Employee Data Sheet Social Security #: Today s Date: NAME Title: Dr. Mr. Ms. Mrs. Miss First: Middle: Last: Suffix: CONTACT INFORMATION Address: Apt/Unit #: City: State: Zip Code: County: Home Phone (include area code): Email Address: Cell Phone (include area code): PERSONAL DATA Marital Status: Married Widowed Single Divorced Gender: Male Female Education: Not Indicated Military Service: No Military Service Less Than HS Graduate Active Reserve HS Graduate or Equivalent Inactive Reserve Some College Armed Forces Service Medal Vet Technical School Other Protected Veteran 2-Year College Degree Protected, Not Classified Bachelor s Level Degree Retired Military Some Graduate School Separated, Service Medal Vet Master s Level Degree Separated, Other Vet Doctorate (Academic) Vietnam Era Veteran Doctorate (Professional) Post-Doctorate Educational Specialist IDENTITY/DIVERSITY Date of Birth: Country of Birth: Citizenship Status: U.S. Citizen Ethnicity/Race: Hispanic/Latino Naturalized Citizen (check all that apply) White Permanent Resident Black/African American Non-Resident Alien American Indian/Alaska Native Asian Native Hawaiian/Pacific Islander EMERGENCY CONTACT Name: Relationship: Phone: Name: Relationship: Phone:
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 Issuing Authority Document Number Issuing Authority Document Number Expiration Date (if any)(mm/dd/yyyy) Expiration Date (if any)(mm/dd/yyyy) 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 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 B LIST C Documents that Establish Employment Authorization OR 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
Board of Regents University System of Georgia SECURITY QUESTIONNAIRE NOTICE TO EMPLOYEES: The Sedition and Subversive Activities Act of 1953 (Ga. Laws, 1953), as amended, requires each employee to complete and sign, prior to his/her employment by the State of Georgia, a questionnaire which is designed to establish that there are no reasonable grounds to believe that he/she is a subversive person. A subversive person is defined as one who commits acts, advocates, or teaches the overthrow of the government of the United States or government of the State of Georgia by force or violence or who is a knowing member of a subversive organization. INSTRUCTIONS: Prepare in original only. Fill in all items. If more space is needed for any item, or explanation, continue under Item 5. Please type or print in ink. 1. Name Social Security No. Other Names Used: (Maiden name, names by former marriages, former names changed legally or otherwise: Aliases, nicknames, etc. Specify which, and show dates used.) 2. Address (Street and No.) (City) (State) (County) (Phone No.) 3. Are you now or have you been within the last ten (10) years a member of any organization which to your knowledge at the time of membership advocates or has as one of its objectives, the overthrow of the government of the United States or of the government of the State of Georgia by force or violence? Yes No. If Yes, state the name of the organization and your past and present membership status including any offices held therein. NOTE: If the answer to Question 3 is yes and the employing authority deems further inquiry necessary, you will be notified of such determination. No action adverse to your application will be taken because of an affirmative answer until such an inquiry, with notice to you and an opportunity for you to present evidence, and only if the results of such inquiry bring your application within the prohibition within the Sedition and Subversive Activities Act of 1953, as amended. 4. (A) Have you ever been convicted or are any charges now pending against you by Federal, State or other law-enforcement authorities, for any violation of any federal law, state law, county or municipal law, regulation, or ordinance? (Do not include anything that happened before your sixteenth birthday. Do not include minor traffic violations for which a fine of $35.00 or less was imposed. All other convictions must be included even if they were pardoned). Yes No (B) If the answer to 4(A) is yes state the reason convicted, the date convicted and the place where convicted. REASON CONVICTED DATE PLACE WHERE CONVICTED 5. SPACE FOR CONTINUING ANSWERS OR EXPLANTIONS: (show item numbers to which answers or explanations apply. Attach a separate sheet if more space is needed. 1
NOTE: Before signing this form, check all answers and explanations to see that you have answered all questions fully and correctly. This form is to be executed under oath subject to the penalties of false swearing as prescribed in Code Section 26-2402 of Criminal Code of Georgia. AFFIDAVIT OF VERIFICATION State of County Personally appeared before the undersigned attesting officer, duly authorized to administer oaths, who, after being sworn, deposes and says and declares under penalties of false swearing that he or she is the person who executed the foregoing instrument; that he or she has read and completed the same and knows and understands the contents thereof; that the matters stated therein and the answers and information furnished by him or her in the foregoing questionnaire, including any attachments thereto, are true and correct. SWORN TO AND SUBSCRIBED BEFORE ME (Signature of Employee) This day of Notary Public County of My commission expires day of 20 (Affix Seal) INFORMATION TO BE FURNISHED BY EMPLOYING UNIT Instructions to unit: If this questionnaire is executed by applicant, insert APPL in the space for date of appointment, and show date of application. If this questionnaire is executed by an individual who has been offered employment or who is already employed, Provide the information requested. DATE OF APPOINTMENT TITLE OF POSITION UNIT AND DEPARTMENT DUTY STATION Board of Regents University System of Georgia LOYALTY OATH State of COUNTY OF I,, a citizen of (State) and being an employee of the University System of Georgia and the recipient of public funds for services rendered as such employee, do hereby solemnly swear and affirm that I will support the Constitution of the United States and the Constitution of the State of Georgia. This day of,. (Signature of Employee) Sworn to and subscribed before me this day And year above set out. Notary Public PLEASE NOTE THAT EACH OF THE ABOVE DOCUMENTS, THE SECURITY QUESTIONNAIRE AND THE LOYALTY OATH, MUST BE SIGNED AND NOTARIZED. 2
