evangeline parislr school district · print your certificate and return with the renewal packet....

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Evangeline Parish Schools

“Our Children, Our Schools, Our Future” Darwan T. Lazard, Superintendent

1123 Te Mamou Road, Ville Platte, LA 70586 Tel: 337-363-6651/Fax: 337-363-8086 Website: www.epsb.com

School Board Members:

Lonnie Sonnier Dr. Bobby Deshotel Karen Vidrine Wayne Dardeau Peggy Forman Mike Fontenot Shelia Jason District One District Two District Three President District Five District Six District Seven

District Four

Wanda Skinner Edward S. Limoges Arthur Savoy Nancy A. Hamlin Ellis Guillory, Sr. Georgianna L. Wilson District Eight Vice President District Ten District Eleven District Twelve District Thirteen

District Nine

“An Equal Opportunity Employer”

June 18, 2020

Dear Substitute Employee,

The substitute renewal process has changed for 2020-2021 school year. Please note the following changes:

• DIRECT DEPOSIT SERVICES

o Contact the accounting department at (337)363-6652 to complete a direct deposit form or to

make changes if necessary

• 2020-21 RENEWAL PACKET o To remain active as a substitute for the 2020-2021 school year, complete a substitute renewal

packet electronically by July 20, 2020.

▪ Renewal Form - Please sign the substitute renewal form acknowledging your

understanding of the requirement to report any arrest and/or conviction, which

involves you, to the Office of the Superintendent of Schools within 24-48 hours of its

occurrence. Failure to report this information may lead to your termination. This new

reporting requirement is in lieu of annual fingerprints (Criminal Background Checks).

▪ Email Address is required to update your information in Frontline (formerly

AESOP) software.

▪ Insurance Acceptance/Declination Form- The form must be completed annually.

▪ Louisiana Workers’ Compensation Second Injury Board Post-Hire/Conditional

Job Offer Knowledge Questionnaire – The form must be completed annually.

▪ Ethics Training - Each year all public servants/substitutes are required to complete the online

Ethics Training. The steps to complete the online Ethics Training are as follows:

1. Go to https://laethics.net (This will take you to the online Training Portal)

2. Enter your user name (e-mail) and enter your password

a. (If you have forgotten your password click forgot password and follow the

directions) or (If you have never done online Ethics Training register as a new

user)

3. Click on Login

4. Complete all parts of the training and answer questions as they appear in the

presentation

5. After completing Part 3, print your certificate and return with the renewal packet.

https://laethics.net/

Evangeline Parish Schools

“Our Children, Our Schools, Our Future” Darwan T. Lazard, Superintendent

1123 Te Mamou Road, Ville Platte, LA 70586 Tel: 337-363-6651/Fax: 337-363-8086 Website: www.epsb.com


Lonnie Sonnier Dr. Bobby Deshotel Karen Vidrine Wayne Dardeau Peggy Forman David Landreneau Shelia Jason District One District Two District Three President District Five District Six District Seven

District Four

Wanda Skinner Edward S. Limoges Arthur Savoy Nancy A. Hamlin Ellis Guillory, Sr. Georgianna L. Wilson District Eight Vice President District Ten District Eleven District Twelve District Thirteen

District Nine

“An Equal Opportunity Employer”

▪ Print your certificate and return with the renewal packet.

Substitutes, must comply with all steps of the Substitute Renewal Process to maintain

employment with Evangeline Parish School System. If you have questions, please contact me at

(337) 363-6654.

Sincerely yours,

Sherral Tezeno

Substitute Presenter

Michael J. Lombas

Assistant Superintendent

ML/ST/aa

EPSB SUBSTITUTE

2020-21 SCHOOL SESSION

To: Principals/Secretaries:

To remain active on the substitute list for the 2020-21 school session, a substitute

must submit the bottom portion of this letter to the Central Office.

Employee# __

Name: SS# ---------------- ------

(Please print) (last four digits)

Address:

Phone#(s):

Email address:

Substitute TEACHER Substitute CUSTODIAN ---- ---

Substitute PARA Substitute NURSE ----- ----

Have you ever been convicted of a felony for which you have not been pardoned? 0 Yes O No

I understand that I must report any arrest or conviction, which involves me, to the office of the

Superintendent of Schools within 24-48 hours. I understand that failure to do so may lead to termination.

