Human Resources Department K-12 STUDENT

Transcription

1 Human Resources Department K-12 STUDENT Congratulations and welcome to Rochester Community Schools. All new employees are required to complete and/or submit the following forms. Forms Checklist for New Employees Notice of Intent to Employ Document that Establishes Identity (i.e. driver s license, school id, etc.) See I9 form for more details Document that Establishes Employment Authorization (i.e. social security card, birth certificate, etc.) See I9 form for more details #2 Criminal Conviction History Form / Print Release #4 Employee History Check PA 189 #5 Michigan New Hire Ethnicity Form #6 I-9 Employment Eligibility Form #7 Federal W-4 Tax Form #8 State W-4 Tax Form #9 Direct Deposit Form with Voided Check Attached #10 Reasonable Assurance / Retirement Acknowledgement #11 Technology Resource Use Agreement #12 Arraignment Disclosure Notice #13 Global Compliance Certificate #14 Stormwater Training Certificate #15 Hepatitis B Secretaries, Recess/Lunch Paraeducators, Special Education Paraeducators, School Age Care, Coaches, and Asst. Coaches ONLY Employee Application (for office use) Work Permit Office Use: Name Location Position Start Date Human Resources Contacts: HR / Teacher and Administrator Personnel: Elizabeth Davis Chief Human Resource Officer (248) edavis1@rochester.k12.mi.us Mary Beth LaChance - Executive Assistant (248) mlachance@rochester.k12.mi.us HR / Support Staff Personnel: Susan DesJardins - HR Manager (248) sdesjardins@rochester.k12.mi.us Lori Schneck - HR Secretary (248) lschneck@rochester.k12.mi.us Benefits / FMLA: Kristine Davis - Benefits/HR Coordinator (248) kdavis1@rochester.k12.mi.us Christina Whitemore HR Receptionist (248) cwhitmore@rochester.k12.mi.us Substitute Employment / Attendance - AESOP: Jennifer Arsenault Substitute Services Secretary (Teachers) ( 248) jarsenault@rochester.k12.mi.us Patricia Radcliffe Substitute Services Secretary (Paras) (248) pradcliffe@rochester.k12.mi.us

2 CRIMINAL CONVICTION HISTORY CHECK AND RELEASE FORM 501 W. University Drive Rochester, Michigan Fax FORM 2 I understand that my conditional employment/involvement with the Rochester Community School District is subject to a criminal history check, and/or fingerprinting, that are satisfactory to the Rochester Community School District. I understand that the information below is required by the Michigan State Police and the FBI for the criminal conviction history/record check. I authorize the Rochester Community School District to utilize this information for the sole purpose of obtaining a criminal history/record check. PLEASE PRINT LEGIBLY NAME: Last First Middle OTHER NAME(s) or MAIDEN NAME: DATE OF BIRTH / / GENDER: Male Female CONTACT PHONE # POSITION APPLIED FOR: DEPARTMENT/CONTRACT COMPANY: RACE: (Please choose best option per ICHAT system choices) White Black Asian or Pacific Islander American Indian or Alaskan Native Other Pursuant to Public Act 68 of 1993, I represent that (you must check one): I do not have any charges pending against me and/or have not been convicted of, or pled guilty, or nolo contendere (no contest) to any crimes. I have charges pending and/or have been convicted of, or pled guilty, or nolo contendere (no contest) to the following crimes. Explain nature of conviction, date, and court result: (Use separate sheet if necessary.) I understand and agree that pursuant to Public Act 68 of 1993 and Public Act 83 of 1995: 1. The Rochester Community Schools Board of Education must request a criminal history/record check from the Central Records Division of the Michigan State Police and the FBI for all potential employees. 2. Until the results of the criminal history/record check are received and reviewed by the Rochester Community School District, my employment status is conditional. 3. If the results of the criminal history/record check, received from either the Michigan State Police or the FBI, are not the same as my representation(s) above respecting either the absence of any conviction(s) or any crimes of which I have been convicted, my employment/status is voidable at the option of the Rochester Community School District. Complete one of the following: I was previously fingerprinted for school employment with a Michigan K-12 school district and have maintained regular and continuous employment (no break in service) with said school district since being fingerprinted. I authorize release of my fingerprints and/or criminal history report from the following Michigan K-12 school district: Approx. Date Fingerprinted: School District Information: Name Phone Address City, Zip I have been fingerprinted for the Rochester Community School District and the completed LIVESCAN Fingerprint Request (Form #3) is attached. I am a student currently enrolled in a K-12 program and 18 years old or younger. I understand that fingerprints are not required, but I authorize the Rochester Community School District to process a background check using the Internet Criminal History Access Tool (ICHAT). DATE: SIGNATURE:

3 ROCHESTER COMMUNITY SCHOOLS 501 W. University Dr. Rochester, MI Fax: FORM 4 Authorization for Release of Information and Employee History Check Pursuant to MCL (b) and MCL (Public Act 189 of Public Acts of 1996) Date: Applicant's Name: Position Applied for: Previous Employer's Name & Address: I authorize my previous employer to provide the Rochester Community Schools any information regarding my employment history and any other information which is job related, including all items within my personnel file. Pursuant to Public Act 189 of the Public Acts of 1996 (Section (b) of the Michigan Compiled Laws). I authorize any current or former employer to disclose any unprofessional conduct which is defined as: One or more acts of misconduct: one or more acts of immorality, moral turpitude, or inappropriate behavior involving a minor; or commission of a crime involving a minor. A criminal conviction is not an essential element of determining whether or not a particular act constitutes unprofessional conduct. I authorize the Rochester Community Schools to obtain disciplinary reports, letters of reprimand, records of disciplinary action, performance evaluations, placement on any program of improvement, and other documents, records or information contained within my personnel records with my former employer. I understand Public Act 189 of the Public Acts of 1996 provides immunity from civil liability for current or former employers and employees acting on behalf of the current or former employers who act in good faith. I release the Rochester Community Schools and its representatives from all liability for seeking such information. I give current and former employers, including agents thereof, my permission to release the above identified personnel record information without requiring them to contact me or to give me written notice before disclosing the information to the requesting school district. I waive my right of prior notice under the Bullard-Plawecki Employee Right to Know Act, No. 397 of the Public Acts of 1987, Section of the Michigan Compiled Laws. I understand that my employment with the Rochester Community Schools is conditioned upon the school district's receipt and review of the personnel record information herein provided for and the school district's determination that nothing herein constitutes a sufficient basis to deny my employment. The school district has the sole authority and discretion to determine if employment shall be denied. I understand and agree that if I refuse to sign this Authorization and Release of Information regarding any unprofessional conduct by me in my current and/or former employment, the school district is prohibited by law from hiring me pursuant to MCL (b). Applicant's signature: Date: NOTE TO CURRENT/PREVIOUS EMPLOYER: Public Act 189 of 1996 requires you to provide Rochester Community Schools copies of any and all information relating to unprofessional conduct contained within the above named person's personnel file within 20 days of receipt of this request. Please return original copy to Human Resources Dept., Rochester Community Schools. I certify that no documentation of unprofessional conduct exists within the above named person's personnel files. I certify that no disciplinary action or unsatisfactory performance exists within the above named person's personnel file. I have enclosed items relating to unprofessional conduct. I have enclosed items relating to disciplinary action and/or unsatisfactory performance. Signed for the Employer, Name & Title Date

4 STATE OF MICHIGAN NEW HIRE/REHIRE REPORTING FORM ROCHESTER COMMUNITY SCHOOLS Federal legislation, effective October 1, 1997, requires all Michigan employers, both public and private, to report all newly hired, rehired, or returning to work employees to the State of Michigan. Rochester Community Schools submits this information electronically and therefore, this form is used only to collect the required information. NEW/REHIRE EMPLOYEE INFORMATION (mandatory) PLEASE PRINT! Social Security Number: Gender: Male Female Birth Date: First name: MI: Last Name: Street Address: City: Zip Code: Primary Phone Number: Secondary Phone Number: Address: (optional, not mandatory) In addition to the Federal EEO-5 reporting requirements for public schools, the 2006 Michigan School Safety Legislation requires that all school districts report ethnicity, in addition to the above information, for all personnel. This information is reported as part of the Michigan Department of Education Registry of Educational Personnel. The information below will be used only for reporting purposes and can only be asked of personnel with whom an offer of employment has been extended. New federal and state legislation (PA 88 and 89 of 1995) mandates the collection of multiracial data separate from the five major racial-ethnic categories. If you consider yourself to be multi-racial, answer yes in the multi-racial box below and continue to Option 2. Do you consider yourself to be multi-racial? yes no (If you checked yes, go to Option 2.) OPTION 1: Race (please choose only one): Caucasian or White Black or African American Hispanic or Latino Asian Native Hawaiian or Pacific Islander American Indian or Alaskan Native OPTION 2: Race Multiple racial/ethnic (please choose all that apply): Caucasian or White Black or African American Hispanic or Latino Asian Native Hawaiian or Pacific Islander American Indian or Alaskan Native Reports will not be processed if required information is missing. FEDERAL EIN:

5 Employment Eligibility Verification Department of Homeland Security U.S. Citizenship and Immigration Services USCIS Form I-9 OMB No Expires 08/31/2019 START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically, during completion of this form. Employers are liable for errors in the completion of this form. ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the documentation presented has a future expiration date may also constitute illegal discrimination. Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form I-9 no later than the first day of employment, but not before accepting a job offer.) Last Name (Family Name) First Name (Given Name) Middle Initial Other Last Names Used (if any) Address (Street Number and Name) Apt. Number City or Town State ZIP Code Date of Birth (mm/dd/yyyy) U.S. Social Security Number - - Employee's Address Employee's Telephone Number I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form. I attest, under penalty of perjury, that I am (check one of the following boxes): 1. A citizen of the United States 2. A noncitizen national of the United States (See instructions) 3. A lawful permanent resident (Alien Registration Number/USCIS Number): 4. An alien authorized to work until (expiration date, if applicable, mm/dd/yyyy): Some aliens may write "N/A" in the expiration date field. (See instructions) Aliens authorized to work must provide only one of the following document numbers to complete Form I-9: An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number. QR Code - Section 1 Do Not Write In This Space 1. Alien Registration Number/USCIS Number: OR 2. Form I-94 Admission Number: OR 3. Foreign Passport Number: Country of Issuance: Signature of Employee Today's Date (mm/dd/yyyy) Preparer and/or Translator Certification (check one): I did not use a preparer or translator. A preparer(s) and/or translator(s) assisted the employee in completing Section 1. (Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.) I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct. Signature of Preparer or Translator Today's Date (mm/dd/yyyy) Last Name (Family Name) First Name (Given Name) Address (Street Number and Name) City or Town State ZIP Code Employer Completes Next Page Form I-9 11/14/2016 N Page 1 of 3

