days notice is not possible, the employee must provide notice as soon as practicable and generally must comply with an employer's normal call-in procedures. Employees must provide sufficient information for the employer to determine if the leave may qualify for FMLA protection and the anticipated timing and duration of the leave. Sufficient information may include that the employee is unable to perform job functions, the family member is unable to perform daily activities, the need for hospitalization or continuing treatment by a health care provider, or circumstances supporting the need for military family leave. Employees also must inform the employer if the requested leave is for a reason for which FMLA leave was previously taken or certified. Employees also may be required to provide a certification and periodic recertification supporting the need for leave. Employer Responsibilities
Covered employers must inform employees requesting leave whether they are eligible under FMLA. If they are, the notice must specify any additional information required as well as the employees' rights and responsibilities. If they are not eligible, the employer must provide a
reason for the ineligibility.
Covered employers must inform employees if leave will be designated as FMLA-protected and the amount of leave counted against the employee's leave entitlement. If the employer determines that the leave is not FMLA-protected, the employer must notifythe employee. Unlawful Acts by Employers FMLA makes it unlawful for any employer to:
• Interfere with, restrain, or deny the exercise of any right provided under FMLA; • Discharge or discriminate against any person for opposing any practice made unlawful by FMLA or for involvement in any proceeding under or relating to FMLA. Enforcement
An employee may file a complaint with the U.S. Department of Labor or may bring a private lawsuit against an employer.
FMLA does not affect any federal or state law prohibiting discrimination, or supersede any state or local law or collective bargaining agreement which provides greater family or medical leave rights.
Certification of Health Care Provider for Employee's Serious Health Condition
U.S. Department of Labor wageandHouroivision
(Family and Medical Leave Act) lX)N'OT-SI-:M)a)MPi,KTi;DK genetic services, asdefined in 29C.F.R. § 1635.3(e). or the manifestation ofdiseaseor disorder in theemployee's family members, 29C.F.R. § 1635.3(b). Please be sure to sign ilje fonn on the last page. Provider's name and business address:
Type of practice/ Medical specialty: _
Telephone: (
pjigg ]
_)
Fax;(_
Form WH-380-E Revised May 2015
m
PART A; MEDICAL FACTS
1. Approximate datecondition commenced: Probable duration of condition:
Mark below as applicable:
Was the patient admitted for an overnight slay in a hospital, hospice, orresidential medical care facility? No
Yes. Ifso. dates of admission:
Date(s) you treated the patient for condition:
Will the patient need to have treatment visits at least twice per year due to the condition? Was medication, other than ovcr-the-coiinicr medication, prescribed?
No
No
Yes.
Yes.
Was the patient referred toother health care provider(s) for evaluation ortreatment (e.g.. physical therapist)? No
Yes. Ifso. stale the naliirc of sucit treatments and expected duration of treatment:
2. Is the medical condition pregnancy?
No
Yes. Ifso. c.xpected delivery date:
3. Use the information provided by the employer in Section 1to answer this question. Ifthe employer fails to
provide a list of the employee's essential functions or a job description, answer these questions based upon the employee's own description of his/herjob functions.
Is the employee unable to perform any of his/her job functions due to thecondition:
No
Yes.
If so, identifythe job functions the employee is unable to perform:
4. Describe other relevantmedical facts, if any, related to the condition for whichthe employee seeks leave (such medical facts may include symptoms, diagnosis, or any regimen of continuing treatment such as the use of specialized equipment):
Page 2
fONl
ON Ni-;\ f PACK
Form WH-SSO-K Revised May 2015
PART B: AMOUNT OP LEAVE NEEDED
5. Willthe employee be incapiicilatcd fora singlecontinuous period ol'time due to his/lier medical condition, including any time for trcaiinent and recovery? No Yes. If so. cstimale the beginningand ending dales for the period of incapacity:
6. Will the employee need to attend follow-up treatment appointments or work part-time or on a reduced schedule because of the employee's medical condition?
No
Yes.
If so. are the treatments or the reduced number of hours of work medically necessary? No
Yes.
Estimate treatment schedule, if any. iitcluding the datesof any scheduled appointments and the time required for each appointment, including any recovery period:
Estimate the part-time or reduced work schedulethe employee needs, if any: dajs per week from
hour(s) per day:
through.
7. Will the condition cause episodic Harc-iips periodically preventing the employee from performing his/lterjob functions?
No
Yes.
Is it medically necessary for the employee to be absent from work during the flare-ups? No
Yes. Ifso, explain:
Based upon the patient's medical history and your knowledge ofthe medical condition, estimate the frequency offlare-ups and lite duration of related inca|5aeity that the patient may have over the next 6 months (e.g.. 1cpis^c every 3months lasting 1-2 days): Frequency
:
times pcr_wcck{s)
Duration:Jioiirsor
Hionth(s)
day(s) per episode
ADDITIONAL INFORMATION: IDENTIFY QUESTION NUMBER WITH YOUR ADDITIONAL ANSWER.
I>agc3
C'(>N"I INUI-:!)ONNi;.\Tl'A(ii;
Komi WIIOSO-E Re%i«dMay20i5
Signature orHeaith Care ProviJcr
Date
PAPERWORK REDUCTtON ACT NOTICE AND PUBLIC BURDEN STATEMENT
Ifsubmitted, itIsmandalon- for employers to retain ncopy ofthis disclosure in their records for three years. 29 U.S.C. § 2616:29 C.F.R. it 825.500. Persons are not required to respond to this collection ofinformation unless itdisplays a currently valid 0MB control number. The Department ofLabor estimates that itwill take art average of20 minutes for respondents to complete this collection ofinformation, including the lime for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection ofinformation. Ifyou have any comntents regarding this burden esiiinateorany other aspect ofthis colieciioninfomialion. including suggestions for reducing this burden, send them to the Administrator. Wage and Hour Division, U.S. Department ofLabor, Room S-3502.200 Constitution Ave., NW, Washington. DC 2O2I0, DONOT SEND COMPLE'I EDFORM TO THE DEPARTMENT OF LABOR; RETURN TO THE PATIENT. I-ormWII.380-1: Re\-ised May20i5
Certification of Health Care Provider for
U.S. Department of Labor
Family Member's Serious Health Condition (Family and Medical Leave Act)
wage arj Hour Division
D(1 NOT SEND C'OMI'l.liTED FORM T( >Till; DIT'ARTMENT OF f.Al«)R, RI-.TIIRN TO THE PATIIIN i'
l-.\nirrs S/M/2018
SECTION I: For Completion by the EMPLOYER INSTRUCTIONS to the EMPLOYER! The Familyand Medical Leave Act (FMLA) provides that an employer
may require an employee seeking FMLA prcleclions because ofa need for leave to care for a covered family member with a serious health condition to submit a medical cenification issued by the health care provider of the
covered family member. Please complete Section I before giving this form toyour employee. Your response is voluntary. While you are not required lo use this fonn. you may not ask the employee to provide more information than allowed under the FMLA regulations, 29 C.F.R. §§ 825.306-825.308, Employers mustgenerally maintain records and documents relating to medical certifications, reccriifications. or medical histories of employees' family members, created for FMLA purposes as confidential medical records in separate (ilcs/rccords from tire usual personnel flics and in accordance with29 C.F.R. § 1630.l4(c)(]). if the Americans withDisabilities Act applies, and in accordance with 29 C.F.R. § 1635.9. if the Genetic Infonnation Nondiscriinination Act applies. Employer name and contact:
SECTION U: For Completion by the EMPLOYEE
INSTRUCTIONS to the EMPLOYEE: Please complete Section 11 before giving this form to your family memberor liis/iier medical provider. The FMLA permits an employerto require that you submit a timely, complete, and.sufficient medical certification to support a request for FMLA leave to care for a covered family memberwith a serious liealth condition. If requested by your employer, your response is required to obtain or retain the benefit of FMLA protections. 29 U.S.C. §§ 2613, 2614(c)(3). Failure lo provide a complete and sufficient medical certification may result in a denial of your FMLA request. 29 C.F.R. § 825.313. Youremployer must give you at least 15 calendar days lo return this form to your employer. 29 C.F.R. § 825.305, Your name: First
Middle
Last
Name of family member for whom you will provide care:_ First
Middle
Last
Relationship of family memberto you: If family member is your son or daughter, date of birtli:_ Describe care you will provide to your family member and estimate leave needed to provide care;
Employee Signature I'agel
Date CONTlNUIiDDNNf-XTPAUE
ForniWIlOSO-F Revised May 2015
SECTION 111: For Completion by the HEALTH CARE PROVIDER INSTRUCTIONS to the HEALTH CARE PROVIDER: The employee listed above has requested leave under
the FMLA to care for your patient. Answer, fully and completely, all applicable parts below. Several questions seek a response as to the frequency orduration of a condition, treatment, etc. Your answer should beyourbest estimate based upon your medical knowledge, experience, and examination of the patient. Be as specific as you can; tenns such as •"lifetime." "iinknown," or ••indeterminate" may not be .sufficient to determine FMLA coverage. Limit your responses to thecondition for which the patient needs leave. Donot provide infonnation about genetic tests, as defined in 29 C.F.R. § 1635.3(0, or genetic services, us defined in29 C.F.R. § 1635.3(e). Page 3 provide.^ space for additional information, should you need it. Please besure to sign the form on the last page.