Date: Signature:

Office use only: Date turned in ________ _ Received by ___ _

Euang eline Parish Schoo Is"Our Children, Our Schools, Our Fufire" Dawen T. Lazandl, Superintendent

1123 Te Mamou Road, Ville Platte, LA 70586Tel: 337-363-665 1 /Fax: 337-363-8086

Website: http://www.epsb.com

April28,2O20

RE: Health Insurance Marketplace

Dear Sir or Madame,

The Affordable Care Act also known as Obamacare requires that employers provide you withinformation regarding our insurance coverage. Enclosed you will find the required information.

Sincerely yours,

Amy LaFleur, CLSBAChief Financial Offic


lrnnic Sonnict Dr. Bobby Deshotel Karen Vi&iDe WayncDardeau Peglc/Fo.man Mike W- Fonteoot Shelia Joseph

Edward S. Limoges Arthur Ssvoy Nsocy A. Hr$lir EIk Grillory, Sr.Watrda A. SkinnerDiqti.r Eish

"An Equal Opportunity Employer"

Gco8ianna L. Wilson

Euang eline Parish Schools"Our Children, Our Schools, Our Fudre"

Api|28,2020

RE: Health Insurance Marketplace

Dear Employee,

The Affordable Care Act (ACA) also known as Obamacare requires your employer, EvangelineParish School Board, to provide you with information regarding the health insurance coverageavailable to you. The law requires employers to offer an affordable employee only coverage.The federal guidelines allow the use of three different models to compute the affordability oftheinsurance. The computational analysis, selected by the administration, has been completed foreach employee as required. Based upon the analysis, the employee only coverage available isconsidered affordable as dehned in the federal guidelines.

Enclosed you will find a handout from the Office of Group Benefits explaining the healthinsurance market place along with the Department of Labor form completed by EvangelineParish School Board regarding the employer offered health insurance. Should you havequestions, please contact the Insurance Secretary, Rachelle Matte.

Si v

Amy BAChief Financ cer

School Board Members

Lonnie Sonnier Dr. Bobby Deshotel Ksrcn Vidrine Wsyne Dardeau Pegry Forman Mike W. Fontenot Shelia Joseph

Edw.rd S. Limogcs Anhut S.voy Nancy A. H.mlin EUis Guillory, Sr. GeorBiarna L. Wilson

Dawaa T. Lazard, Superlntendent1123Te Mamou Road, Ville Platte, LA 70586

Tel: 337-363-6651 /Fax: 337-363-8086Website: http: //svw.epsb.com

C

Wanda A. Skinner

"An Equal Opportunity Employer"

New Health Insurance Marketplace Coverage Options and Your Health Coverage

PART A: General Information

Form Approved

0MB No. 1210-0149

(expires 11-30-2013)

When key parts of the health care law take effect in 2014, there will be a new way to buy health insurance: the Health

Insurance Marketplace. To assist you as you evaluate options for you and your family, this notice provides some basic

information about the new Marketplace and employment-based health coverage offered by your employer.

What is the Health Insurance Marketplace?

The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. The

Marketplace offers "one-stop shopping" to find and compare private health insurance options. You may also be eligible

for a new kind of tax credit that lowers your monthly premium right away. Open enrollment for health insurance

coverage through the Marketplace begins in October 201 3 for coverage starting as early as January 1, 201 4.

Can I Save Money on my Health Insurance Premiums in the Marketplace?

You may qualify to save money and lower your monthly premium, but only 1f your employer does not offer coverage, or

offers coverage that doesn't meet certain standards. The savings on your premium that you re eligible for depends on

your household income.

Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace?

Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be eligible

for a tax credit through the Marketplace and may wish to enroll in your employer s health plan. However, you may be

eligible for a tax credit that lowers your monthly premium, or a reduction in certain cost-sharing if your employer does

not offer coverage to you at all or does not offer coverage that meets certain standards. If the cost of a plan from your

employer that would cover you (and not any other members of your family) is more than 9.5% of your household

income for the year, or if the coverage your employer provides does not meet the "minimum value standard set by the

Affordable Care Act, you may be eligible for a tax credit. 1

Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered by your

employer, then you may lose the employer contribution (if any) to the employer-offered coverage. Also, this employer

contribution -as well as your employee contribution to employer-offered coverage- is often excluded from income for

Federal and State income tax purposes. Your payments for coverage through the Marketplace are made on an after

tax basis.