6 Employment Eligibility Verification Department of Homeland Security U.S. Citizenship and Immigration Services USCIS Form I-9 OMB No Expires 08/31/2019 Section 2. Employer or Authorized Representative Review and Verification (Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You must physically examine one document from List A OR a combination of one document from List B and one document from List C as listed on the "Lists of Acceptable Documents.") Employee Info from Section 1 Last Name (Family Name) First Name (Given Name) M.I. Citizenship/Immigration Status List A OR List B AND List C Identity and Employment Authorization Identity Employment Authorization Document Title Document Title Document Title Issuing Authority Issuing Authority Issuing Authority Document Number Expiration Date (if any)(mm/dd/yyyy) Document Number Expiration Date (if any)(mm/dd/yyyy) Document Number Expiration Date (if any)(mm/dd/yyyy) Document Title Issuing Authority Document Number Additional Information QR Code - Sections 2 & 3 Do Not Write In This Space Expiration Date (if any)(mm/dd/yyyy) Document Title Issuing Authority Document Number Expiration Date (if any)(mm/dd/yyyy) Certification: I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee, (2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the employee is authorized to work in the United States. The employee's first day of employment (mm/dd/yyyy): (See instructions for exemptions) Signature of Employer or Authorized Representative Today's Date(mm/dd/yyyy) Title of Employer or Authorized Representative Last Name of Employer or Authorized Representative First Name of Employer or Authorized Representative Employer's Business or Organization Name Employer's Business or Organization Address (Street Number and Name) City or Town State ZIP Code Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.) A. New Name (if applicable) B. Date of Rehire (if applicable) Last Name (Family Name) First Name (Given Name) Middle Initial Date (mm/dd/yyyy) C. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes continuing employment authorization in the space provided below. Document Title Document Number Expiration Date (if any) (mm/dd/yyyy) I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual. Signature of Employer or Authorized Representative Today's Date (mm/dd/yyyy) Name of Employer or Authorized Representative Form I-9 11/14/2016 N Page 2 of 3

7 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. LIST A Documents that Establish Both Identity and Employment Authorization OR LIST B Documents that Establish Identity AND LIST C Documents that Establish Employment Authorization 1. U.S. Passport or U.S. Passport Card 2. Permanent Resident Card or Alien Registration Receipt Card (Form I-551) 3. Foreign passport that contains a temporary I-551 stamp or temporary I-551 printed notation on a machinereadable immigrant visa 4. Employment Authorization Document that contains a photograph (Form I-766) 5. For a nonimmigrant alien authorized to work for a specific employer because of his or her status: a. Foreign passport; and b. Form I-94 or Form I-94A that has the following: (1) The same name as the passport; and (2) An endorsement of the alien's nonimmigrant status as long as that period of endorsement has not yet expired and the proposed employment is not in conflict with any restrictions or limitations identified on the form. 6. Passport from the Federated States of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with Form I-94 or Form I-94A indicating nonimmigrant admission under the Compact of Free Association Between the United States and the FSM or RMI 1. Driver's license or ID card issued by a State or outlying possession of the United States provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address 2. ID card issued by federal, state or local government agencies or entities, provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address 3. School ID card with a photograph 4. Voter's registration card 5. U.S. Military card or draft record 6. Military dependent's ID card 7. U.S. Coast Guard Merchant Mariner Card 8. Native American tribal document 9. Driver's license issued by a Canadian government authority For persons under age 18 who are unable to present a document listed above: 10. School record or report card 11. Clinic, doctor, or hospital record 12. Day-care or nursery school record 1. A Social Security Account Number card, unless the card includes one of the following restrictions: (1) NOT VALID FOR EMPLOYMENT (2) VALID FOR WORK ONLY WITH INS AUTHORIZATION (3) VALID FOR WORK ONLY WITH DHS AUTHORIZATION 2. Certification of Birth Abroad issued by the Department of State (Form FS-545) 3. Certification of Report of Birth issued by the Department of State (Form DS-1350) 4. Original or certified copy of birth certificate issued by a State, county, municipal authority, or territory of the United States bearing an official seal 5. Native American tribal document 6. U.S. Citizen ID Card (Form I-197) 7. Identification Card for Use of Resident Citizen in the United States (Form I-179) 8. Employment authorization document issued by the Department of Homeland Security Examples of many of these documents appear in Part 8 of the Handbook for Employers (M-274). Refer to the instructions for more information about acceptable receipts. Form I-9 11/14/2016 N Page 3 of 3