Provider's name and business address:^ Type of practice / Medical specially; _
Telephone: (
1
Fax:(_
PART A: MEDICAL FACTS
I. Approximate date condition commenced; Probable duration of condition:
W.1S the patientadmitted for an overnightstay in a hospital, hospice, or residential medical care facility? No
Yes. If so. dates of admission:
Datc(s) you treated the patient for condition:
Was medication, other than over-the-counter medication, prescribed?
No
Yes.
Will the patient need to have treatment visits at least twice per year due to the condition?
No
Yes
Was the patientreferred to other health care provider(s) for evaluation or treatment(e.g.. physical therapist)? No Yes. If so, state the nature of such treatments and expected duration of treatment;
2. Is the medical condition pregnancy?
No
Yes. If so. expecteddelivery dale:.
3. Describe other relevantmedical facts, if any. related to the condition for which the patientneeds care (such medical facts may include symptoms, diagnosis, or any regimen of continuingtreatment such as the use of specialized equipment):
l'Jee2
CONTINUi:i}ONNI-:XTl'Atii-:
Form Wit-JSO-F Reviscil May20lS
PART B: AMOUNT OF CARE NEEDED: Wlien answering these questions, keep in mind thatyourpatient's need
for care by the employee seeking leave may Include assistance with basic medicd, hyaenip»nuttitionaljjafety or transportation needs, or the provision ofphysical or psychological care:
4. Will the piUicni be incapacitated for a single continuous period of time, including any time for treatment and recovery?
No
Yes.
Estimatethe beginning and ending dates for the period of incapacity:
During this time, will the patient need care?
No
Yes.
Explain thecare needed by the patient and why suchcore is medically necessary:
5. Will the patient require follow-up treatments, including any lime for recovery?
No
Yes.
Estimate ireaiment .schedule, if any, including the dates of any scheduled appointments and the time required for each appointment, including any recovery period:
Explain the care needed by the patient, and why such care is medically necessary:
6. Will the patient require care on an intermittent or reduced schedule basis, including any time for recovery?. No _ Yes. Estimate the hours the patient needs care on an intermittent basis, if any:
houits) per day:
days per week
from
ihrou]^
Explain the care needed by the patient, and why such care is medically necessary;
PageJ
CONTINl)EDONNl-:XTI'AGl-
FonnWII-iSO-t' RtvbciJ Nta> 2015
7. Will the condition cause episodic flare-ups periodically preventing the patient from participating in normal daily activities?
No
Yes.
Based upon the patient's medical liislory' arid your knowledge ofthe medical condition, estimate the frequency of flare-ups and the duration ofrelated incapacity that the patient may have over the next 6 months (e.c.. I episode every 3 months lasting 1-2 days):
Frequency: Duration:
times per hours or
week{s)
month(s)
day(s) per episode
Does the patient need care during these flare-ups?
No
Yes.
Explain the care needed by the patient, and why such care is medically necessary:
ADDITIONAL INFORMATION: IDENTIFYQUESTION NUMBERWITH YOUR ADDITIONAL ANSWER.
Signature of Health Care Provider
Date
PAPERWORK REDUCTION ACT NOTICE ANDPUBI.IC BURDEN STATEMENT
ifsubmittcd. it is mandatory for employersto retain a copy of this disclosure in their records for three years. 29 U.S.C.§ 2616; 29 C.F.R. $ 82S.500. I'ersoas are iioi requiredto respond to this eolleclinnofinfiinnalion unless It displaysa currentlyvalid 0MB control numher. The DepariiriL-m ol'l.ahor esiimaies that ii will lake un average (ir2() miimlcs lor respondenis In complete lliis collection oriiUi)rmaiii)n. including ilie lime lor reviewing insirueiion.s. searchingexlMlngdaiasources, gaihering and mainiaining the data needed, and compleiing and re\ iewing the colieciinn orinliimialinn. If you have any cnitimenu regarding this burden estimate or any other a.speci of this collection iiirorinalion. including siiggesllons for reducing tlii.s burden, send them to the Administrator. Wageand Hour Division. U.S. Depaiimemof Labor. Room S-.1502, 201) Consiilution Avc.. NW. Wasbingtoii. DC" 20210. DO NOT SEND COMPLETED FORM TO THE DEPARTMENT OF LABOR; RETURN TO THE PATIENT. Form Wly\V>v,tt!iC'SigOv/ l-9Central before completing Section 1. These individuals have special procedures for establishing identity if they cannot present an identity document for Form 1-9. The special procedures include (1) the parent or legal guardian filling out Section I and writing "minor under age 18" or "special placement." whichever applies, in the employee signature block; and (2) the employer writing "minor under age 18" or "special placement" under List B in Section 2.
l orm 1-9 inslniclions Oj/OH/lj N
Pagc2or9
Section 2. Employer or Authorized Representative Review and Verification Before completing Section 2. employers must ensure that Section I is complcied properly and on time. Employers may not ask an individual to complete Section I before he or she has accepted a job offer. Employers or theirauthorized representative must complete Section 2 by examining evidence of identity andemployment authorization within 3 business days of the employee's llrst day of employment. For e.\ample. if an employee begins employment on Monday, the employer must complete Section 2 by Thursday ofthat week. However, ifan employer hires an individual for less than 3 business days. Section 2 iinist be completed no laterthan the first day of employment. An
employer may complete Form 1-9 before the first day ofemployment ifthe employer has olTered the individual aJob and the individual has accepted.
Employers cannot specify which documcnl(s) employees may present from the Lists ofAcceptable Documents, found on the last page of Form 1-9. to establish identitv' and employment authorization. Employees must present one selection from List A OR a combination of one selection from List B and one selection from List C. List A contains documents that
show both identity and employment aiilhorizaiion. Some List Adocuments arc combination documents. The employee must present combination documents together to be considered a List Adocument. For example, a foreign passport and a Form 1-94 containing .tn endorsement ofthe alien'.s notiimmigrani status must be presented together to be considered a List A document. List B contains documents that show identity only, and List C contains documents that show
employment aiilhorizaiion only. Ifan employee presents a List Adocument, he or she should not present a List Band List Cdocument, and vice versa. Ifan employer particip.iles in E-Vcrify. the List Bdocument must include a photograph. In the field below the Section 2 introduction, employers must enter the last name, first name and middle initial, ifany. that the employee entered in Section I. This will help to identify the pages ofthe form should they get separated. Employers or their authorized representative must:
1. Physically e.xamine each origimal document the employee presents to determine ifit reasonably appears to be genuine and to relate to the person presenting it. The person wtio examines the documents must be the same person who si^ Section 2. The examiner ofthe documents and the employee must both be pliysieally present during the examination of the employee's documents.
2. Record the document title shown on the Lists ofAcceptable Documents, issuing authority, document number and
expiration date (ifany) from the original document(s) the employee presents. You may write "N/A" in any unused fields.
Ifthe employee is a student or exchange visitor who presented uforeign passport with a Fonn 1-94, the employer should also enter in Section 2:
a. The student's Fonn 1-20 or DS-2019 number (Student and Exchange Visitor Information System-SEVIS Number); and the program end date from Form 1-20or DS-2019.
3. Under Certification, enter the employee's first day ofemployment. Temporary staffing agencies may enter the first day the employee was pLnced in ajob pool. Recruiters and recruiters for a fee do not enter the employee's first day of employment.
4. Provide the name and title ofthe person completing Section 2 in the Signature of Employer or Authorized Representative field.
5. Sign and date the attestation on the date Section 2 is completed. 6. Record the empIo>er's business name and address. 7. Return the employee's documentation.
Employers may. but are not required to. photocopy the documcnl(s) presented. Ifphotocopies arc made, they should be made for ALL new hires or revcrificaiions. Photocopies must be retained and presented with Form 1-9 in caseof an inspection by DHS or other federal government agency. Employers must always complete Section 2 even if they photocopy an employee's documem(s). Making photocopies of an employee's documenl(s) cannot take the place of completing Form 1-9. Employers are .still responsible for completingand retaining Form 1-9.
Fonn 1-9 Insiruciions 03/08/13 N
FagcSofO
Uncxpired Documents
Generally, only unexpired. original documentation is acceptable. Hie only e.xception is that an employee may present a certifiedcopy of a birth certificate. Additionally, in some instances, a document that appears to be expired may be acceptable if the expiration date shown on the face of the document has been extended, such as for individuals with temporary protected status. Refer to the Hamthoukfor Employers: Instructions for Completing Form 1-9 (M-27-1) or 1-9 Centra! fwww.iiscis.gov/l-9Ceniran for examples. Receipts
If an employee is unable to present a required document (or documents), the employee can present an acceptable receipt in lieu ofadocumem from the Listsof Acceptable Documents on the last page of this form. Receipts showingthat a person has applied for an initialgrant of employment authorization, or for renewal of employment authorization, are not acceptable. Employers cannot accept receipts if employment will last less than 3 days. Receipts arc acceptable when completing f-orm 1-9 for a new hire or when rcveriflcation is required.
Employees must present receipts wilhin 3 biisiiic.ss days of their first day ofemployment, or in the case ofrevcrirication, by thedate that revcrificaiion is required, and must present valid replacement documents within the time frames described below.