EMPLOYEE INFORMATION AND TRAINING VERIFICATION FORM YOU HAVE THE RIGHT TO KNOW ABOUT THE HAZARDOUS CHEMICALS IN YOUR WORKPLACE Last Name First Name Middle Initial This is to certify that I have been told about my rights as a public employee of the State of Georgia to know about any and all hazardous chemicals used in my work area. As required under the Public Employee Hazardous Chemical Protection and Right to Know Act of 1988, I was informed of the following: my right to receive information regarding hazardous chemicals on my job my right to receive formal training and education on hazardous chemicals what a Material Safety Data Sheet (MSDS) is and how to use it where hazardous chemicals (if any) are used in my work area my physician s right to receive information on the chemicals to which I may be exposed I have also been told that I cannot be terminated, discriminated against, or disciplined for exercising my rights as provided by this statute. No pay, position, seniority or other benefits may be lost for exercising my right to know. I may present a written request to receive a Material Safety Data Sheet for any chemical used on my job. I have the right to refuse to work with a hazardous chemical if a Material Safety Data Sheet in my employer s possession has not been provided to me within five (5) working days after my written request, unless I am required to perform essential services. If I am not satisfied with the results listed above, I also have the right to file a grievance through the established grievance and appeals procedure for Kennesaw State University and/or the Department of Labor. I have either viewed the 2000 version of the Department of Labor videotape entitled Your Right To Know or completed the online Right To Know Training Module found at https://www.usg.edu/facilities/rtk-ghs both of which feature the above information. I have also been given the name, address and telephone number of the KSU Right to Know Coordinator and instructed to contact this person if I have any additional questions. Employee s Signature Employee s Department Date
NOTICE TO ALL NON-BENEFITED EMPLOYEES All employees who are ineligible for benefits are subject to Georgia Defined Contribution Plan deductions. This after tax deduction will be 7½ % of your take home pay. The Georgia Defined Contribution Plan was created by the 1992 Georgia Law, Act 996, and was effective July 1, 1992. The purpose of the law is to provide a retirement plan for temporary, seasonal, and part-time employees of the State of Georgia who are not eligible for membership in the Employees Retirement System or the Teachers Retirement System. At the end of your non-benefited employment you are entitled to a refund of these monies. Employees who are contributing members or retirees under the Teachers Retirement System (TRS) or Employees Retirement System (ERS) are not required to take part in the Georgia Defined Contribution Plan. Proof of current TRS/ERS membership is required. If you have any questions regarding the Georgia Defined Contribution Plan, please contact Human Resources at (470) 578-6030. I have read and understand the above information regarding the Georgia Defined Contribution Plan. Printed Name: Signature: Date:
GDCP NEW HIRE LETTER Congratulations on your new employment! One of the benefits included with your employment is membership in the Georgia Defined Contribution Plan (GDCP). Enrollment in the Defined Contribution Plan is a mandatory condition of your employment and requires you to contribute to the Plan through payroll deduction beginningg immediately. As a member of the Georgia Defined Contribution Plan, your contribution is equal to 7.5% of your eligible pay. More information about your contributions and the benefits provided by the Georgia Defined Contribution Plan are available in the Employee Handbook. You can access the Handbook online at www.ers.ga.gov by choosing Georgia Defined Contribution Plan under Pensionn Plans in the left hand menu, then clicking on Handbook in the right hand menu. Once the Georgia Defined Contribution Plan has received your first monthly contribution and set up a pension record for you on our system, you will receive a letter from us asking that you visit our website and register for your online account. We will also request that you provide information on your beneficiary elections in the event that you pass away before you start your retirement benefits. This is very important as we want to follow your wishes in the distribution of any benefits. If you have been a member in the Georgia Defined Contribution Plan before, you can accesss your online account now and provide this information. If not, you will receive your letter from us in about 30 to 45 days. Once again, congratulations on your new employment and welcome to the Georgia Defined Contribution Plan. If you need any additional information on the Plan, please visit our web site at www.ers.ga.gov.