8 Form W-4 (2017) Purpose. Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. Consider completing a new Form W-4 each year and when your personal or financial situation changes. Exemption from withholding. If you are exempt, complete only lines 1, 2, 3, 4, and 7 and sign the form to validate it. Your exemption for 2017 expires February 15, See Pub. 505, Tax Withholding and Estimated Tax. Note: If another person can claim you as a dependent on his or her tax return, you can t claim exemption from withholding if your total income exceeds $1,050 and includes more than $350 of unearned income (for example, interest and dividends). Exceptions. An employee may be able to claim exemption from withholding even if the employee is a dependent, if the employee: Is age 65 or older, Is blind, or Will claim adjustments to income; tax credits; or itemized deductions, on his or her tax return. The exceptions don t apply to supplemental wages greater than $1,000,000. Basic instructions. If you aren t exempt, complete the Personal Allowances Worksheet below. The worksheets on page 2 further adjust your withholding allowances based on itemized deductions, certain credits, adjustments to income, or two-earners/multiple jobs situations. Complete all worksheets that apply. However, you may claim fewer (or zero) allowances. For regular wages, withholding must be based on allowances you claimed and may not be a flat amount or percentage of wages. Head of household. Generally, you can claim head of household filing status on your tax return only if you are unmarried and pay more than 50% of the costs of keeping up a home for yourself and your dependent(s) or other qualifying individuals. See Pub. 501, Exemptions, Standard Deduction, and Filing Information, for information. Tax credits. You can take projected tax credits into account in figuring your allowable number of withholding allowances. Credits for child or dependent care expenses and the child tax credit may be claimed using the Personal Allowances Worksheet below. See Pub. 505 for information on converting your other credits into withholding allowances. Nonwage income. If you have a large amount of nonwage income, such as interest or dividends, consider making estimated tax payments using Form 1040-ES, Estimated Tax for Individuals. Otherwise, you may owe additional tax. If you have pension or annuity income, see Pub. 505 to find out if you should adjust your withholding on Form W-4 or W-4P. Two earners or multiple jobs. If you have a working spouse or more than one job, figure the total number of allowances you are entitled to claim on all jobs using worksheets from only one Form W-4. Your withholding usually will be most accurate when all allowances are claimed on the Form W-4 for the highest paying job and zero allowances are claimed on the others. See Pub. 505 for details. Nonresident alien. If you are a nonresident alien, see Notice 1392, Supplemental Form W-4 Instructions for Nonresident Aliens, before completing this form. Check your withholding. After your Form W-4 takes effect, use Pub. 505 to see how the amount you are having withheld compares to your projected total tax for See Pub. 505, especially if your earnings exceed $130,000 (Single) or $180,000 (Married). Future developments. Information about any future developments affecting Form W-4 (such as legislation enacted after we release it) will be posted at Personal Allowances Worksheet (Keep for your records.) A Enter 1 for yourself if no one else can claim you as a dependent A You re single and have only one job; or B Enter 1 if: You re married, have only one job, and your spouse doesn t work; or... B { } Your wages from a second job or your spouse s wages (or the total of both) are $1,500 or less. C Enter 1 for your spouse. But, you may choose to enter -0- if you are married and have either a working spouse or more than one job. (Entering -0- may help you avoid having too little tax withheld.) C D Enter number of dependents (other than your spouse or yourself) you will claim on your tax return D E Enter 1 if you will file as head of household on your tax return (see conditions under Head of household above).. E F Enter 1 if you have at least $2,000 of child or dependent care expenses for which you plan to claim a credit... F (Note: Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for details.) G Child Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information. If your total income will be less than $70,000 ($100,000 if married), enter 2 for each eligible child; then less 1 if you have two to four eligible children or less 2 if you have five or more eligible children. If your total income will be between $70,000 and $84,000 ($100,000 and $119,000 if married), enter 1 for each eligible child. G H Add lines A through G and enter total here. (Note: This may be different from the number of exemptions you claim on your tax return.) H { If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions For accuracy, and Adjustments Worksheet on page 2. complete all If you are single and have more than one job or are married and you and your spouse both work and the combined worksheets earnings from all jobs exceed $50,000 ($20,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2 that apply. to avoid having too little tax withheld. If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W-4 below. Separate here and give Form W-4 to your employer. Keep the top part for your records. Employee s Withholding Allowance Certificate Form W-4 Department of the Treasury Whether you are entitled to claim a certain number of allowances or exemption from withholding is Internal Revenue Service subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS. 1 Your first name and middle initial Last name OMB No Your social security number Home address (number and street or rural route) 3 Single Married Married, but withhold at higher Single rate. Note: If married, but legally separated, or spouse is a nonresident alien, check the Single box. City or town, state, and ZIP code 4 If your last name differs from that shown on your social security card, check here. You must call for a replacement card. 5 Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2) 5 6 Additional amount, if any, you want withheld from each paycheck $ 7 I claim exemption from withholding for 2017, and I certify that I meet both of the following conditions for exemption. Last year I had a right to a refund of all federal income tax withheld because I had no tax liability, and This year I expect a refund of all federal income tax withheld because I expect to have no tax liability. If you meet both conditions, write Exempt here Under penalties of perjury, I declare that I have examined this certificate and, to the best of my knowledge and belief, it is true, correct, and complete. Employee s signature (This form is not valid unless you sign it.) Date 8 Employer s name and address (Employer: Complete lines 8 and 10 only if sending to the IRS.) 9 Office code (optional) 10 Employer identification number (EIN) For Privacy Updated Act and Paperwork Reduction Act Notice, see page 2. Cat. No Q Form W-4 (2017)