Tltere are three types of acceptable receipts:
1. A receipt showing that the employee has applied to replace a document that was lost, stolen or damaged. The employee must present the actual document within 90 days from the date of hire. 2. The arrival portion of Form j-94/l-94A with a temporary 1-551 stamp anda photograph of the individual. The employee must present theactual Permanent Resident Card (Form 1-551) by the expiration dateof the temporary I-55I stamp, or. if there is no expiration date, within I year from the date of issue.
3. The departure portion of Form I-94/I-94A with a refugee admission stamp. The employee must present an uncxpired Employment Authorization Document {Fonn 1-766) ora combination of a List 8 document and an unrestricted Social Security card within 90 days. When the employee provides an acceptable receipt, the employer should: 1. Record the document tilic in Section 2 under the sections titled List A, List B. or List C. as applicable.
2. Write the word "receipt" and its document number in the "Document Number" field. Record the last day that iho receipt is valid in the "Expiration Dale" field.
By the end of the receipt validity period, the employershould: 1. Cross out the word "receipt" and any accompanying document numberand expirationdate. 2. Record the numberand other required document information from the actual document presented. 3. Initial and date the change.
Seethe HanJhnokfor Employers: iiisiructions for Completing Form 1-9(M-27-1) at www.uscis.gov/I-9Central for more information on receipts. ScctioQ 3. Reveriflcation and Rchires
Employers or their authorized representatives should complete Section3 when rcvcritylng that on employeeis authorized to work. When rchiring an employeewithin 3 years of the date Form 1-9 was originally completed, employershave the option to complete a new I'orm 1-9 or compicte Section 3. When completing Section 3 ineithera reveriflcation or rchire situation, ifihe employee's name has changed, record the name change in Block A. For employees who provide an employmctu authorization expiration date in Section 1.employers must reveiify employment authorization on or before the date provided.
Form 1-9 Insiruciioiis 03/08/13 N
Pugc4or9
Some employees may write "N/A" in the space provided forthc expiration date in Section I if they are aliens whose employment authorization does not expire (e.g.. asylees. refugees, certain citizens of the Federated Slates of Micronesia, the Republic of the Marshall Islands, or Paiau). Reveritlcation does not apply for such employees unless they chose to present evidence of employment authorization in Section 2 that contains an expiration date and requires revcrification, such as Form 1-766, Employment Authorization Document. Reveritlcation applies if evidence of employment authorization (List A or List C document) presented in Section 2 expires. However, employers should not reverify: 1. U.S. citizens and noncitizen nationals; or
2. Lawful permanent residents who presented a Pertiianenl Resident Card (Form 1-551)for Section 2. Reveritlcation does not apply to List B documents.
If both Section I and Section 2 indicate expiration dales triggering the reverification requirement, the employershould reverify by the earlier dale.
Forreveritlcation. an employee must present une.\pired documcniation from either List A or List C showing heor she is still authorized to work. Employers CANNOT require the employeeto present a particular document from List A or List C. The employee may choose which document to present. To complete Section 3. employersshould follow these instructions: 1. Complete Block A if an employee's name has changed at the time you complete Section 3.
2. Complete Block B with the date of rchire if you reliirc anemployee within 3 years of the dale this form was originally completed, and the employee is still authorized to be employed on the same basis aspreviously indicated on this form. Also completethe "Signature of Employer or Authorized Representative" block. 3. Complete Block C if:
a. The employment authorization oremployment authorization document ofacurrent employee isabout to expire and requiresreverification; or
b. You rchire an employee within 3 years ofthe date this form was originally completed and his orher employment authorization oremployment authorization document has c.xpired. (Complete Block Bfor this employee as well.) To complete Block C:
a. E.Kamine either a List A or List C document the employee presents that shows that the employee is currently authorized to work in the United Stales: and
b. Record the document title, document number, and expiration date (if any).
4. After completing block A. Bor C. complete tiie "Signature of Employer orAuthorized Representative" block, including the date.
For reverification purposes, employers may either complete Section 3 of a new Form 1-9 orSection 3 ofthe previously completed Form 1-9. Any new pages ol'Form 1-9 completed during reverification must be altuched to the employee's original Form 1-9. Ifyou choose to complete Section 3 ofa nc« Foim 1-9. you may attach just the page containing Section 3. with the employee's name entered at the lopof the page, to the employee's original Form 1-9. Ifthere is a more current version of Form 1-9 at the time ofrevcriUcation. you must complete Section 3 of that version of the form. What Is the Filing Fee?
There is no fee for completing Form 1-9. This form is not filed with USCIS or any government agency. Fonn 1-9 must be retained by theemployer and made available for inspection by U.S. Government officials as specified inthe "USCIS Privacy Act Statement" below. USCIS Forms and Information
Formore detailed infonn.ilion about completing Form 1-9, employers and employees should refer to theHandbookfor Employers: Instruciioiisfor Coinpleiiny Form 1-9 (M-27-1).
I'orm 1-9 tnsiniclions
N
Page 5 of 9
You can also oblain inConnalion aboul Form 1-9 from ihc USCIS Web site at wvvw.iiscis.pov/l-9Centrai. by c-mailing USCiS at l-9Ccntralfgiihs.pov. or by calling 1-888-46-1-4218. For TDD (hearing impaired), call 1-877-875-6028. To oblain USCIS forms or the HaiiJI»uikfor Einphyers. you can download them from the USCIS Web site at: tfov/form.s. You may order USCIS forms by calling our toll-free number at 1-800-870-3676. You may also obtain forms and information by contacting the USCIS National Customer Service Center at 1-800-375-5283. For TDD (hearing impaired), call 1-800-767-1833.
Information aboul E-Verify, a free and voluntary program that allows participating employersto electronically verify the employment eligibility of their newly hired employees, can be obtained from the USCIS Web site at www.dhs.gov/EVerifv. by e-mailing USCISat
[email protected] or by calling 1-888-464-4218. For TDD (hearing impaired), call 1-877-875-6028.
Employees with questions about Form 1-9and/or E-Vcriiy can reach the USCIS employee hotline by calling 1-888-897-7781. For TDD (hearing impaired), call 1-877-875-6028.
Photocopying and Retaining Form 1-9 A blank Form 1-9 may be reproduced, provided all sides are copied. 'ITie instructions and Lists of Acceptable Documents
must be available toall employees coinpleiing this form. Employers must retain each employee's completed Fonn 1-9 for as long as the individual works for the employer. Employers arc required to retain the pages ofthe fonn on which the employee and employer enter data. Ifcopies ofdocumentation presented by the employee arc made, those copies must also be kept with the form. Once the individual's employment ends, the employer must retain this form for either 3 years after the dale of hire or I year after the dale employment ended, whichever is later.
Form 1-9 may be signed and retained electronically, in compliance with Department ofHomeiand Security regulations at 8 CFR 274a.2.
USCIS Privacy Act Statement
AUTHORITIES: The authority for collecting this information is the Immigration Reform and Control Act of 1986, Public Law 99-603 (8 USC 1324a).
PURPOSE: This information iscollected by employers to comply with the requirements of the Immigration Reform and Control Act of 1986. This law requires that employers verify the identity and employment authorization of individuals they hire for employment to preclude the unlawful hiring, or recruiting or referring for a fee. ofaliens who arc not authorized to work in (he United Stales.
DISCLOSURE: Submission of the infonnaiion required in this form is voluntary'. However, failure of the employer to ensure proper completion ofthis fonn for each employee may result in the imposition ofcivil orcriminal penalties, In addition, employing individuals knowing that they arc unauthorized to work inthe United States may subject (he employer to civil and/or criminal penalties.
ROUTINE USES: This infonnation will beused byemployers asa record of their basis fordetennining eligibility of an employee to work in the United States. The employer will keep this form and make it available for inspection by authorized olTicials of the Departmem ofHomeiand .Security, Department of Labor, and Office of Special Counsel for Immigration-Rciaied Unfair Employment Practices. Paperwork Reduction Act
An agency may not conduct or sponsor an information collection and a person is not required to respond to a collection of information unless it displays a currently valid 0MB eontrol number. The public reporting burden for this collection of information is estimated at 35 minutes per response, including the lime for reviewing instructions andcompleting and retaining the form. Send comments regarding this burden estimate or anyotheraspect of this collection of infonnation, including suggestions for reducing (his burden, to: U.S. Citizenship and Immigration Services. Regulatory Coordination Division. Office of Policy and Strategy. 20 Massachusetts Avenue NW. Washington. DC 20529-2140; 0MB No. 1615-0047. Do not mail your completed Form 1-9 Co this address. Fonn 1-9Insimciions 03/0K/I3 N
l'aec6of9
Employment Eligibility Verincation
USCIS Form 1-9
Dcpiirtmcnt of Homeland Sccurily U.S. Citizenship and Immigration Services
OMItNo. 1615-0047
Expires 03/31/2016
^START HERE. Read instructions carefully boforo comploUng this form. The Instructions must be available during completion of this form.