Parking Information for Employees and Acknowledgement of Pretax Parking Benefit Parking Information Information pertaining to parking on the Kennesaw or Marietta campuses can be found at the following web address: http://parking.kennesaw.edu/ Faculty and Staff Part-Time, Full-Time, and Temporary Payroll Parking Deductions Most positions (excluding only those specifically listed below) are eligible for payroll parking deductions. Parking plan enrollments for these employees are sent to Payroll so the fees can be deducted directly from your paycheck. Please visit Card Services on or before your first day of employment to enroll in a parking plan and obtain a parking decal. Failure to do so in a timely manner may result in a parking ticket for parking without the proper authorization. Student Employees*, Continuing Education Instructors, and Occasional/Contract Workers Non-Payroll Parking Fees These employee types are not eligible for payroll parking deductions and should not request faculty or staff parking decals from Card Services upon employment. However, these employees are still eligible for ticketing if payment of parking is not made. If you are currently enrolled as a student at KSU, you are paying for parking via the tuition and fees you pay at the beginning of each semester. Please utilize student parking as appropriate. If you are NOT currently enrolled as a student at KSU, you should NOT utilize student parking. Instead, please park in the paid visitor lot or contact Card Services to inquire about other parking payment options. *Student employees include Student Assistants, Federal Work Study Students, SALT Student Assistants, Graduate Research Assistants, Graduate Teaching Assistants, and Graduate Assistants. Acknowledgement of Pretax Parking Benefit as Defined by IRS Code Section 132(f) When making your election in the parking program, you acknowledge that any fees from the parking plan that are deducted from your paycheck will be deducted from your paycheck on a pretax basis thereby reducing the overall effect of the deduction to your net pay. This acknowledgment does NOT enroll you in a parking plan; it only serves as notice of your pretax benefit. Last Name: First Name: Employee Signature: Date:
REQUEST FOR MOTOR VEHICLE REPORT (MVR) Employee has submitted this form as a (SELECT ONE): New / 1st Time Request ~OR~ Name or License Number Change Request Office of Enterprise Risk Management
Send completed forms to Human Resources. DO NOT EMAIL COMPLETED DIRECT DEPOSIT FORMS. In Person: Town Point Suite 2000 / Fax: 470-578-9174 / Mail: 3391 Town Point Dr, MD#9120, Kennesaw, GA 30144 Direct Deposit Acknowledgement and Enrollment By signing this form, you agree to the following: I understand, that as a condition of my employment, I must comply with the Board of Regents policy and enroll in direct deposit within one pay period of being hired or rehired and remain enrolled in direct deposit during the remainder of my employment. I understand that I can apply for an exemption from this requirement as provided by the policy. I understand that if I am not granted an exemption, I may be subject to dismissal. I acknowledge the responsibility of ensuring the accuracy of banking information (i.e. routing/transit numbers, account numbers, etc) before I complete this form or enroll in direct deposit via Employee Self Service. Board of Regents Required Electronic Transfer of Funds Policy (Section 7.5.1.1): http://www.usg.edu/policymanual/ Board of Regents Method of Payment for Compensation (Section 5.3.1): https://www.usg.edu/business_procedures_manual/ Print Name (First Middle Last) Signature Date NOTE: Final net pay account is required for all employees. Partial amount and percent accounts should be listed before net pay account and require an amount or percent, as applicable for deposit type selected. Account #1 Account #2 Account #3 Routing Number Routing Number Routing Number Checking Saving Checking Saving Checking Saving Account Type Account Type Account Type Amount Percent Net Pay Amount Percent Net Pay Amount Percent Net Pay Deposit Type Deposit Type Deposit Type Amount/Percent, if applicable Amount/Percent, if applicable Amount/Percent, if applicable Account Number Account Number Account Number Account #4 Account #5 Account #6 Routing Number Routing Number Routing Number Checking Saving Checking Saving Checking Saving Account Type Account Type Account Type Amount Percent Net Pay Amount Percent Net Pay Amount Percent Net Pay Deposit Type Deposit Type Deposit Type Amount/Percent, if applicable Amount/Percent, if applicable Amount/Percent, if applicable Account Number Account Number Account Number