How Can I Get More Information?

For more information about your coverage offered by your employer, please check your summary plan description or

contact------------------------------------------------

The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the

Marketplace and its cost. Please visit HealthCare.gov for more information, including an online application for health

insurance coverage and contact information for a Health Insurance Marketplace in your area.

1 An employer-sponsored health plan meets lhe "minimum value standard" 1f lhe plan's share of the total allowed benefit costs covered

by lhe plan 1s no less than 60 percent of such cosls.

PART B: lnformation About Health Coverage Offered by Your EmployerThis section contains information about any health coverage offered by your employer. lf you decide to complete anapplication for coverage in the Marketplace, you will be asked to provide this anformation. This intormation is numberedto correspond to the Marketplace application.

Here is some basic inlormation about health coverage olfered by this employer. As your employer, we oller a health plan to:

E All em ployees.

B Some employees. Etigible employees are

With respect to dependents:A We do offer coverage. Eligible dependenis are

E We do not offer coverage

Even if your employer intends your coverage to be affordable, you may still be eligible for a Oaemiumdiscount through the Marketplace. Ihe Marketplace will use your household income, along wilh other factors,to determine whether you may be eligible for a Dremium discounl. lf , for example, your wages vary fromweek to week (perhaps you are an hourly employee or you work on a commission basis), if you are newlyemployed mid-year, or iI you have other income losses, you may still qualify for a Oremium discount.

lI you decide to shop lor coverage in the Markelplace. Hsalthcare.Oov will guide you through the process. Here's theemployer intormalion you ll enter when you visit Healthcare.gov to find out if you can gel a tax credit to lower yourmonthly orem ium s.

E lf checked, this coverage meets the minimum value standard, and the cost of this coverage to you is intended tobe alfordable, based on employee waOes.

3. Employer name

EVANGELINE PARISH SCHOOL BOARDI 4. Employer ldentificauon Number (ElN)

I 726000392

5. Employer address1 123 TE ['Ai,4OU ROAD

6. Employer phone number337-363-6651

7. City

VILLE PLATTE| 8. sbte

I LOUTSTANA

9. zP code70586

10. Who can we contact about employee health coverage at this job?

RACHELLE MATTE, INSURANCE SECRETARY

11. Phone number (if different from above)

337 -363-7419

I 12- Email address

I [email protected]

EPSB INSURANCE ACCEPTANCE/DECLINATION

2020-2021 SCHOOL SESSION

NAME OF EMPLOYEE ---------

DATE OF NOTICE ____________ _

AS A PART TIME EMPLOYEE OF THE EVANGELINE PARISH SCHOOL

BOARD, I HAVE RECEIVED THE INFORMATION AS REQUIRED BY

THE AFFORABLE CARE ACT REGARDING THE HEALTH INSURANCE

COVERAGES PROVIDED BY THE SCHOOL BOARD.

EMPLOYEE SIGNATURE DATE

I HAVE ACCEPTED THE COVERAGE OFFERED BY THE --

EVANGELINE PARISH SCHOOL BOARD SHOULD I REACH 30 HOURS

OF WORK PER WEEK.

__ I HAVE DECLINED THE COVERAGE OFFERED BY THE

EVANGELINE PARISH SCHOOL BOARD SHOULD I REACH 30 HOURS

OF WORK PER WEEK.

EMPLOYEE SIGNATURE DATE

This form must be filled out annually for each school session.

PAGE _____ OF ______

SIB FORM D (10/17)

LOUISIANA WORKERS’ COMPENSATION SECOND INJURY BOARD POST‐HIRE/CONDITIONAL JOB OFFER KNOWLEDGE QUESTIONNAIRE

EMPLOYEE: The intent of this questionnaire is to provide your employer with knowledge about any pre‐existing medical condition or disability which may entitle your employer to reimbursement from the Louisiana Workers’ Compensation Second Injury Board in the event you suffer an on‐the‐job injury.1 This reimbursement in no way affects the benefits owed to you by your employer or its insurance company under the Louisiana Workers’ Compensation Act. La. R.S. 23:1021‐1361. However, your failure to answer truthfully and/or correctly to any of the question on this questionnaire may result in a forfeiture of your workers’ compensation benefits.