ANTI-DISCRIMINATION NOTICE: It is illegal lo discnminate against woOt-aulhorlzed individuais. Employers CANNOT specifywhicfi 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 completeend sign Section 1 of Fonn 1-9 no later than the firstday of employment but not before acceptinga joti offer.) Last Name (Family Name)
Apt. Number
Address (SIreef Number and Name)
Date of Birth (mm/Mfyyyy)
Middle initial Oltwr Names Used (Hany)
First Name (Given Neme)
U.S. Social Security fhimber
City or Town
Stale
Zip Code
Tetephooe Nund>er
E-maii Address
3 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 I am (check one of the following):
D A citizen of the United States
Q Anondtizen national ofthe United States(Seeinstructions) r~| Alawful permanent resident (Alien Registration Number/USCIS Number):
Q An alien authorized lo work until (expiration date, if applicable, mm/dd/yyyy)
. Some aliens may write "N/A" in this
(See instructions)
For aliens authorizedlo work, provideyour Alien Registration NumberAJSCIS NumberOR Form 1-94 Admission Number 1. Alien Registration Number/USCiS Number
3-0 Barcode
OR
Oo NotWrito In This Space
2. Form 1-94 Admission Number:
If you obtained your admission number from GBP inconnection with your arrival In the United States. Include the following:
Foreign Passport Number:. Country of issuance:
Some aliens may write"N/A" on the ForeignPassport Number and Country of Issuance fields. (See instmctions) Date (mm/dd/yyyy):
Signature of Employee:
Preparer and/or Translator Certification (Tobe comp/sfedand s^ned rfSecfrdn 1 is prepared by a person other then the employee.)
I attest, under penalty of perjury, that I have assisted In the completion of this form and that to the best of my Itnowledge the Information Is true and correct
Dale (mm/dd/yyyy):
Sgnature of Preparer or Translator
Lasi Name (Family Name)
First Name (Srven Name)
Address (Sfreef Number and Neme)
City or Town
^1^ ronnl-9 03/08/13 N
State
Zip Code
Employer Completes Next Page Page 7 ofO
Section 2. Employer or Authorized Representative Review and Verification (Employersor their authorized representative must complete and sign Section 2 ivihin 3 tusiness days of the employee's first day of employment. You
mustphysically examine one document from UsIAORexamine a comhination ofone document from List Band onedocument from List C as listed on the 'Lists of Acceptable Documents'on the next page of this form. For each document you review. recordthefoSowinginformation:documenltltte, issuing authority, document number, end explretion date, if any.} Employee Last Name, First Name and Middle Initial from Section 1: List A Identity and Employment Authorization
OR
AND
LiStB
LIstC
Employmont Authorization
Identity
Document Title:
Document Title:
Document Htle:
Issuing Aulhonty;
issuing Authority;
Issuing Authority:
Oocumeni Number
Document Number:
Document Numtier
Expiration Date (if any)(mmAidfyyyy).
Expiration Dale (Ifanyllmm/dd/yyyy):
Expiration Dale (if any)(mm/ddfyyyyy.
Oocumeni Title:
issuing Aulhonty: Oocumeni Number
Expiration Dale (S anyjirjmi/dd/yyyyy. 3*0 Barcode
Do Not Write In This Space
Document Title:
Issuing Aulhonty: Document Number
Expiration Dale (if any)(mm/ddfyyyy)'.
Certification
Iattest, under penaltyof perjury,that (1) Ihave 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 ofemployment (mm/dd/yyyy): Signature of Employeror Authorized Represenlallve Last Name (Family Name)
(S®® Instruetlons for exemptions.) Date (mm/dd/yyyy)
First Name (Given Name)
Title of Employer or Authorized Represenlative
Employers Business or Organization Name
Employer's Business or Organization Address (Street Number and Name) City or Town
State
Zip Code
Section 3. Reverlflcation and Rehires (To be completed and signed by employer or authorized representative.) A. New Name (if applicable) Last Name (Family Name) First NamefSrwe/) Narrre)
Middle Initial B. Date of Rehire (if appfiealM) (mm/dd/yyyy):
C. IIemployee's previousgrant ol employment autnonza^ has expired, provide (he infonnation forthe document from ListAor ListC tne employee presented lhal establishes current employment authorization In the space provided below Document Title:
Document Number'
Expiration Date (if any)(mmJdii/yyyyy
1attest, under penalty of perjury, that to the best of my knowledge, this employee Is authorized to work in the United States, and if Uieemployee presented documentjs), the documeiit(s) 1have examined appear to be genuine and to relate to the Individual. Signature of Employer or Authorized Representative:
Form 1-9
O.vnK/13 N
Date (mm/dd/yyyy):
Print Name of Employer or Authorized Represenlative:
I'agc 8of9
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 B and one selection from List C.
2.
Employment Authorization
Identity
Both Identity and
1. U.S. Passport or U.S. Passport Card
Documents that Establish
Documents that Establish
Documents that Establish
Employment Authorization
LISTC
LISTB
LIST A
OR
AND
1. Driver's license or 10 card issued by a
State or outlying possession of the
Permanent Resident Card or Alien
Registration Receipt Card (Form 1-551)
1. A Social Security Account Number card, unless the card incudes one of
United States provided it contains a
the following restrictions:
photograph or information such as
(1) NOTVALIO FOR EMPLOYMENT
name, date of birth, gender, height, eye
3. Foreign passport that contains a temporary 1-551 stamp or temporary i-551 printed notation on a machinereadable immigrate visa
4. Employment Authorization Document that contains a photograph (Form
(2) VALID FOR WORK ONLY WITH
color, and address
INS AUTHORIZATION
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,
(3) VALID FOR WORK ONLY WITH DHS AUTHORIZATION
2. Certification of Birth Abroad issued
by the Department of State (Form
gender, height, eye color, and address
FS-545)
1-766)
3.
School ID card with a photograph
5. For a nonimmigrant alien authorized to work for a specific employer because of his or her status:
5. U.S. Military card or draft record
the following:
Card
Native American tribal document
5.
6. Military dependent's 10 card 7.
(1) The same name as the passport: and
8.
(2) An endorsement of the alien's nonimmigrant status as long as that penod of endorsement has
not yet expired and the proposed employment is not in conflict with any restrictions or
Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with Fotm 1-94 or Form I-94A Indicating
nonimmigrant admission under the
U.S. Coast Guard Merchant Mariner
9. Driver's license issued by a Canadian government authority
Native American tribal document
6. U.S. Citizen 10 Card (Form 1-197) 7. Identification Card for Use of
For persons under age 18 who are unable to present a document
limitations identified on the form.
6. Passport from the Federated States of
issued by the Department of Stale (Form DS-1350)
4. Original or certifiedcopy of birth certificate issued by a State, county, municipal authority, or territory of the United States bearing an official seal
a. Foreign passport: and b. Form 1-94 or Form I-94A that has
3. Certlfcatlon of Report of Birth
4. Voter's registration card
Resident Citizen in the United
States (Form 1-179)
listed above:
10. School record or report card 11.
8. Employment authorizaflon document issued by the Department of Homeland Security
Clinic, doctor, or hospital record
12. Day-care ornursery school record
Compact of Free Association Between the United States and the FSM or RMI
Illustrations of many of these documents appear in Part 6 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.
l-orm 1-9 03/08/13 N
Page 9 of9
Social Security Administration
Statement Concerning Your Employment in a Job Not Covered by Social Security Employee Name
Employee ID#
Employer Name
Employer ID#
Yourearnings from this job are not covered under Social Security. When you retire, or ifyou become disabled,
you may receive a pension based on earningsfrom 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 benefityou 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
Underthe 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 Securitytax. As a result, you will receive a lowerSocial Security benefitthan if you were not entitled to a pension from this job. For example, if you are age 62 in 2013. the maximum monthly reduction in your Social Security benefit as a result of this provision is S395.50. 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 Securityspouse or widow(er) benefit by two-thirds of the amount of your pension.
Forexample, ifyou get a monthly pension of $600 based on earnings that are not covered underSocial Security, two-thirds ofthat amount, $400, is used to offset your Social Security spouse or widowfer) benefit. If you are eligible for a $500 widow(er) benefit, you will receive $100 per month from Social Security ($500 $400=$100). Even ifyour 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 referto Social Security Publication, "Government Pension Offeet." For More Information
Social Security publications and additional information, including information about exceptions to each provision, are available at www.socialsecuritv.Qov. You may also call toll free 1-800-772-1213. or for the deaf or hard of hearing call theTTY number 1-800-325-0778, or contact your localSocial Securityoffice, I certify that 1have received Form SSA-194S that contains information about the possible effects of the Windfall Elimination Provision and the Government Pension Offeet Provision on my potential future Social Security Benefits.
Signature of Employee Form SSA-1945 (01-2013) Destroy Prior Editions
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 afifect 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, surviving 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.soclalsecuritv.aov/Qnline/ssa-1945.pdf. 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-i 945 (01-2013)
The Varnett Public School Human Resources SEXUAL HARASSMENT POLICY
The Varnett Public School prohibits allforms of sexual harassment. Such conduct may result in disciplinary action up to and including dismissal. No administrator or employee shall threaten or insinuate, either explicitly or Implicitly, that an employee's refusal to submit to or rejection of sexual advances will adversely affect the employee's employment, evaluation, wages, advancement assigned duties, work environment, shifts, or any other condition of employment or career development.
Sexually harassing conduct in the workplace, whether committed by administrators or non-supervisory personnel or by third parties, is strictly prohibited. This includes, but is not limited to, unwelcome advances related to sexual flirtations or propositions, verbal abuse of a sexual nature, graphic verbal commentaries about an individual's body, sexually degrading words used to describe an individual, humor and jokes about sex or gender specific traits, sexual innuendo, the display in the workplace of sexually suggestive objects or pictures, and the transmission ofsexual messages via voice mail, company mail, electronic mail (e-mail) or the internet/intranet.
