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1 L LAPTOP RESPONSIBILITY Name: School: Title: I accept full responsibility for the safe and secure handling of the laptop. I accept full responsibility for the proper use of said laptop under all applicable School District of Pickens County policies. I understandd that it is my responsibility to immediately report any damage, theft or problems with the laptop to the school/site administrator. While laptop computers are made to withstand the rigors of portable use, they are delicate electronic equipment. The following guidelines are provided: Secure the laptop at all times. If left at school, secure the laptop in a locked location and never leavee it in an openn area. Do not leave the laptop in a vehicle or expose it to excessive heat. Turn offf the laptop and place it in its collapsed or folded position any time that it is to be moved. Always place the computer in its carrying case before transporting it. Becausee the laptop computer contains a magnetic hard disk,, do not expose it to any magnetic fields that could damage the contents of the hard disk. d To ensure your privacy, remove all stored files from the laptop before returning it. Use district-approved USB flashh drives for storage. The technology staff is not responsible forr any remaining files after the computer is returned. Do not install any software to the laptop withoutt prior coordination with your AITS tech or school technology team leader; this could change the systems setup and make the unit unusable. When traveling by plane, train or bus do not check laptop as luggage or place it in a suitcase for check-through. If the laptop is damaged, lost or stolen, be sure to report the incident accordingly and record or get copies of any documents used to report the incident. These will be neededd when the unit is returned. If you leave the district for any reason, return the laptop to your school/site administrator for them to inventory andd inspect. You will be responsible for any damage or lost partss at that time. Keep a backup of important files. The AITS department will likely reimagee the unit to resolve technical issues. I will adhere to the guidelines outlined above. I understand that if I am found to be the cause of deliberate damage or loss of the laptop, I will be responsible for up to the first $250 of repair/replacement cost. Signature: Date: Revised January 2011 School District off Pickens County Instructional Services 1348 Griffin Mill Road Easley, SC P F

2 NEW HEALTH INSURANCE MARKETPLACE COVERAGE OPTIONS PART A When key parts of the health care law take effect in 2014, there will be a new way to buy health insurance: the Health Insurance Marketplace. To assist you as you evaluate options for you and your family, this notice provides some basic information about the new marketplace and employment-based health coverage offered by your employer. What is the Health Insurance Marketplace? The marketplace is designed to help you find health insurance that meets your needs and fits your budget. The marketplace offers "one-stop shopping" to find and compare private health insurance options. You may also be eligible for a new kind of tax credit that lowers your monthly premium right away. The next open enrollment period for health insurance coverage through the marketplace will be from November 15, 2014, to February 15, 2015, for coverage starting as early as January 1, However, you can buy a health plan on the marketplace outside of open enrollment if you qualify for a special enrollment period. See for more details on special enrollment periods. Can I save money on my health insurance premiums in the marketplace? You may qualify to save money and lower your monthly premium, but only if your employer does not offer coverage, or offers coverage that doesn't meet certain standards. The savings on your premium that you're eligible for depends on your household income. Does employer health coverage affect eligibility for premium savings through the marketplace? Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be eligible for a tax credit through the marketplace and may wish to enroll in your employer's health plan. However, you may be eligible for a tax credit that lowers your monthly premium, or a reduction in certain cost-sharing if your employer does not offer coverage to you at all or does not offer coverage that meets certain standards. If the cost of a plan from your employer that would cover you (and not any other members of your family) is more than 9.5% of your household income for the year, or if the coverage your employer provides does not meet the "minimum value" standard set by the Affordable Care Act, you may be eligible for a tax credit. 1 Note: If you purchase a health plan through the marketplace instead of accepting health coverage offered by your employer, then you may lose the employer contribution (if any) to the employer-offered coverage. 1 An employer-sponsored health plan meets the minimum value standard if the plan's share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs.

3 Also, this employer contribution -as well as your employee contribution to employer-offered coverage- is often excluded from income for federal and state income tax purposes. Your payments for coverage through the marketplace are made on an after-tax basis. How can I get more information? For more information about your coverage offered by your employer, please check your summary plan description or contact Missy Ducker or Tammy Brazinski at or The marketplace can help you evaluate your coverage options, including your eligibility for coverage through the marketplace and its cost. Please visit for more information, including an online application for health insurance coverage and contact information for a health insurance marketplace in your area. HEALTH COVERAGE INFORMATION FOR MARKETPLACE APPLICATION PART B If you decide to complete an application for coverage in the Health Insurance Marketplace, you will be asked to provide the information below. This information is numbered to correspond to the marketplace application. 3. Employer Name SDPC 5. Employer Address 1348 Griffin Mill Road 7. City Easley 4. Employer Identification Number (EIN) Employer Phone Number State SC 10. Who can we contact about employee health coverage at this job? Missy Ducker or Tammy Brazinski 11. Phone Number (if different from above) or ZIP Code address missyducker@pickens.k12.sc.us or tammybrazinski@pickens.k12.sc.us Here is some basic information about health coverage offered by this employer: As your employer, we offer a health plan to: All employees.