9 MI-W4 (Rev. 8-08) EMPLOYEE'S MICHIGAN WITHHOLDING EXEMPTION CERTIFICATE STATE OF MICHIGAN - DEPARTMENT OF TREASURY This certificate is for Michigan income tax withholding purposes only. You must file a revised form within 10 days if your exemptions decrease or your residency status changes from nonresident to resident. Read instructions below before completing this form. 1. Social Security Number 2. Date of Birth Issued under P.A. 281 of Type or Print Your First Name, Middle Initial and Last Name 4. Driver License Number Home Address (No., Street, P.O. Box or Rural Route) 5. Are you a new employee? City or Town State ZIP Code Yes No If Yes, enter date of hire Enter the number of personal and dependent exemptions you are claiming Additional amount you want deducted from each pay (if employer agrees) I claim exemption from withholding because (does not apply to nonresident members of flow-through entities - see instructions): a. A Michigan income tax liability is not expected this year. b. Wages are exempt from withholding. Explain: c. Permanent home (domicile) is located in the following Renaissance Zone: EMPLOYEE: If you fail or refuse to file this form, your employer must withhold Michigan income tax from your wages without allowance for any exemptions. Keep a copy of this form for your records. INSTRUCTIONS TO EMPLOYER: Employers must report all new hires to the State of Michigan. Keep a copy of this certificate with your records. If the employee claims 10 or more personal and dependent exemptions or claims a status exempting the employee from withholding, you must file their original MI-W4 form with the Michigan Department of Treasury. Mail to: New Hire Operations Center, P.O. Box 85010; Lansing, MI You must submit a Michigan withholding exemption certificate (form MI-W4) to your employer on or before the date that employment begins. If you fail or refuse to submit this certificate, your employer must withhold tax from your compensation without allowance for any exemptions. Your employer is required to notify the Michigan Department of Treasury if you have claimed 10 or more personal and dependent exemptions or claimed a status which exempts you from withholding. You MUST file a new MI-W4 within 10 days if your residency status changes or if your exemptions decrease because: a) your spouse, for whom you have been claiming an exemption, is divorced or legally separated from you or claims his/her own exemption(s) on a separate certificate, or b) a dependent must be dropped for federal purposes. Line 5: If you check "Yes," enter your date of hire (mo/day/year). Line 6: Personal and dependent exemptions. The total number of exemptions you claim on the MI-W4 may not exceed the number of exemptions you are entitled to claim when you file your Michigan individual income tax return. 6. $.00 Under penalty of perjury, I certify that the number of withholding exemptions claimed on this certificate does not exceed the number to which I am entitled. If claiming exemption from withholding, I certify that I anticipate that I will not incur a Michigan income tax liability for this year. 9. Employee's Signature Date Employer: Complete lines 10 and 11 before sending to the Michigan Department of Treasury. 10. Employer's Name, Address, Phone No. and Name of Contact Person INSTRUCTIONS TO EMPLOYEE Federal Employer Identification Number If you hold more than one job, you may not claim the same exemptions with more than one employer. If you claim the same exemptions at more than one job, your tax will be under withheld. Line 7: You may designate additional withholding if you expect to owe more than the amount withheld. Line 8: You may claim exemption from Michigan income tax withholding ONLY if you do not anticipate a Michigan income tax liability for the current year because all of the following exist: a) your employment is less than full time, b) your personal and dependent exemption allowance exceeds your annual compensation, c) you claimed exemption from federal withholding, d) you did not incur a Michigan income tax liability for the previous year. You may also claim exemption if your permanent home (domicile) is located in a Renaissance Zone. Members of flow-through entities may not claim exemption from nonresident flow-through withholding. For more information on Renaissance Zones call the Michigan Tele-Help System, Full-time students that do not satisfy all of the above requirements cannot claim exempt status. If you are married and you and your spouse are both employed, you both may not claim the same exemptions with each of your employers. Web Site Visit the Treasury Web site at:

10 Direct Deposit Authorization for RCS Employees Options for direct deposit of your pay: 1. Deposit your entire pay into one bank account. 2. Deposit of a specific dollar amount in up to three bank accounts, with the remaining balance of your pay deposited into a different bank account. If you would like to choose option 1, please complete Section A. If you would like to choose option 2, complete Section A and the reverse side of this form. Section A Primary Net Pay Account Bank Name checking OR savings Routing Number Account Number I have read the rules and guidelines listed on the back of this form, and I authorize the deposit of funds into the account(s) listed above. Signature Date Name (Please print) District Employee Number ** PLEASE NOTE ** - YOU WILL RECEIVE A PHYSICAL CHECK FOR THE FIRST PAY AFTER THIS FORM IS SUBMITTED.