Verification of Receipt of KSU Policy and Procedure I acknowledge receipt of each of the Kennesaw State University information, materials, policies, and procedures listed below. I have been made aware that it is my responsibility to know and understand all information regarding the policies and procedures covered therein and to keep abreast of any future changes. I further understand that the information does not constitute a contractual obligation on the part of Kennesaw State University, as policies set forth are determined by the Human Resources office (in conjunction with the Board of Regents of the University System and by the State of Georgia and/or the United States Government) through various executive orders and federal employment guidelines and are subject to change. I acknowledge receipt of the following: Employee Handbook(s) as appropriate to my position o Online at: http://handbooks.kennesaw.edu/ KSU Drug and Alcohol Policy o Online at: https://policy.kennesaw.edu/content/alcohol-and-other-drug-policy KSU Restricted Smoking Campus Policy o Online at: https://policy.kennesaw.edu/content/smoke-free-and-tobacco-free-policy Worker s Compensation Procedures for On-the-Job Injury/Illness Reporting (including how to access network of physicians) Employee Name Printed: Employee Signature: Date:
Human Resources On-the-Job Injury/Illness Reporting All University employees are covered by state Workers' Compensation laws that may provide medical and income benefits if you are injured on the job. Below provides a brief overview of the steps you should follow if you are injured or become ill while working. A detailed procedure and further information is available below. Step One: In an emergency situation, seek immediate medical treatment. If this is a life-threatening emergency, notify Public Safety at extension 6666 or 470-578-6666. Public Safety will dispatch an ambulance and direct it to your location. Or emergency medical care should be sought at the nearest emergency room. The emergency room closest to KSU is Kennestone Hospital located at 677 Church Street, Marietta, GA 30060, 770-793-5000. Directions: 75 South to Exit 267B (GA-5 S) towards Marietta, merge onto GA 5 South towards Church Street, continue.9 miles to Kennestone If urgent care is needed, the Police Officer will direct you to the Wellstar Clinic located at 3805 Cherokee Street in Kennesaw, 770-426-5665. This is the only approved location for a non-emergency initial visit. Please make sure to tell clinic staff you are a KSU employee seeking treatment under Worker's Comp. Important note: Except in emergency or urgent care situations, medical care must first be authorized through Worker's Comp. and you will be referred to a Worker's Comp. approved physician. Failure to use the Worker's Comp. physician will jeopardize payment of your medical bills under Worker's Comp. insurance. Step Two: After seeking medical treatment, or if not an emergency situation, the employee must complete an Employee Report of Injury/Illness within 24 hours of the incident, if possible, and submit to their supervisor. Step Three: Supervisor should review and complete the Employee Report of Injury/Illness and submit to Human Resources (HR) within 24 hours of completion. Step Four: HR will file the workers compensation claim and make initial contact with the Workers Compensation Managed Care Organization (WC/MCO). The WC/MCO Medical Case Manager will then contact the employee directly to obtain further information regarding their injury/illness and provide information regarding the AMERISYS, INC. network of providers. Your case manager will direct you to the physician(s) you need to see to be covered under the Worker's Comp. insurance. If you are out of work for more than 5 days due to the injury, you will be placed on a leave of absence from the university. HR will provide you information about your leave and what you need to do to continue your benefits. Worker's Comp. leave runs concurrent with FMLA Leave. Step Five: Employees are required to receive all medical care through the AMERISYS, INC. network of providers. Failure to use the network physicians will jeopardize payment of medical bills under Workers' compensation and the employee may be personally liable. If you have questions or need assistance, please contact Human Resources at 470-578-6030 between the hours of 8:00am - 5:00pm, Monday through Friday. 3391 Town Point Drive MD 9120 Bldg. 3391 Ste. 2000 Kennesaw, GA 30144-5591 Phone: 470-578-6030 Fax: 470-578-9174 www.kennesaw.edu