4 Some employees. An eligible employee is: Employed by the state, a higher education institution, a public school district or a participating local subdivision; works in a permanent, full-time position; and receives compensation from the state, a higher education institution, a public school district or a participating local subdivision. Eligible employees also include clerical and administrative employees of the S.C. General Assembly and judges in the state courts; General Assembly members; elected members of the councils of participating counties or municipalities who also participate in PEBA Retirement Benefits; and permanent, part-time teachers, who are considered employees for insurance purposes. With respect to dependents: We do offer coverage. An eligible dependent is: A lawful spouse or a former spouse who is required to be covered by a divorce decree; and a child younger than 26 who is the subscriber s natural child, adopted child, stepchild, foster child, a child for whom the subscriber has legal custody or a child the subscriber is required to cover due to a court order. We do not offer coverage. If checked, this coverage meets the minimum value standard, and the cost of this coverage to you is intended to be affordable, based on employee wages. ** Even if your employer intends your coverage to be affordable, you may still be eligible for a premium discount through the Health Insurance Marketplace. The marketplace will use your household income, along with other factors, to determine whether you may be eligible for a premium discount. If, for example, your wages vary from week to week (perhaps you are an hourly employee or you work on a commission basis), if you are newly employed mid-year, or if you have other income losses, you may still qualify for a premium discount. If you decide to shop for coverage in the marketplace, will guide you through the process. Here s the employer information you ll enter when you visit to find out if you can get a tax credit to lower your monthly premiums. COMPLETE INFO BELOW IF EMPLOYEE REQUESTS IT FOR EXCHANCE APPLICATION: The information below corresponds to the Marketplace Employer Coverage Tool. Completing this section is optional for employers, but will help ensure employees understand their coverage choices.

5 13. Is the employee currently eligible for coverage offered by this employer, or will the employee be eligible in the next 3 months? Yes (Continue) 13a. If the employee is not eligible today, including as a result of a waiting or probationary period, when is the employee eligible for coverage? No (STOP and return this form to employee) 14. Does the employer offer a health plan that meets the minimum value standard 2? Yes (Go to question 15) No (STOP and return this form to employee) 15. For the lowest-cost plan that meets the minimum value standard 1 offered only to the employee (don t include family plans): If the employer has wellness programs, provide the premium that the employee would pay if he/she received the maximum discount for any tobacco cessation programs, and didn t receive any other discounts based on wellness programs. a. How much would the employee have to pay in premiums for this plan $9.70 enrollee coverage b. How often? Weekly Every 2 weeks Twice a month Monthly Quarterly Yearly If the plan year will end soon and you know that the health plans offered will change, go to question 16. If you don t know, STOP and return form to employee. 16. What change will the employer make for the new plan year? Employer won t offer health coverage Employer will start offering health coverage to employees or change the premium for the lowestcost plan available only to the employee that meets the minimum value standard. 1 (Premium should reflect the discount for wellness programs. See question 15.) a. How much would the employee have to pay in premiums for this plan $ b. How often? Weekly Every 2 weeks Twice a month Monthly Quarterly Yearly Date of change: 2 An employer-sponsored health plan meets the minimum value standard if the plan s share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs (Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986)