11 Section B Additional Account (Optional) Specific dollar amount of deposit $ Bank Name checking OR savings Routing Number Account Number Section C Additional Account (Optional) Specific dollar amount of deposit $ Bank Name checking OR savings Routing Number Account Number Section D Additional Account (Optional) Specific dollar amount of deposit $ Bank Name checking OR savings Routing Number Account Number I understand that due to the necessity to test this account, it will take one or more pay cycles before your direct deposit will begin. I understand that if this is a change to an existing direct deposit order, I will receive a check rather than a direct deposit voucher in the interim while my new request is processed. I will not close any bank account that I have my pay deposited to without first notifying the Payroll Department. I hereby authorize Rochester Community Schools to make deposits in the account(s) identified on this form and authorize the bank to accept these deposits. Adjusting entries to correct errors are also authorized. It is agreed that these deposits and adjustments may be made electronically and under the Rules of the National Automated Clearing House Association. I understand that Rochester Community Schools may discontinue my direct deposit if needed. Advance notification will be provided.

12 ROCHESTER COMMUNITY SCHOOLS FORM 10 REASONABLE ASSURANCE ACKNOWLEDGEMENT This school district has regularly scheduled breaks during its school year. Theses breaks occur when school is not in session. During these breaks, the district provides you, in good faith, the reasonable assurance that you will return to work in the same or similar position at the completion of the break. Your return to work validates your reasonable assurance. Michigan Unemployment Agency regulations prohibit you from receiving unemployment benefits from a school district during breaks of a school year when you have a reasonable assurance of employment at the end of that break. Initial CHANGES MADE TO PUBLIC SCHOOLS RETIREMENT ACT ACKNOWLEDGEMENT Public School employees are now required to contribute 3.0% of their gross wages to the State of Michigan to help fund the retiree healthcare system. The deduction is listed on your pay stub as Healthcare Contribution and it is not associated with healthcare benefits you may or may not receive from Rochester Community Schools. Per the new legislation, Rochester Community Schools is required to make this deduction. For further information, please contact the Office of Retirement Services at or visit Initial OFFICE OF RETIREMENT SERVICES BENEFICIARY INFORMATION ACKNOWLEDGEMENT All information regarding naming a beneficiary for public school employees in the State of Michigan is handled directly with the Office of Retirement Services (ORS). If you are a new employee, the ORS will issue you a member ID after you have received your first paycheck from Rochester Community Schools. You are able to get your ID number by contacting them directly at At that time, you would be able to go the ORS website, and click on the miaccount link on the right side to name a beneficiary. Naming a beneficiary is critical. In every paycheck, school employees contribute to the retirement system. Should something happen to you, you want to be sure you have named a beneficiary who will be able to collect the money you have contributed. An employee who is making a change to a beneficiary would need to contact the ORS at to get his/her ID number. The ID number is also listed on the statement the ORS mails to your home each year listing your years of service. This number is not your RCS Den Number. It is a number that is solely used by the IRS. If you have any questions, please contact the ORS who will be glad to help. Initial I have read and acknowledge these notices: SIGNATURE DATE

13 REGULATION Rochester Community Schools Rochester, Michigan APPENDIX E ROCHESTER COMMUNITY SCHOOLS TECHNOLOGY RESOURCES USE AGREEMENT School Personnel/Representatives and Other Users Authorization Form The following must be completed and signed by all employees, administrators, other staff and other users Name: School: 1. Introduction - Rochester Community Schools (the "District") believes that the Internet offers unique resources for students, administrators, teachers and others. The District s goal in providing Internet access to students and staff is to promote educational excellence by facilitating resource sharing, innovation, and communication. All District Technology Resource users are required to sign this Technology Resources Use Agreement ("Agreement") and to abide by the terms and conditions of the District s Acceptable Technology Use Policy and Regulations. The District does not authorize any use of the Technology Resources which is not conducted in strict compliance with this Agreement and the District s Acceptable Technology Use Policy and Regulations. Your signature below indicates that you have read the terms and conditions of the District s Acceptable Technology Use Policy and Regulations (located on the District s website) and this Agreement carefully and understand their significance. 2. Inappropriate Use/Discipline - Teachers, administrators and other staff that violate the District s Acceptable Technology Use Policy and Regulations and/or this Agreement may have their use privileges suspended or revoked, or may be subject to other disciplinary measures and/or legal action in accordance with the terms and conditions of any applicable contract or collective bargaining agreement. 3. Staff Acknowledgement and Release - I have read the District s Acceptable Technology Use Policy and Regulations and this Technology Resources Use Agreement and I understand my responsibilities. I also consent to and understand that District staff may monitor my electronic communications, including logs showing my Internet access, , and downloaded files. I acknowledge my responsibility to uphold the integrity of the Technology Resources and to retain copies of all e- mails and applicable attachments which conduct official District business in accordance with the District s Record Retention Policy and Guidelines. If I commit any violation of the District s Acceptable Technology Use Policy and Regulations and/or this Agreement, my privileges to use the District Technology Resources may be terminated, and other disciplinary action may be taken. I also hereby agree to release the District, as well as its Board Members, employees and agents, from any substantiated claims arising out of any illegal or inappropriate activities with which I have been involved, whether such claims arise from Internet use performed on District Technology Resources or out of my violation of this Acceptable Technology Use Agreement. I also hereby agree to indemnify the District as well as all Board members, school teachers, administrators, and adult volunteers from any claims arising out of my violation of, or conduct inconsistent with, the District s Acceptable Technology Use Policy and Regulations and/or this Agreement, made by third parties and whether such claims arise from Internet use performed on District Technology Resources through school accounts or personal accounts. Finally, I agree to report any substantial student misuse of District Technology Resources, including the Internet, to my immediate supervisor. Signature: Date: Please print name:

14 Dear Rochester Community Schools Employee: FORM 12 This notice is a reminder that as a result of School Safety legislation enacted into law last January 1, 2006, any employee of a public school system must self-report if he or she has been arraigned/charged with certain identified crimes. (See reportable offenses below.) The school employee must report this information within three business days to the following: the Superintendent of the school district in which they are employed; the Michigan Department of Education Office of Professional Preparation Services; and, the school employee must inform the court administrator that he/she is a public school employee. An employee s failure to report such information will automatically result in guilt of an additional crime. Provided below are the REPORTABLE OFFENSES: 1. ANY FELONY 2. ANY of the following misdemeanors: Criminal sexual conduct in the fourth degree or an attempt to commit criminal sexual conduct in the third or fourth degree Child abuse in the third or fourth degree or an attempt to commit child abuse in the third or fourth degree Cruelty, torture, or indecent exposure involving a child Delivery of a narcotic to a minor or student or within 1,000 feet of a school property Breaking and entering, or entering without breaking, without permission Knowingly allowing a minor to consume or possess alcohol or a controlled substance at a social gathering Accosting, enticing, or soliciting a child for immoral purposes Larceny from a vacant dwelling Assault and assault and battery including domestic assault Assault and infliction of serious injury Internet crime against a minor Indecent exposure Selling or furnishing liquor to a person less than 21 years of age 3. ANY violation of a substantially similar law of another State, a political subdivision of this State or another State, or the United States. For further information regarding the School Safety legislation, a website link has been placed on our district website ( under the Human Resources page, or by visiting Michigan Department of Education website and selecting the Office of Professional Preparation. The Arraignment Disclosure Form can be found on the Human Resource page-current RSC Employee tab-forms and Information file. Sincerely, Dr. Robert Shaner Superintendent I have read the above information and understand that I am responsible to self-report if I have been arraigned/charged with certain identified crimes. Employee Signature Date

15 FORM 13 REQUIRED NEW HIRE TRAINING For Employees Hired by Rochester Community Schools TUTORIALS ARE PROVIDED BY GLOBAL COMPLIANCE NETWORK As a new Rochester Community Schools employee, you are required to complete specific training modules to be an active employee with our district. These training modules are available at no cost and can be viewed at your convenience via an online web based program. You can start and stop at any given time; the program notes what has been completed and will start back where you left off. Simple instructions on how to access the Global Compliance Network Training Programs is provided in your new hire paperwork. Please Remember: Before you can begin working for Rochester Community Schools, you will be required to complete the following training modules. To verify you have met this requirement, print and submit a copy of the Tutorial Completion Certificate available through GLOBAL COMPLIANCE NETWORK to the Human Resources Department. Required Training Modules Allergy Management (18 minutes) Bloodborne Pathogens (20 minutes) Child Abuse Michigan (18 minutes) Concussions in Schools (29 minutes) Computer Use Policies (13 minutes) Note: Annually you will be required to acknowledge your understanding and agreement to adhere to the Rochester Community Schools Technology Resources Use Agreement. The agreement form is included in your new hire paperwork. FERPA (18 minutes) Hazard Communications (29 minutes) Sexual Harassment (22 minutes) Note: District Policy 3367, entitled Policy Statement on Sexual Harassment, is available on the District Website.

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17 Stormwater Training Video Requirement Rochester Community School District is regulated by the USEPA and State of Michigan under the Federal Clean Water Act to control pollution entering surface waters through storm drains. These regulations are referred to as the National Pollution Discharge Elimination System which requires that ALL public entities located within urbanized areas obtain a permit to discharge stormwater runoff. To meet these requirements, ALL district employees will be asked to watch a short (11-minute) training video. This video was produced specifically to provide school district administrators, faculty, and support staff with an understanding of the problems associated with pollution from stormwater runoff and identify ways district employees can help with this ever growing problem within our communities. The training is hosted on the Arch Environmental Group s website using the following link: When arriving at the website, click on the Stormwater Training Video icon. At the login screen, you asked for a username and password. The username and password for our district are: Username: roccs Password: paintcreek Step 1: Select TRAINING SURVEY and fill out the survey after it opens. The survey is a required part of General Awareness Training. Step 2: Select INFORMATION TAB. When you log in, the will be asked for some basic information (Name, address, last 4 digits of SSN, and building name) to allow us to track and document your participation. Please enter the numbers 0000 into SSN box. Step 3: Select CONTINUE. You will be asked to watch the video When it Rains, it Drains The Stormwater Puzzle. Upon completion, you will receive an receipt of your participation. Step 4: Please print a copy of this receipt and return it with your New Hire paperwork to the HR Department. For additional information on the School Districts Stormwater Management Program or other watershed and pollution prevention educational materials, please visit the district website at the following link:

18 ROCHESTER COMMUNITY SCHOOLS 501 W. University Dr. Rochester MI Fax FORM 15 Hepatitis B Vaccination Series Notification/Information To: New Employees - Secretaries, Recess/Lunch Paraeducators, Special Education Paraeducators, School Age Care, Coaches, and Asst. Coaches ONLY From: Sue Desjardins, Human Resources Manager Welcome to Rochester Community Schools! The position for which you have been hired (Secretary, Recess/Lunch Paraeducators, Special Education Paraeducators, School Age Care, Coach, and/or Asst. Coach ONLY) is designated within the Rochester Community Schools' Bloodborne Pathogen Exposure Control Plan as a first aid provider or a position in which the employee could be responsible for exposure and/or clean-up of blood or other potentially infectious material. Based on this designation you are eligible to receive the Hepatitis B vaccination at no cost to you. (It is a series of three vaccinations administered at the Crittenton Occupational Medicine Clinic). As a new hire to Rochester, it is also important for you to review the attached documentation which includes detailed information regarding our district's bloodborne pathogen guidelines, universal precautions, and factual information provided by the United States Department of Labor about the Hepatitis B vaccination, in addition to the required completion of the Bloodborne Pathogens tutorial, through Global Compliance Network. Also attached is a form called, Hepatitis B Vaccination Response Statement. Regardless of your decision, this form must be completed and returned to the district's Human Resources office no later than 10 business days after your hire date. If it is your decision to receive the Hepatitis B vaccination series immediately, upon receipt of your Hepatitis B Vaccination Response Statement, I will forward an authorization for you to go to the Crittenton Occupational Medicine Clinic to begin your series of vaccinations. Finally, if you have questions, please feel free to contact me at (248) or via at, sdesjardins@rochester.k12.mi.us. Thank you, Sue DesJardins Human Resources Manager Page 1 of 4 rev

19 ROCHESTER COMMUNITY SCHOOLS 501 W. University Dr. Rochester MI Fax FORM 15 Bloodborne Pathogen Guidelines In 1991, the Occupational Safety and Health Administration issued a standard designed to help employees limit their exposure to blood which, if contaminated, could transmit diseases. Exposure is limited when employees are knowledgeable about "universal precautions" and follow guidelines designed to prevent contact with blood, or other body fluids containing visible blood. More specifically, the regulation provides special protection for regular employees who are considered first aid providers - those who are called upon to care for students with injuries, bloody noses, toileting needs, and those required to clean up blood. UNIVERSAL PRECAUTIONS: "Universal precautions" means that we treat all human blood as though it were infectious, that we wear gloves when in contact with the blood of others, and that we wash our hands thoroughly and frequently. (Gloves are available in every classroom and are carried by first aid providers). Additional precautions involve arranging for clean-up of contaminated surfaces with the custodial staff as soon as possible, and disposing of blood soiled items into specially marked hazardous waste receptacles (those identified with red bag). When dealing with any body fluid, it is wise to follow the above procedures, and use "self-care" techniques when possible. 1. The student applies direct pressure with tissue for bloody nose. 2. Students do their own direct pressure on large wounds until the first aid provider is prepared with gloves. 3. The student uses tissue and receptacle for vomit until first aid provider is prepared with gloves. (Not a bloodborne concern unless vomit is visibly contaminated with blood). 4. Female students are instructed on proper disposal of feminine hygiene products. Page 2 of 4 rev

20 ROCHESTER COMMUNITY SCHOOLS 501 W. University Dr. Rochester MI Fax FORM 15 REPORTING PROCEDURES: To ensure that employees in contact with blood receive necessary follow-up care, all blood contacts must be reported within 24 hours to the Building Administrator and to the Manager of Human Resources on extension The verbal report must be followed by submission of an Incident Report Form available from your building secretary withio two (2) days of the incident. TYPES OF INCIDENTS: There are two types of blood contacts that must be reported: 1. Exposure Incident: Blood or other "potentially infectious materials" (other body fluids that contain visible blood) that come into contact with a mucous membrane (eye, mouth), non-intact skin, or parenteral contact (cut, abrasion, or bite), 2. First Aid Incident: Contact with blood, but no contact with a mucous membrane or nonintact skin, Employees who are involved in either incident are entitled to the Hepatitis B infection series. Additionally, employees who have been identified as First Aid Providers are eligible for the Hepatitis B injection series at no cost. (See the Exposure Control Plan in your building for a detailed listing of employees considered First Aid Providers) If your position has been identified as a First Aid Provider and you do not accept the Hepatitis B injections when first hired, you may accept at any time by contacting Sue DesJardins, Human Resources Page 3 of 4 rev

21 ROCHESTER COMMUNITY SCHOOLS 501 W. University Dr. Rochester MI Fax FORM 15 HEPATITIS B VACCINATION RESPONSE STATEMENT I understand that due to my potential for occupational exposure to blood, or other potentially infectious materials, I may be at risk for acquiring the Hepatitis B virus infection. I have been given information on the Bloodborne Pathogens Regulations and Universal Precautions, and have been informed that the Hepatitis B vaccination series will be provided free of charge. AT THIS TIME, I CHOOSE THE FOLLOWING OPTION: To complete the vaccination series. To decline the vaccination series at this time. I understand that in the future, if I am still working in this position and decide to receive the vaccination series, I may do so at no cost. I was previously vaccinated in (year) Please Print: EMPLOYEE NAME POSITION: BUILDING DATE: EMPLOYEE SIGNATURE: HIRE DATE: Must be submitted to Human Resources within 10 days from the date of hire. Page 4 of 4 rev