All employees should report any incident of sexual harassment immediately to an administrator. In addition, all employees have the right to file a complaint with a federal or state agency. Employees are protected from retaliation for reporting, participating in an investigation or opposing potentially unlawful discrimination or harassment.
Signature
Date
Printed Name
UPDATED: MAY 2015
The Varnett Public School Human Resources
SUBSTANCE ABUSE POLICY
The Varnett Public School is committed to providing a safe workplace and an alcohol- and drug- free environment for its employees. The use of alcohol and drugs can undermine productivity and the quality of The Varnett Public School's image. We ask for the help and cooperation of all employees In promoting The Varnett Public School's commitment to providing an alcohol-and drug-free workplace. Such an effort requires each employee to accept his or her share of responsibility in complying with this Substance Abuse Policy.
The use, manufacture, possession, purchase, sale, distribution, taking, carrying, transfer, handling, being under the influence of. or other involvement with controlled substances, inhalants illegal drugs, legal drugs Illegally used (not taken as directed by the individual's physician) by any employee is strictly prohibited. The presence of any of the above prohibited substances in an employee's system is strictly prohibited. Alcohol abuse is also prohibited. Reporting to work or working under the influence of alcohol is prohibited. The possession or use of alcohol on The Varnett School's premises is prohibited.
Any violation of this policy will result in disciplinary action, up to and including immediate termination. The Vamett Public School recognizes drug and alcohol abuse as a potential health, safety, and security problem. Employees experiencing problems resulting from drug or alcohol abuse may be
required to seek assistance. If any employee has questions concerning available assistance, he or she should contact the Program Director.
An employee who is convicted under any criminal drug statute for violation occurring while conducting The Varnett Public School's business must notify the Superintendent.
This policy pertains to all employees (including part-time and contract) of The Varnett Public School. Employees must abide by the terms of this policy.
I acknowledge full understanding and acceptance of the SUBSTANCE ABUSE POLICY as stated.
Signature
Date
Printed Name
UPDATED: MAY 2015
The Varnett Public School Human Resources
Employee Direct Deposit Authorization Empiovee Information - Please provide the following personal information. Employee Name:
Bank Information - All bank information refers to the bank in which the employee has chosen as the recipient of his/her payroll check. The bank routing transit numberis 9 digit bank code, which appears on the bottom of your check or deposit slip to identify the financial institution. The bank account number refers to your personal bank account number. If you are
splitting your direct deposit between multiple banks, please be sure to identify each bank accurately along with the specified account type, melhod, and amount. It is recommended that once you have completed the authorization form that you have someone from your bank verify the accuracyof this information prior to submitting to the payroll office. Bank Name 1:
Bank Address: City, State, Zip:
Bank Contact/Phone Number: Bank Routing Transit Number Bank Account Number:
Account Type (Check One}: Method (Check One):
• •
Checking Account Percentage
Amount:
or
•
Savings Account
or
•
Flat Amount
S
%
Additional Bank Information (optional) Bank Name 2: Bank Address: City, State, Zip:
Bank Contact/Phone Number; Bank Routing Transit Number: Bank Account Number:
Account Type (Check One): Method (Check One):
• •
Checking Account
or
•
Savings Account
Percentage
or
•
Flat Amount
% $ I authorize the school district to electronically direct deposit my payroll check on a monthly basis. I am aware that 1must notify my bank that my check will be deposited in this manner, and I must supply the school district with accurate and
Amount:
complete bank account information.
Employee Signature
Date
The authorization form must be signed and dated before we can set up your payroll checks for direct deposit. In addition, I authorize the district to e-mail my check stub to.
Employee Signature
Date
The Varnett Public School Human Resources
WAGE DEDUCTION AUTHORIZATION AGREEMENT
!;Public School, —; may deduct money from my payundersland that mythatemployer, Thefollowina Varnett form time toand timeagree for reasons fall into the categories:
1. My share of the premiums for Varnetfs group medical/dental plans;
2. Any contributions I may make into in a retirement or pension plan sponsored controlled or managed by The Varnett Public School;
3. Installment payments on loans or wage advances given to me by The Varnett Public School, and if there is a balance remaining when Ileave The Varnett Public School, the balance ofsuch loans or advances;
4. If I receive an overpayment of wages for any reason, repayment of such overpayments to The Varnett Public School;
5. The cost to The Varnett Public School of personal long distance calls Imay make on The Varnett Public School phones or on The Varnett Public School accounts, of personal faxes sent by me using The Varnett Public School equipment or The Varnett Public School accounts, or of nonwork-related access to the Internet or other computer networks by me using The Varnett Public School equipment or The Varnett Public School accounts;
6. The cost of repairing or replacing any Varnett Public School supplies, materials, equipment, money or other property that I maydamage (other than normal wear and tear), lose, fail to return or take without appropriate authorization from The Varnett Public School during my employment; 7. The cost ofThe Varnett Public School uniforms and of cleaning the uniforms; 8. The reasonable cost or fair value, whichever is less, of meals, lodging and other facilities ftjmish to me by The Varnett Public School in connection with my employment; 9. If I take paid vacation or sick leave in advance of the date I would normally be entitled to it and I separate from The Varnett Public School before accruing time to cover such advance leave, the value of such leave taken in advance that is not so covered; and 10. In the event Employee wishes to resign from Employee's position. Employee will provide at least fourteen (14) work days' written notice to the Superintendent of The Varnett Public School, personally delivered by Employee to the Superintendent. Certified mail or delivery by someone other than the Employee is not acceptable. 11. Authorized payments required by legal and/or court documents.
I agree that The Varnett CharierSchool my deduct money from mypay underthe above circumstances.
Signature
Date
The Varnett Public School Representative
Date UPDATED; MAY 2015
The Varnett Public School Human Resources
Texas Education Agency
Texas Public School Student/Staff Ethnicity and Race Data Questionnaire The United States Department of Education (USDE) requires all state and local education Institutions to collect
data on ethnicity and race for students and staff. This information is used for state and federal accountability reporting as well as for reporting to the Office of Civil Rights (OCR) and the Equal Employment Opportunity
Commission (EEOC).
School district staff and parents or guardians of students enrolling in school are requested to provide this information. If you decline to provide this information, please be aware that the USDE requires school districts
to use observer Identification as a last resort for collecting thedata for federal reporting, Please answer both parts of the following questions on the student's or staff member's ethnicity and race. UnitedStates Federal Register (71 FR44866)
Part1. Ethnicitv: Isthe person Hispanic/Latino? (Choose onlyone)
O Hispanic/Latino •Aperson of Cuban, Mexican, Puerto RIcan. South or Central American, or other Spanish culture or origin, regardless of race.
•
Not Hispanic/Latino
Part 2. Race: What is the person's race? (Chooseone or more)
Q American Indian orAlaska Native -Aperson having origins In any of the original peoples of North and South America (Including Central America), and who maintains a tribal affiliation orcommunity attachment. D Asian - Aperson having origins in any ofthe original peoples ofthe Far East, Southeast Asia, orthe Indian subcontinent including, for example, Cambodia. China, India, Japan, Korea. Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
n Black or African American -Aperson having origins in any of the black racial groups ofAfrica. • Native Hawaiian or Other Pacific Islander - Aperson having origins in any ofthe original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
•
White - Aperson having origins in any ofthe original peoples ofEurope, the Middle East, or North Africa.
Student/Stafi Name (please print)
(Parent/Guardian)/(Staff) Signature
Student/Staff Identification Number
Date
This space reserved for Local school observer- upon completion and entering data instudentsoftware system, file this fomi in student's oermanent folder.
Ethnicity - choose only one:
Race - choose one or more:
American Indian or Alaska Native Hispanic / Latino
Asian Black or African American
___ Not Hispanic/Latino
Native Hawaiian or Other Pacific Islander
White
Observer signature:
Campus and Date:
Texas Education Agency - March 2010
2011-2012 PEIMS Data Standards
Appendix F; Ethnicity and Race Reporting Guidance
UPDATED: tVtAY2016
The Varnett Public School Human Resources
EMERGENCY CONTACT FORM Employee Name:
^
Spouse's Name:
nuiiHfMuutess:
Place of Employmeni;
Lily, oldie, Zip:
Spouse Daytime Number
Mome Knone Numper
Name&Relationship'
Emergency Contact Information Name & Relaiionsh^:
Address:
Address:
Daytime Phone Number
Daytime Phone Numlier
Medical Information Name;
Primary Care Physician
Phone Number
Address;
Medical History LisIany known allergies;
Iam allergicto the following:
Lisi anyknow medical ecndltionfs) thaimayrequire Immediate attention: List any medications that are regularly taken forany condition: Additional informaiion or comments
Signature
Date
Printed Name UPDATED: MAY 2015
The Varnett Public School Human Resources ATTENDANCE HISTORY FORM Employee Last Name
First
Mi
P
1
Employee Number
WONTH
2
3
Date of Hire
4
6
e
7
B
8
10
11
12
IN ORDER TO DEDUCT TIME FROM LEAVE BANK AN
Personal Time Illness
L
Leave w/o Pay
H
Holiday
V
Vacation
J
Jury Duty
F
Funeral
13
14
1S
16
17
APPROVED ABSENCE FROM DUTY FORM MUST BE ON FILE IN HUMAN RESOURCES PRIOR TO ABSENCE.