6 DHEC Promote Project Prosper School Employee/Individual Certificate of Evaluation for Tuberculosis Name: Last First M.I. Residence Address City County Public or private school, kindergarten, nursery or day care center of current employment or other employer or individual Date Employed TEST RESULTS TUBERCULIN SKIN TEST Date Given 5 TU PPD MANTOUX METHOD mm Date Interpreted CHEST X-RAY Date: Interpretation: REMARKS DISPOSITION No tuberculosis infection per 5 TU PPD 1 Tuberculosis infection, no evidence of disease Prevention treatment started and completed 1 Prevention treatment started but not completed 2 Prevention treatment not prescribed/refused 2 History of tuberculosis disease Treatment started and completed 1 Current tuberculosis disease Non contagious as of and medically cleared to start/resume school other employment on 2 1 No further routine screening required 2 Remains at lifelong risk of developing tuberculosis CERTIFICATION This is to certify that I have examined the school employee named herein for tuberculosis and report my finding as indicated above pursuant to the Code of Laws of South Carolina, 1976, as amended April 24, 1979 This is to certify that I have examined the individual named herein for tuberculosis and report my findings as indicated above. Physician s Signature Date DHEC 1420 (08/1998) DISPOSITION: This form shall be retained in the files of the current employer or individual following evaluation and certification. SCHOOL EMPLOYEE/INDIVIDUAL CERTIFICATE OF EVALUATION FOR TUBERCULOSIS: this form may be used for school employees or other individuals who need documentation of tuberculosis evaluation. It should be maintained in the current employer s file for school employees and by employer or individual for other needs. CODE OF LAWS OF SOUTH CAROLINA, 1976, AS AMENDED APRIL 1979, SECTION No person will be initially hired to work in any public or private school, kindergarten, nursery or day care center for infants and children until appropriately evaluated for tuberculosis according to guidelines approved by the south Carolina department of Health and Environmental Control. Reevaluation will not be required for employment in consecutive years unless otherwise indicated by such guidelines. SECTION Any person applying for a position in any of the public or private schools, kindergartens, nurseries, or day care centers for infants and children of the State shall, as a prerequisite to employment, secure a health certificate from a licensed physician certifying that such person does not have tuberculosis in an active state. SECTION the physician shall make the aforesaid certificate on a form supplied by the Department of Health and Environmental control, whose duty it shall be to provide such forms upon request of the applicant. SUMMARY OF GUIDELINES OF THE DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL. (Regulation 61-22) Each employee shall have, prior to employment, and unless so previously tested, as a condition for further employment, a tuberculin skin test performed by intradermal injection of 5 tuberculin units of purified protein derivative of tuberculin (Mantoux test with 5 TU of PPD). Employees with test reactions measuring lest than 10mm or more shall have a chest x-ray, shall be recorded on the DHEC for 1420 which shall be kept in the files of the school principal/designee. These forms shall be subject to review by DHEC. If the chest x-ray (and examination of sputum, if necessary) shows evidence of current tuberculosis disease, the employee shall not be allowed to work until she/she receives written certification for DHEC that he/she is not contagious. Employees whose skin text reactions measure 10mm or more and who have a normal chest x-ray shall be evaluated for preventive therapy for their tuberculous infection. If preventive therapy is not prescribed, or is prescribed, but refused, a notation shall be made on the employee s certificate that he/she is considered to be infected with tubercle bacilli and remains at lifelong risk, of developing tuberculosis disease. Testing other than the described above, shall be required only if there is epidemiological evidence that employees, attendees, or students in the school, nursery, day care center, or kindergarten have become infected with tuberculosis. DHEC 1420 (08/1998) 5

7 DIRECT DEPOSIT ELECTION AUTHORIZATION AGREEMENT FOR AUTOMATIC DEPOSITS (CREDITS) AND DEPOSITS REVERSALS (DEBITS) I (We) hereby authorize the School District of Pickens County, hereinafter called the COMPANY, to initiate credit entries to my (our) checking and/or savings account(s) listed below and the bank named below, hereinafter called the DEPOSITORY, to credit the same to such account. In the event of overpayment to my account, I (we) authorize the COMPANY to make an adjusting debit entry to my (our) account up to the amount of the overpayment. CHECKING ACCOUNT: Depository Name: City: Account Number: Bank Transit/Routing Number: SAVINGS ACCOUNT: Depository Name: City: Account Number: Bank Transit/Routing Number: Branch: State: Amount of Deposit: Branch: State: Amount of Deposit: This authority is to remain in full force and effect until COMPANY has received written notification from me (or either of us) of its termination in such time and in such manner as to afford COMPANY a reasonable opportunity to act on it. Employee Name: Employee SS#: Date: Signed: Home Address: Please attach a voided check to this form and return to Central Services. FNS-102 Revised September 2014 Signed original: Central Services, Payroll Keep a copy for your records School District of Pickens County Financial Services 1348 Griffin Mill Road Easley, SC P F