In order for your employer to be considered for reimbursement from the Second Injury Board, it has to show that it knowingly hired or retained you with a pre‐existing medical condition or disability. To establish its knowledge, your employer is requesting that this questionnaire be completed.

INSTRUCTIONS: Please answer ALL questions completely. If a response requires an explanation, please provide a brief description on the Explanation Page. If you have any questions or need help in answering the questions on this form, please ask for assistance from the Employer Representative signing this form.

NOTE: Since this questionnaire contains medical information, you can request that the form be kept CONFIDENTIAL and not made part of your personnel file. Please let your employer know that you want the completed questionnaire placed in a sealed folder for confidentiality purposes.

EMPLOYEE WARNING

FAILURE TO ANSWER TRUTHFULLY AND/OR CORRECTLY TO ANY OF THE QUESTIONS ON THIS FORM MAY RESULT IN A FORFEITURE OF YOUR WORKERS’ COMPENSATION BENEFITS UNDER La. R.S. 23:1208.1.

Employee Signature: _____________________________________________________ Date: _____________

Employer Representative Signature: _________________________________ _______ Date: _____________

Employer Name: ____________________________________________________________________________

Employee Name: ____________________________________________________________________________

Date of Birth (mm/dd/yyyy): ____________ Male: Female:

Soc. Sec. # (last 4 digits only): ____________

Home Address: _____________________________________________________________________________

Telephone Number: ( ____ ) __________________

1 Under La. R.S. 23:1371(A), the purpose of the Second Injury Board is to encourage the employment, re‐employment, or retention of employees who have a permanent partial disability.

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PAGE _____ OF ______

SIB FORM D (10/17)

Disease and Other Medical Conditions you currently have or have ever had. For all conditions that you check yes, write a brief explanation on the Explanation Page. [Please check the appropriate box next to each. Every illness/injury requires a Yes (Y) or No (N) answer.]

Y N Y N Y N Y N

Diabetes Cerebral Palsy Arthritis Heart Disease/Heart Attack Silicosis Tuberculosis Parkinson’s Congestive Heart Failure Varicose Veins Multiple Sclerosis Brain Damage Vision Loss, one or both eyes Asbestosis Post Traumatic Stress Asthma Disability from Polio Hyperinsulinism Osteomyelitis Dementia Psychoneurotic Disability Alzheimer’s Nervous Disorder Thrombophlebitis Ruptured or Herniated Disc Emphysema Muscular Dystropy Arteriosclerosis Ankylosis or Joint Stiffening Hearing Loss Migraine Headaches Hodgkin’s High/Low Blood Pressure COPD Mental Retardation Cancer Carpal Tunnel Syndrome Hypertension Kidney Disorder Double Vision Compressed Air Sequelae Head Injury Loss of Use of Limb Mental Disorders Disease of the Lung Epilepsy Seizure Disorder Hemophilia Coronary Artery Disease Stroke Sickle Cell Disease Bleeding Disorder Heavy Metal Poisoning

Surgical Treatment [Please check the appropriate box. Each illness/injury requires a Yes (Y) or No (N) answer.] For each Yes (Y) answer, please complete the information corresponding to the surgery on the right. Additional information can be provided on the Explanation Page, if necessary.

Y N Spinal Disc Surgery Year (approximate if unsure) ___________

Spinal Fusion Surgery Year (approximate if unsure) ___________

Amputated Foot Left Right Year (approx. if unsure) ___________

Amputated Leg Left Right Year (approx. if unsure) ___________

Amputated Arm Left Right Year (approx. if unsure) ___________

Amputated Hand Left Right Year (approx. if unsure) ___________

Knee Replacement Left Right Year (approx. if unsure) ___________

Hip Replacement Left Right Year (approx. if unsure) ___________

Other Joint Replacement Joint ________________________ Year ________________

Other Surgical Procedure Procedure ___________________ Year ________________




Employee Signature: ________________________________________ Date: _________________________

Employer Representative: ___________________________________ Date: _________________________

2 6

SIB FORM D (10/17)

EXPLANATION PAGE Please use the space below to explain the illnesses and/or conditions that you checked a Yes (Y) or any other medical conditions that may not be listed on this form. Ask your employer for additional copies of this page if needed.