18
19
20
21
22
23
24
2S
26
27
28
28
30
31
SUMMARY
AUG SEP
•
OCT NOV
•
DEC JAN
1 1• •
FEB
MAR
y
APR MAY
•
JUN JUL -
MONTH
P
L
H
V
J
F
SUMMARY
MONTH
AUG
FEB
SEP
MAR
OCT
APR
NOV
MAY
DEC
JUN
JAN
JUL
P
1
L
H
V
J
F
SUMMARY
UPDATED; MAY 2015
The Varnett Public School Human Resources
EMPLOYEE HANDBOOK ACKNOWLEDGMENT STATEMENT Dear Employee;
The Varnett Public School strives to provide a quality education to its students through a structured prograni of basic skills acquisition. The program of activities is designed to prepare students to be productive, valuable members of society while building a strong foundation of knowledge and essential
skills.
The Varnett Public School seeks to accomplish its mission through a student-centered, heterogeneous school that believes that the underpinnings of change rely on the creation of a learning community, where everyone has something to learn and to teach.
We at The Varnett Public School will provide all students with quality curriculum and instruction. We will
communicate regularly and openly to parent/guardians about their child's progress through progress reports and scheduled conferences, as well as keeping the administration informed.
As a part of the Varnett family in working toward this goal, you are expected to read the policies and procedures setforth in this EMPLOYEE HANDBOOK by logging onto www.varnetLorg, click onAbout Us, then scroll down to EMPLOYEE HANDBOOK.
Failure to comply with any of the policies and procedures contained in the personnel handbook will result Injob termination, effectively Immediately.
After you have signed this form; please return it to Human Resources. Your signature acknowledges receipt of this handbook and indicates that you understand and consent to the responsibilities outlined in the handbook. This form will be kept in your personnel file.
Signature
Date
Printed Name
UPDATED: MAY 2015
The Varnett Public School Human Resources
RELEASE OF PERSONAL INFORMATION
how you would like your personal demographic
D Yes, I hereby authorize
and its duly authorized
to release information concerning or relating to my employment with the school aistnct. This employment information may include material contained in my personnel file, which includes but is not limited to, academic, salary, achievement, performance, attendance, personal history, disciplinary records, address, home phone number, position, and whether or not you are a full/part time employee. Print Name
Social Security Number
Employee Signature
Date
"OR"
D No, Ido not wish to have my personal information released. Print Name
Sociai Security Number
Employee Signature
Date
By checking that you do not want any information released, will require an authorized release form for any personal information requests. If at any time you wish to change your request, you wiii need to submit a written authorization.
UPDATED: MAY 2015
The Varnett Public School Phone 713-567-.051
5025 Soulti Willow Drive Houston Texas 77035
www varnetl.orq
713-723-5853
CONFIDENTIALITY AGREEMFMT
arid
confidentiality of all matters related to students, parents
use a^iS use. access, ornl otherwise nfhp^il c course acquireof your confidential employment information. with the Varnett As aPublic condition School,of youcontinued may haveemptoyrSenT occasion to
confidential information as set forth below:
agrees to protect any such
In me course of employment with the Varnett Public School, Employee may have authorized access to or
^ m l WndaT^ •
3"^ disciplinary records, and the information
• All information contained in an individual employee's or applicant's personnel file• All compensation and benefit information;
• Any medical records or other medical information related to employees or students* . Any information pertaining to agrievance or disciplinary action concerning an employee*
dSL' lv unwarranted invasion disclosure of which would cause an embarrassment to an employee or constitute a aeariy of privacy. Employee hereby agrees to hold the Varnett Public School's confidential information In the strictest confidence and
not to disclose or otherwise utilize this confidential information except as necessary for Employee to perform his or her customaryand regular job duties. This means that:
• Employee will not reveal confidential health or personnellnformatlon concerning colleagues unless disclosure serves lawful professional purposes oris required by law; • Employee will not reveal confidential information concerning students unless disclosure serves lawful professional purposes or is required by law;
• Employee will only access confidential information for which Employee has a legitimate business need to know;
•
Employee will not in any way disclose, divulge, copy, release, review, alter, or destroy any of the Varnett Public Schools confidential information except as properly authorized \Mthin the scope of Employee's employment with the Varnett Public School;
•
Employee will not otherwise misuse ormisappropriate the Vamett Public School's confidential information* and
• Employee will prevent unauthorized use of confidential informafion and Immediately report the misuse or any accidental disclosure ofconfidential information to his orher immediate supervisor
Employee understands that if he or she has any doubts asto whether any information is confidential or whether any
information should be disclosed. Employee shall request clarification from his orher immediate supervisor.
Employee understands that confidential information remains confidential both in and outside the workplace, and agrees nottodiscuss such information with any individual or organization thatdoes not have a valid business reason
to have access to this information. Employee acknowledges that failure to comply with the obligations contained in
this Confidentiality Agreement will result in disciplinary action up to and including possible termination of employment.
By signing and dating this Confidentiality Agreement in the space below, I certify that I have read and undersfood this Confidentiality Agreement in its entirety, and i agree to be bound byits terms during my employment and after I leave my position with the Varnett Public School.
Signature of Employee
Date
frRs
ActivcCarc
ELIGtClLTY'
WillSystenis'
Enrollment, Change and Declination Form
monthly contributions to TRS? • Yes O No l f'^®^0^')' VOU3''enot
ifno.areyouregularlyscheduiedtoworklOormorehoursperweek? ZJ Yes
• No ;i, coverage)
ActweC.ire
^^PSI^BPltMENT/CHANGETRANSACTIONTYPE
• Annual Enrollment • New Employee
• Add Dependent
• Special Enrollment
For District Use Only
• For New Employee (check one):C Effective on Actively at Work nEffective l" day of month following
TRS District #
Actively at Work Date:
Special Enrollment Event Date:
/
CMarrisge
/
-jCouri Order
CBlrth/Adoption
• tosi of Coverage
Change Only:
Decline Coverage:
•Yes (Complete Section 6) • Name
•N/A
•Address
Effective Date of Chanec/Cance!
Effective/Change Date:
•other:
Cancel Employee
Cancel Dependent
• Death
•Divorce
• Loss of Eligibility
QDeath
Employer Approval:
•Retirement/Terminated DLossof Eligibllitv • Non-payment GDropped Coverage
• Plan/Coverage
• Other: __
Were you covered by another district? • Yes • If so, which:
nother
No
jSgcnoMasEMPLOYESiwaii Last Name:
First Name:
Social Security f:
MaiiingAddress:
State;
Residence Address:
State:
jceli Phone Number;
Home Phone Number: Date of Birth:
Sex:GM Df
Email:
Language: • English
•Spanish
Ethnicity:
Do you have adisability affecting your ability tocommunicate or read? DYes (Please complete Section 8) Is the Employee Covered By Other Insurance? PYes Carrier/Plan:
•
Is the Employee Covered byMedicare? pYes GPartA Reason for Medicare Coverage: u Entitlement Age
•No
GPartB
DPartC
Disability
DPartP
No
•No
Effective:
•End Stage Renal Disease (ESRD)
SECnON 3;COVElWSESa^dlbHtPJeasertlectaBBi^ Plan Selection:
PActiveCare 1-HO
HMO Selection:
pFirstCare Health Plans
Coverage Type Selected:
•ActiveCareSeiect
uActiveCare 2
uScottS White Health Plan nAlleeian Health Plans irocmeriy vaiiey Baptin HeaHh Wans) nEmployee + Spouse •Employee t Chlld(ren) DEmployeet Family
•EmployeeOnly
ijpj^n-fbr.addMonil
SECnONA: DEPENDENT INFO SPOUSE Last Name:
First Name:
Street Address:
•Same as Employee
City:
State:
Sex:PM
GF
Zip:
Date of Birth;
Other Insurance: PYes. Carrier/Plan CHILD
•No
Last Name:
• Natural/Adopted
Phone Number:
Social Security 0: •Medicare;
•PartA
pPartB
PStepchild
_FosterChlld
•Grandchild
•legal Guardian •Disabled
Zip Code:
State:
Phone Number:
Social Security U:
Sex: Dm
Other Insurance: DYes. Carrler/Pian
• no
Last Name:
uNatural/Adopted
nMedicare: DPartA
GF
PPartB
nPartC
First Name:
PStepchild
DFosterChild
•Grandchild
•PartD Ml:
• Legal Guardian
• Disabled
Street Address:
• Other •Same as Employee
City;
Date of Birth;
• Other •Same as Employee
City:
CHILD
QPartO Ml:
Street Address;
Date of Birth:
DPartC
First Name:
State:
Zip Code:
Phone Number:
1Sex; PM
Social Security »;
OlVier Insurance; OVes.Carrier/Plan
•No
DMedicare; GPartA PPartB DPartC
PLEASE CONTINUE ON NEXT PAGE
DPartP
\
CHILD
Last Name:
•Natural/Adopted
1Ml:
First Name:
•stepchild
GFoster Child
•Grandchild
DLeRaiGuardian
•DIuhlpri
Street Address:
•Same as Employee
City:
Zip Code:
State:
Phone Number:
Date of Birth;
SocialSecurity P: Otherlnsurance: •Ves.Carrier/Plan CHILD Last Name:
• Natural/Adopted
nnthor
Sex; Dm
•No
uMedlcare; GPartA
1 First Name; •stepchild
-iFosterChild
GF
.PartR
noartr
1 Ml;
•Grandchild
• Legal Guardian
• Disabled
Street Address:
Pi Other •Same as Employee
City:
1 State:
Date of Birth:
npanr)
Zip Code;
Phone Number:
Social Security#:
Sex: GM
Other Insurance: DVes.Carrier/Plan
• No
DMedicare: QPartA
DF:
DPartB
DPartC
npartl^
,5ttT10N5: DISABLED DEPENDENTS OVER AGEi26
r your «««.uc« .or Loniinuaiion of Coverage for Handicapped Child form Statement are requlrec age 26. See Bcnefn> Adminmraior for the formt. which mu« be completed In fullandandAHeodm«Phvaic.a..-a lubmitted lo your BenefiW Adn^lnlwrator. SEaiON6: DECjJNATIONOFfaVHWGl
r Name:
SSN:
Gender:|
riM
Name:
Gender; 1 [F | |M 1'
-
Gender!
