YOU DO NOT NEED TO PRINT THIS PAGE. Appointment Date & Time: Name: Date: Substitute Records Requirements I-9 (only complete page 1) W-4 Social Security Card (copies not accepted) Driver s License Direct Deposit Form w/voided check Insurance Enrollment Accept/Decline Letter Transcript (can be unofficial) Fingerprint receipt Substitute Agreement Acknowledgement of Policies Substitute Handbook Receipt *Oath of Office Please complete all forms. We will be unable to process your hire until we have received all documents. We require a fingerprint record through the State of Texas Education Department. You will be required to pay the $47.00 fee associated with this requirement. This fee is non-refundable by Lubbock ISD or the State of Texas. *Oath of office is completed during orientation and notarized by an LISD employee.
Employment Eligibility Verification Department of Homeland Security U.S. Citizenship and Immigration Services USCIS Form I-9 OMB No. 1615-0047 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 E-mail 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 07/17/17 N Page 1 of 3
Employment Eligibility Verification Department of Homeland Security U.S. Citizenship and Immigration Services USCIS Form I-9 OMB No. 1615-0047 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 Document Number Expiration Date (if any)(mm/dd/yyyy) Issuing Authority Document Number Expiration Date (if any)(mm/dd/yyyy) Issuing Authority 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) Last Name (Family Name) First Name (Given Name) Middle Initial Lubbock ISD 1628 19th St, Suite 122 Lubbock TX 79401 B. Date of Rehire (if applicable) 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 07/17/17 N Page 2 of 3
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 LIST C Documents that Establish Employment Authorization OR LIST B Documents that Establish Identity AND 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 report of birth issued by the Department of State (Forms DS-1350, FS-545, FS-240) 3. Original or certified copy of birth certificate issued by a State, county, municipal authority, or territory of the United States bearing an official seal 4. Native American tribal document 5. U.S. Citizen ID Card (Form I-197) 6. Identification Card for Use of Resident Citizen in the United States (Form I-179) 7. Employment authorization document issued by the Department of Homeland Security Examples of many of these documents appear in Part 13 of the Handbook for Employers (M-274). Refer to the instructions for more information about acceptable receipts. Form I-9 07/17/17 N Page 3 of 3
SUBSTITUTE AGREEMENT As a substitute for the Lubbock Independent School District, I understand and agree to the following statements: 1. The substitute is an at-will employee on an as needed basis. Employment at-will may be terminated with or without cause and with or without notice at any time by the employee or the District. There is no guarantee as to the number of workdays available annually to the substitute. 2. A substitute must accept assignments at any school in the District as arranged upon employment. 3. To complete a full day of employment, a substitute teacher must remain at the school for a full eight hour day. The eight hour day includes preparation period(s) and the lunch break. Failure to adhere to the eight hour rule could result in partial loss of wages for the day. Substitute educational aides, clerks, and secretaries are on duty thirty minutes longer than the substitute teachers. 4. At its discretion, the District has the right to cancel any substitute assignment on short notice and without penalty to the District. I HAVE READ AND ACCEPT THE CONDITIONS OF EMPLOYMENT LISTED ABOVE. Employee Signature Print Name Date Substitute Agreement Revised June 21, 2018
ATTENTION ALL STAFF MEMBERS PLEASE READ THE FOLLOWING STATEMENT CAREFULLY AND SIGN BELOW. YOU WILL NEED TO RETURN THIS FORM TO HUMAN RESOURCES AS SOON AS POSSIBLE. The Lubbock Independent School District employment policies are electronically distributed. Electronic distribution of these policies reduces paperwork and gives employees easy access to district employment policies. Employees are able to view and make copies of any policy. To access district employment policies and print a hard copy, you may use the following address: https://pol.tasb.org/home/index/830 * Use the hardware located in the library or hardware designated by your principal to access these policies. Employee Signature Print Name Date Electronic Distribution of Policies Revised June 21, 2018
SUBSTITUTE HANDBOOK RECEIPT I hereby acknowledge receipt of the Lubbock ISD Substitute Employee Handbook. I agree to read the handbook and abide by the standards, policies, and procedures defined or referenced in this document. I understand that I must return this signed form to the Substitute Office located in the Human Resources Department of Lubbock ISD prior to beginning my substitute employment for the 2018-2019 school year. The information in this handbook is subject to change. I understand that changes in district policies may supersede, modify, or eliminate the information summarized in this booklet. As the district provides updated policy information, I accept responsibility for reading and abiding by the changes. I understand that no modifications to contractual relationships or alterations of at-will relationships are intended by this handbook. Employee Signature Print Name Date Substitute Handbook Receipt Revised June 21, 2018
January 1, 2019 Dear Substitute, Lubbock ISD provides health coverage to employees through a self-funded health care plan. A district substitute is eligible to enroll in this plan if the district reasonably expects the substitute to work at least 2 days per week. Days worked for other school districts are not considered in determining whether a substitute is eligible for benefits through Lubbock ISD. Although the district reasonably expects substitutes to work at least 2 days per week, the district does not guarantee that you will receive 2 days every week. The district s need for substitutes varies from week to week. In some weeks, you may not receive any assignments. Similarly, the district understands that some weeks you may not be able to accept assignments due to illness or other personal reasons. If you are a new substitute, you must enroll in or decline medical coverage within 31 days from date of hire. If you are a returning substitute, you must enroll in or decline medical coverage during the annual open enrollment. If you decline coverage, you cannot enroll again until the next plan year unless you experience a special enrollment event. If you elect to enroll, a sub must work an average of 30 hours per week or 130 hours per month for a period of 6 months to qualify for district health coverage. You will be responsible for the full premium. You must submit payment for one calendar month with your enrollment form. The premiums for subsequent months will be deducted from your pay for the preceding month. If your pay is not sufficient to cover the full premium, you must submit the difference to the district by the 15 th day of the preceding month. If the 15 th day falls on a weekend or a day the district is closed, the payment must be made the preceding business day. If you fail to timely pay the monthly premiums, the district will proceed with the coverage cancellation process. Your coverage may also be cancelled if you lose eligibility for the district s plan. You may be removed from the district s substitute roster for poor performance or misconduct. In addition, you may be removed from the substitute roster if: you repeatedly turn down assignments, are repeatedly unavailable for assignments, or frequently cancel assigned positions you do not accept at least 4 assignments per month you do not timely return a letter of reasonable assurance
A substitute who is enrolled in the district s health plan and who is then removed from the substitute roster becomes ineligible for health coverage and will be provided notice regarding continuation coverage under COBRA (if eligible). Cancellation due to non-payment is considered a voluntary drop: Therefore you would not be eligible for COBRA. If you have any questions regarding this communication please contact Bill Tarro, Executive Director Risk Management at 806-219-0280 or Bill.Tarro@lubbockisd.org.