CONDITION: ____________________________________________________ Year Diagnosed (approx): _______________

Are you still treating for this condition? Yes No

Are you taking medication for this condition? Yes No

Do you have any permanent restrictions for this condition? Yes No

Brief Explanation: ___________________________________________________________________________________


















PAGE _____3 OF _____ 6

PAGE _____ OF ______

SIB FORM D (10/17)

Please answer the following questions.

1. Has any doctor ever restricted your activities? Yes No If “Yes,” please list the restrictions: __________________________________________________________Were the restrictions: Permanent ____ Temporary ____Are your activities currently restricted? Yes No What is the medical condition for which you have restrictions? ____________________________________

2. Are you presently treating with a doctor, chiropractor, psychiatrist, psychologist or other health‐careprovider? Yes No

Please list the medical condition being treated: ________________________________________________

Doctor’s Name: ________________________________Specialty: __________________________________

Doctor’s Address: ________________________________________________________________________

3. If you are currently taking prescription medication other than those listed on the Explanation Page, pleasecomplete the requested information below.

Medication: ___________________________________Prescribing Doctor: __________________________

Medication: ___________________________________Prescribing Doctor: __________________________

4. Have you ever had an on the job accident? Yes No If you answered “YES,” please provide the date for each injury and the nature of the injury:

_______________________________________________________________________________________

How long were you on compensation? _________________________

Name of Employer: _______________________________________________________________________

5. Has a doctor recommended a surgical procedure, which has not been completed prior to this date,including but not limited to knee, hip or shoulder replacement? Yes No If you answered YES, please provide:

Recommended surgery: _____________________________________

Approximate date of recommendation: _________________________

Doctor’s Name: ________________________________Specialty: __________________________________

Doctor’s Address: ________________________________________________________________________



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PAGE _____ OF ______

SIB FORM D (10/17)

TO BE COMPLETED BY EMPLOYEE

EMPLOYEE WARNING

FAILURE TO ANSWER TRUTHFULLY AND/OR CORRECTLY TO ANY OF THE QUESTIONS ON THIS FORM MAY RESULT IN A FORFEITURE OF ANY AND ALL WORKERS COMPENSATION BENEFITS UNDER La. R.S. 23:1208.1.

I have completed this form honestly and to the best of my knowledge. I understand that providing false information or omitting pertinent information could result in loss of my workers compensation benefits should I become injured on the job.

Employee Signature: _____________________________________________________ Date: _____________

Employee Printed Name: _____________________________________________________________________

5 6

PAGE _____ OF ______

SIB FORM D (10/17)

TO BE COMPLETED BY EMPLOYER REPRESENTATIVE

EMPLOYER WARNING

PURSUANT TO La. R.S. 23:1208 OF THE LOUISIANA WORKERS’ COMPENSATION ACT, IT SHALL BE UNLAWFUL FOR A PERSON, FOR THE PURPOSE OF OBTAINING OR DEFEATING ANY BENEFIT PAYMENT UNDER THE PROVISIONS OF THIS CHAPTER, EITHER FOR HIMSELF OR FOR ANY OTHER PERSON, TO WILLFULLY MAKE A FALSE STATEMENT OR REPRESENTATION. PENALTIES FOR VIOLATIONS INCLUDE IMPRISONMENT, FINES, AND/OR THE FORFEITURE OF BENEFITS.

You must certify the following:

1. That I am an authorized representative of the employer designated to obtain and review theinformation provided by the employee on this questionnaire;

2. That I have provided the employee with as many copies of the Explanation Page as neededand have confirmed the number of and labeled the pages of this questionnaire;

3. That I have provided assistance to the employee (if requested) in responding to the questionson this questionnaire;

4. That the information sought by this authorization is made on an applicant for employmentonly after a conditional job offer has been made and accepted, or on a current employee; and

5. That the information obtained in the authorization will NOT be used to discriminate in anymanner against the individual who is the subject of this authorization on any basis, in violationof the Americans with Disabilities Act of 1990, 42 U.S.C. §12101, et seq., or any other state orfederal law;

6. That if requested, a photocopy of this fully completed and signed form will be provided tothe employee.

Employer Representative Signature:__________________________________________ Date: _____________

Employer Representative Printed Name: _________________________________________________________

Title: _____________________________________________________________________________________

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