IM |M
Gender! "If Dm
1 Name:
Gender: |
Date of Birth:
Date of Birth:
M |M
Gender; |
Date of Birch:
•OlherCoverage
•Other
•Spouse
Reason:
•Other Coverage
•other:
•Child
Reason:
•OtherCoverage
•Other:
•Child
Reason:
•OtherCoverage
•other:
• Child
Reason:
•OtherCoverage
•Other:
• Child
Reason:
•Other Coverage
•Other:
1 Uame as employee
1 |sameat nmplnyao 1 Itame at pmnlnvea
1 [sameas pmnlnwi'
Address:
Osame asemployee
Address:
SSN;
Date of Birth:
Reason:
Address:
SSN:
' Name:
_l
• Employee
Address:
SSN;
1
1
Date of Birth;
•••—»«»'' < « " » » - - -
Address:
SSN:
Name:
1
Date of Birth: SSN:
1Name: 1
"••r
1 Isame as employee
Address:
;.S|CT19M.3;,C0VERAg6C0NPMi
• Iam employed by the Employer named in this Enrollment Application and Change Form. Iam eligible to participate in the coverage(s7offeredbym TRS-ActcveCare program which is administered by Aetna, withHfvIO benefits provided by SHA LLC dba RrstCare Health Wan. Scon and White Health Plan, and Allegian Insurance Company dba Allegian Health Plans. On behalf of myself and any dependents listed on their Enrollment Application andChange Form, Iapply for those coveragcfs) for which Iam eligible.
0 If! am enrolling agrandchild in Section i. Icertify that my household is the grandchild's primary residence and the grandchild is my dependent for federal Income tax purposes for the reporting year in which coverage ofthe grandchild is in effect,
o if Iarn enrolling achild as an "other Child" in Section d, Icertify that my household is the child's primary residence, that Iprovide at least 50* of the child support, that neither ofthe children's natural parents reside in my household, and that I have the legal right to make decisions regarding the child's medical care.
• Only those covcraec(sl and amount for which Iam eligible will be available to me. 1understand that if this Enrollment Application and Change Form
IS accepted, the coverage(s) wiil become effective in accordance with the provisions orthe TRS-AaiveCare program. . I understand that by enrolling for coverage with Employer named in the Enrollment Application and Change Form that any TRS-ActiveCare coverage 1previously elected under anotherTRS-ActlveCare parlieipaiing district/entity will beterminated under TRS Rules.
• Iauthoriie necessary payroll deduction by my Employer, if any, to cover the cost of my coverage(s). Iagree that my Employer acts as my agent All notices given to my Empioyerare binding upon me. Ialso agree that my participation in the coverage{sHs subject to any futureamendmcnts. . Iunderstand that by declining TRS-ActiveCare coverage now or by terminating TRS-AetiveCarc coverage during the plan year, Jam not eligible to re-enroll in TRS-AciiveCarc until the next plan year, unless Iexperience a special enrollment event.
• I Slate that the information given on the Enrollment Application and Change Form is true and correct. I understand and agree that any Incorrect statements material tothe risk and knowingly made by mc will invalidate my eoveragejs).
Applicant Signature:
Date:.
SECTION 8: SPECIAL NOTES RESARDINa IVtV ENROLLMENT (Please indicate any special information regarding myenroUraentfor Aetna.Catamarkor my selected HMO)
Employee Application Please print clearly In blue or black Ink. ISSUE
Check one - Employer Use • New Employee
• Change
•
COBRA
EMPLOYEE INFORMATION—Failure to accurately complete the questions on this application may affect the existence or amount of coverage. Please correct any errors in the information listed below. Employee name (last, ffrsf. initial)
Employer
Employment location
The Varnett Charter School
Group policy/participant U
Account # or Bill Group
Employee SSN
Cert.#
Employee birthdate
Name
Multiple Sex
Job title or position
Employee hire
# hours
date
Per week
• m • f Address
Earnings S
Children
Married
• Hourly • Weekly • Monthly
•
• Yearly
•
• Other
City
Slate
Yes
• Yes
No
•
No
Zip
ELECTIONS ARE NOT VALID WITHOUT A SIGNATURE AT THE END OF THIS APPLICATION.
DEPENDENT INFORMATION—Required if Dependent coverage applies ^lame (Last Name. First Name)
Date of Birth
Gender
Relationship
NOTE — Coverage not elected will be assumed refused even if not specifically refused Employee Choice Life, Short Term Disability, Accident, Critical Illness, Cancer Benefits - You may select the benefit(s) below. If you enroll, you will pay ail or a portion of the premium. Accept
• • • • • • • •
Refuse
Coverage
• •
Employee Voluntary Life - Amount
• • • • • •
Spouse Life- Amount Spouse Matching Voluntary AD&D
Employee Matching Voluntary AD&D
Child(ren) Voluntary Life - Amount
Child(ren) Matching Voluntary AD&D
Short Term Disability - Amount Accident:
•Employee
•Employee + Spouse •Employee + Child(ren) •Employee + Family •
•
Critical Illness;
•Employee Critical Illness - Amount. Have you used tobacco, In any form in the past 12 months? • Yes • No •Spouse Critical Illness- Amount Has your spouse used tobacco, in any form in the past 12 months? • Yes • No
•Child(ren) Critical Illness - Amount Union Security Insurance Company Mail to: P.O. BOX 419596, Kansas City. MO64141-6596 Fofm 61 {03/2010)
Pago 1 of 4
ISSUE
Employee name
Employer The Varnett Charter School
Group policy/participant no.
Account no.
Cert. no.
Multiple
•
•
Cancer
• Employee • Employee Plus Spouse • Employee Plus Child(ren) • Family DENTAL BENEFITS- You may select the benefiKs) below. If you enroll, you will pay all or aportion of the premium. Accept Refuse Coverage
D • •
G •
Accept
Employee Employee ♦ 1Dependent
Q
Refuse Coverage
p
Employee +2 or More Dependents
Refuse Dental Benefits
VISION BENEFITS- You may select (he benem{s) below. If you enroll, you will pay all or aportion of the premium. Plan 3 - Option:
Accept Refuse Coverage
Accept
•
•
Employee
•
•
Employee + Spouse
n
Refuse
•
•
Coverage
Employee +Clifld(ren) Employee + Family
Plan 1 - Option:
Accept Refuse Coverage
D • •
• •
Employee Employee +Spouse
Accept
Q •
Refuse
• •
Coverage
Employee Chlld(ren) Employee + Family
Refuse Vision Benefits
L/COJV9I1MI l u n l o r%cwu»r\cu
Last name
First
Ml
Relationship*
• Primary • Secondary • Primary • Secondary
1^1 beneficiap^ is not related to you, please provide Date of Birth, Social Security Number, and full address, y which names and relationships of each beneficiary,3) If2)primary/secondary Beneficiaries elected will apply all coverage elected on this form for abeneficiary designation is required. election is nottonoted, the beneficiary will be considered primary. 4) Proceeds will be paid in equal shares to those primary beneficiaries who survive you. If no pnmary benencianes survive you. the proceeds will be paid in equal shares to the surviving secondary beneficiaries. 5) If ^urdesigna ion does not fit in the above arrangement or you want to specify a beneficiary by coverage, please contact Union Security Insurance Company for the appropriate forms.
Fomei (0112010)
Pago2a( 4
ISSUE
Employee name
Employer The Vamett Charter School
Group policy/participant no.
Account no.
Cert. no.
Multiple MY SIGNATURE ON THIS APPLICATION CERTIFIES THAT I:
(1) Apply for the coverages designated forwhich I am eligible under myemployer's plan with Union SecurityInsurance Company. (2) Understand ifcoverages have been refused, I am not entitled to benefits under those coverages and that if Iwant to apply later. I must furnish at my own expense proofof good health satisfactory to Union Security insurance Company. For Dental coverage, I understand that 1will not be entitled to benefits until the expiration of any Late Entrant Limitation period specified in the policy. (3) Authorize any requireddeductions from myearnings. (4) Designate the beneficiary named on this application to receive any benefits payable inthe event of my death. (5) Represent that all of the information on this application is complete, correct and true to the best of my knowledge and belief. (6) Understand Uiat i must be actively at workthe number of hours specified in the policy/participation agreement to remain insured.(7) Understandthat I have the right to select any dental care provider of mychoice. {8) Understand that the dental plan includes a pre-estimate provision that will advise me in advance of the benefits i may be eligible for ifthe procedure is performed. (9) Understand thatcoverages Include waiting periods, limitations, exclusions and a pre-existing conditions provision that may affect myentitlement to benefits. When necessary, Imay be asked to execute a HIPAA authorization form, allowing Union Security Insurance Companyto use and disclose protected health information.