To: Lubbock ISD Substitute From: Lubbock ISD Risk Management Office Date: January, 2019 Re: 2019 Health Care Election Form Substitutes (temporary workers) are not eligible for Health Insurance if they are: a.) A TRS Retiree receiving, or who declined coverage under TRS-Care, including a retiree who has returned to work. b.) Receiving health insurance as an employee or retiree under the Texas State College and the University Employees Uniform Insurance Benefits Act or under ERS and the Texas Employees Uniform Group Insurance Benefit Act. Also, substitute s paychecks must be sufficient to cover their premiums in full. See the 2019 Health Premiums below: 2019 Health Plan Premiums for Substitutes or Other Temporary Workers Employee Contribution Bronze PPO Medical Plan Bronze HMO Medical Plan Silver PPO Medical Plan Silver HMO Medical Plan Employee Only $454.00 $443.00 $622.00 $595.00 Employee & Children $529.00 $511.00 $749.00 $711.00 Employee & Spouse $580.00 $557.00 $878.00 $828.00 Employee & Family $738.00 $701.00 $1135.00 $1062.00 2019 Health Insurance Election: I elect to enroll in LISD Health Insurance Coverage and would like more information. I decline LISD Health Insurance Coverage for the 2019 Plan Year. Print Your Name: Signature: Employee ID: Date: / /
Lubbock ISD Health Plan administered by Blue Cross and Blue Shield of Texas Major Medical Plans Employee Premium Office Visit In Network Out of Network Prescriptions PPO-Bronze Plan Monthly Premiums Employee Only $454 $6,650 Deductible Employee & Children $529 Employee & Spouse $580 Employee & Family $738 ($13,300 Family Total) HMO-Bronze Plan Monthly Premiums Employee Only $443 $6,650 Deductible Employee & Children $511 Employee & Spouse $557 ($13,300 Family Total) Employee & Family $701 100% of allowable costs 100% of allowable costs Deductible, then 100% of allowable costs after Deductible is met after Deductible is met $5,000 individual after deductible is met. $10,000 Family HSA Option $6,650 max out of pocket $13,300 max out of pocket Lubbock ISD will match for an individual for an individual employee's contributions up to $500 for $13,300 max out of pocket $26,600 max out of pocket the 2019 Plan Year for a family for a family HMO Bronze & HMO Silver require Primary Care Provider referrals for Specialist visits. PPO-Silver Plan Monthly Premiums Employee Only $622 $100 Rx Deductible per person: $4,000 Deductible Employee & Children $749 Deductible, then Retail: Employee & Spouse $878 80% of allowable costs 80% of allowable costs $8,000 Individual $15 for Generic ($8,000 Family Total) Employee & Family $1,135 after Deductible is met after Deductible is met $16,000 Family $35 for Brand Formulary $60 for Brand Non Formulary $7,050 max out of pocket $14,100 max out of pocket HMO-Silver Plan Monthly Premiums for an individual for an individual Mail In: 3X Retail Co-Pay for Employee Only $595 90 day supply of Brand $4,000 Deductible Employee & Children $711 $14,100 max out of pocket $28,200 max out of pocket Employee & Spouse $828 for a family for a family $25 Total Co-Pay for ($8,000 Family Total) Employee & Family $1,062 90 day supply of Generic 1 In addition to routine annual physical examinations, well-baby exams, immunizations for those 6 years of age and over and any other preventive health services as determined by the U.S. Preventive Services Task Force (USPSTF) will be covered at no cost. For further information, please contact Risk Management at 806-219-0283 Updated 10/25/18 for 2019 Plan Year
Preferred Name As we move towards converting to our new email standard of firstname.lastname@lubbockisd.org, we would like to accommodate your name preference when creating your new email address. If you have a preferred name that is different from your first name, please let us know below. (ie. Your first name is Janet but you prefer to go by Rose ) Legal Name: Preferred Name: Preferred Name - Email Revised June 21, 2018