8 NOTICE OF HIPAA SPECIAL ENROLLMENT RIGHTS You are eligible to participate in the health insurance plans offered through PEBA Insurance Benefits. To actually participate, you must complete a Notice of Election form and pay the premium. The Health Insurance Portability and Accountability Act ( HIPAA ) requires PEBA Insurance Benefits to notify you of a very important provision in its health insurance plan. You have the right to enroll in PEBA Insurance Benefits health insurance plans under its special enrollment provision if you acquire a new dependent or if you decline coverage under PEBA Insurance Benefits health insurance plans for yourself or an eligible dependent while other coverage is in effect and later lose that other coverage for certain qualifying reasons. I. SPECIAL ENROLLMENT PROVISION Loss of Other Coverage (Excluding Medicaid or a State Children s Health Insurance Program [CHIP]). If you decline enrollment for yourself or for an eligible dependent (including your spouse) while other health insurance or group health plan coverage is in effect, you may be able to enroll yourself and your dependents in PEBA Insurance Benefits health insurance plans if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependents other coverage). However, you must request enrollment within 31 days after your or your dependents other coverage ends (or after the employer stops contributing toward the other coverage). Loss of Coverage for Medicaid or a State Children s Health Insurance Program (CHIP). If you decline enrollment for yourself or for an eligible dependent (including your spouse) while Medicaid coverage or coverage under a state children s health insurance program is in effect, you may be able to enroll yourself and your dependents in PEBA Insurance Benefits health insurance plans if you or your dependents lose eligibility for that other coverage. However, you must request enrollment within 60 days after your or your dependents coverage ends under Medicaid or a state children s health insurance program. New Dependent by Marriage, Birth, Adoption or Placement for Adoption. If you have a new dependent as a result of marriage, birth, adoption or placement for adoption, you may be able to enroll yourself and your new dependents in PEBA Insurance Benefits health insurance plans. However, you must request enrollment within 31 days after the marriage, birth, adoption or placement for adoption. Eligibility for Medicaid or a State Children s Health Insurance Program (CHIP). If you or your dependents (including your spouse) become eligible for a state premium assistance subsidy from Medicaid or through a state children s health insurance program, you may be able to enroll yourself and your dependents in PEBA Insurance Benefits health insurance plans. However, you must request enrollment within 60 days after your or your dependents determination of eligibility for such assistance. To request special enrollment or to obtain more information about special enrollment provisions in PEBA Insurance Benefits health insurance plans, contact your Benefits Administrator [ insert name, title, telephone number and any additional contact information for the appropriate plan representative].

9 II. PREMIUM ASSISTANCE: If you live in one of the States on the attached list, you may be eligible for assistance paying your employer health plan premiums. The attached list of States is current as of November 3, You should contact your State for further information on eligibility. To see if any more States have added a premium assistance program since November 3, 2010, or for more information on special enrollment rights, you can contact either: U.S. Department of Labor U.S. Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare & Medicaid Services EBSA (3272) , Ext If you are not enrolled in Medicaid or CHIP, but think you or your dependent might be eligible, contact your State Medicaid or CHIP office, or call KIDS-NOW or visit to apply. CHIP ASSISTANCE: Arizona Arkansas Colorado Idaho Massachusetts Nevada New Jersey New Mexico click on Insure New Mexico Oregon Virginia MEDICAID ASSISTANCE: Alabama Alaska Outside Anchorage: ; Anchorage: California Colorado Florida Georgia click Programs then select Medicaid Idaho Indiana Iowa Kansas Kentucky Louisiana Maine Massachusetts Minnesota Outside Twin City area: ; Twin City area: click on Health Care, then Medical Assistance Missouri Montana Nebraska Nevada

10 New Hampshire New Jersey New Mexico New York North Carolina North Dakota Oklahoma Oregon Pennsylvania Rhode Island South Carolina Texas Utah Vermont Virginia Washington , ext West Virginia Wisconsin Wyoming

11 SCHOOL DISTRICTT OF PICKENS COUNTY Legal Name: (name on social security card) Nickname: Your address and computer login will be your first and last unless you have a nickname. Then it would be nickname and 2.sc.us. See examples below: Example 1: Name: address: Computer Login: Example 2: Name: address: Computer Login: Example 3: Name: address: Computer Login: Example 2 Name: address: Computer Login: Jane Mary Elizabeth Doe janedoe Jane Mary Elizabeth Doe with a preferred nickname as Mary marydoe John Franklin Doe, Jr. johndoe@pickens.k12. sc.us johndoe Jane Wilson-Doe janewilsondoe@pickens.k12.sc.us janewilsondoe You must login to a computer on the district network (either at your school or at Central Services) using the login provided below. Your temporary and computer login password in changeme. You will be prompted to create your own password. Computer Login: Password: changeme (Please note that you may only use 19 characters for your computer login. Your address has no limit on characters used.) School District of Pickens County Human Resource Services 1348 Griffin Mill Road Easley, SC P F