Any person who knowingly and with intent to defraud any Insurance company or other person files an application for insurance or statement of claim containing any materially false Information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent Insurance act, which is a crime and subjects such person to criminal and civil penalties. Employee's signature Date AGENT, BROKER, AND/OR ENROLLER INFORMATION:
Agency Name; Agent/Broker Name: Enroller Name:
Form61 (03/2010)
Pag«3ol 4
GROUP ENROLLMENT FORM PLEASE PRINT CLEARLY IN BLUE OR BLACK INK Group Name
THE VARNETT CHARTER SCHOOL
Group Number
Effective Date /
a
I
Iapply for the following coverage for myselfand dependants, as listed. HMO Plan
a
Plus
cnwyeiTcir?
TKTISne"
tmpUyMSmi Aodiesf
M
•
F
/
I
bscmr tiiumetr
uviMnfDapMTwnwutt"
0«al»tr«
L
Dependents to be Included for coverage; First Name Ml Last Name(ifdifferenti speuM
Facility ID#
Date of Birth
fcmpiorn
"Zip" TwEpfoni"
(
•
I
Relationship
Sex
Date of Birth
I
Facility ID#
a M vniairan)
•
F
• • •
M F M
•
F
•
M
•
F
/
/
Check any boxes that apply and follow instiuctions. • Are you coveririg more than three chiWren? Pleasecontinue listing on additional Enrollment Forms. • Is the address ofanychild different than the member's? Show that child's name &address on the back of this form.
• Are you requesting coverage for a dependent child other than a son or daughter? Forward legal custody paper. • Are you requesttng coverage for dependent child over age 25? Furnish proof ofIncapacity within 31 days ofthe Effective Date. a
Check thisbox if you have a disability affecting your ability to communicate or read.
Please indicate your primary language by placing a check in the appropriate box: • English • Spanish • Other • Ielect not to have coverage for myself ormy dependents and Ihereby waive coverage under theabove mentioned plans. Signature:.
Date:
To the best of my knowledge and belief, each of the statements and answers supplied in this form is complete and true, and they constitute the sole basis for, and are the Inducement for. the issuance ofany coverage. Please read (he following and sign below.
The HMO Plan Is provided by United Dental Careof Texas, Inc. and administered by Union Security Insurance Company. I hereby apply for membership inthis dental Planformyself and (or any eligible dependents listed above. Iauthorize the Group named above to make deductions, ifany. required as my contribution I agree, for myself and for any eligible dependents listed, to abide by the rules and regulations of the Plan and the terms and conditions ofthe Group Dental Service Agreement. I authorize any licensed dentist, physician, hospital or other health care provider to ftjrnish United Dental Care of Texas, Inc., Union Security Insurance
Company, and their affiliated dental companies with any required denial or medical information, as permitted by law about myself and any eligible dependents listed. I represent the information provided is true and correct to the best of my knowledge. I further understand that my coverage and benefits may be affected by failure to provide complete and accurate information. 1vnll promptly advise the Plan and my Group of any changes in this information. The authorization is not governed by HIPAA, however, when necessary, I may be asked to execute a HIPAA authohzation form, allowing United Dental Care of Texas. Inc., Union Security Insurance Company, and their affiliated dental companies to use and disclose protected health information. IMPORTANT WARNING: It is a crime to knowingly provide false, incompieto or misleading information to an Insurance company for the purpose of defraudingthe company. Penalties IncludeImprisonment, fines and denial of benefits. Signature:.
BOC-ENR-TX
Date:
KC412SB'rX (2/2010)
Employee Application for
ASSURANT Employee
Hospital Confinement Indemnity "Gap"
Benefits*
Insurance
Please print clearly in blue or black Ink. Issue
Policy Number: MG-111«
APPLICANT INFORMATION:
Name (last, first, micidie)
Sex
•m Age
Date of Birth(mm/dthyy)
Social Security Number
l-lome Phone «
Street Address
Df
Wo rk Phone
E-Mail
City
Zip Code
State
Kmployer
Occupation
Coverage Selected:
y Employee 1 1Employee & Child(ren)
Monthly Prcmiunt:
Date of Hire
• Employee & Spouse 1 I Emolovee & Familv Requested Effective Date of Coverage/Change:
S
DEPENDENT INFORMATION Name (last, first, middle)
Birth Dale
Sex
Snrial Seciirltv (/
Spouse Child Child Child
(Use reverse side of form if additional space is needed)
1hereby: • ENROLL, or O CHANCE asindicated above, for this group insurance coverage for which I am eligible. I understand and acknowledge: That no coverage will take effect for any person to be covered who is not also covered by a Major Mcdical/Coniprchcnsive Policy including Coinsurance and Deductible, in force at the time of my proposed Effective Date for this coverage.
Applicant's Signature
Dale
Parentor Legal Guardian If the Applicant is UnderAge 18 Agent's Signature
•
(where applicable by law)
A.0102(.
M-9054
Assurant Employee Benefrts is tba brand name for Group Hospital Confinement Indemnity insurance underwritten by Fidelity Security Ufe Insurance Company.
Mail to: Assurant Employee Benefits Attn: Worksite, P.O. BOX 419569, Kansas City, MO 64141-6596 03/2010
Employee Health Statement for Voluntary and Worksite Coverage Employee name (last, first, initial)
Employer The Vamett Charter School
Group policy/participant no.
Account no.
Cert. no.
Employee SSN
Employee birthdate
Multiple
• New Enrollee • Annual Enrollment • Life Event-Type/Oate Answer the following questions based uponthe coverage for which you are applying for you and your dependents. For CANCER, answer questions 1 and 2 only. For CRITICAL ILLNESS, HOSPITAL INDEMNITY or LIFE, answer questions 1 through 6.
Applicant Height:.
Weight:.
Spouse Height:
Weight:,
YES
1. Have you or your dependents used tobacco, in any form in the past 12 months? • 2. In the last 10 years, have you or yourdependents been diagnosed, treated, or received advice to seek treatment for any tumor, malignancy or any typeofinternal cancer, melanoma, leukemia, lymphoma, sarcoma or Hodgkin's disease or been diagnosed with an elevated PSA, abnormal Pap or colposcopy? Have you had a hysterectomy or prostate removal? •
NO
•
•
3. In the past5 years, have you oryour dependents beenhospitalized, undergone anyinpatieni oroutpatient surgeryor procedureor been adwsed to be hospitalized or have surgeryby a physician or medical provider? 4. In the past 12 months, have you or yourdependents been prescribed or advised to take prescription medication?
•
•
•
•
O
D
5. Have youor your dependents ever been diagnosed, received treaiment, or been advised to seek treatment
for any mental, psychiatric, emotional oreating disorder, alcoholism, alcohol abuse, prescription orillegal drug abuse? Have you or your dependents ever been arrestedfor DUI, illegal drugpossession or use? 6. Have you or yourdependents ever been diagnosed, received treatment, or been advised to seek treatment for (circle all that apply and provide details below) diabetes, heart or vascular disease, heartattack, blood disorder, stroke, high blood pressure, asthma, emphysema or other lungdisorder, kidney disease, liver disease, gallstones, pancreas disorder, colitis, Crohn's disease, glaucoma, seizures, lupus or autoimmune disorder, multiple sclerosis, Parkinson's, Muscular dystrophy or any paralysis, arthritis, disorder of the back, neck, spine, or joint, including hip or
knee? Have you or your dependents ever been diagnosed, treated, or advised to seek treatment forhuman immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS)? • Note: "Disorder" is defined as a disease, illness. Injury and/or condition differing In any way from the usual
•
or normal state or structure. REMARKS
Ifyou answered "Yes" to any medical questions above, please provide details below: Sign and date the form on back. Description of illness
injury or pregnancy,
Question no.
First name
medication and treatment
Duration (dates) & no. of episodes
Residual effects
Name and address of attending Physician or hospital (including zip)
Union Security Insurance Company
Mail to: P.O. BOX 419596, Kansas City. MO 64141-6596 Form 73 9tn(polCOi«'*9caxu'n«ntswill
l;V4vj>U^iviUn^. jTidprmletf C0(M^nv,b9'v.>iUR)l*tii]mva,r IfMD TRS-AcliwcCdlY WrieftH will Dep^aA^cerdWflDlhe evm-TKBocilelO' vrunrAO'sCviaefKeorcovHditeondothei le^il docurrmrti99wmin^ theprogrerw.
Vou (ill ,|I«>>«(V 0 Summprvol Se.iefiUdiHl (oveiiigr ,il vrHW.liMcllvKareMtM.cem o' cell TliS-ActnKeirCiKlomef Service el 1 80O ?22'9205 toieouesieccDy.
lhivCivi}llmcn