fingerprinting requirements hire... · it is the legal requirement of every school district...

Governing Board: Stacy Carlson Pam Lindamood Janet McClean Jay Petrek Randy Walton

Kevin D. Holt, Ed.D. Superintendent

255 Pico Avenue, Suite 250 San Marcos, CA 92069

T 760.752.1299 F 760.752.1138 www.smusd.org

FINGERPRINTING REQUIREMENTS

Assembly Bill 1610 amends Education Code Section 45125 to require that criminal background checks be completed on all applicants for classified employment before they commence work. To adhere to this Education Code, it is necessary that you submit your fingerprints for this criminal background check. FINGERPRINTING PROCEDURE:

1. Fingerprints will be done through the Live Scan procedure at:

San Diego County Office of Education North County Regional Education Center 255 Pico Avenue, Suite 102 San Marcos, CA 92069 Online appointments: http://ims.sdcoe.net/livescan/loc.asp

2. Obtain a money order in the amount of $58.00 (Department of Justice – DOJ Clearance)

payable to the San Marcos Unified School District (SMUSD). Bring your money order to San Marcos Unified School District, Human Resources Department so you can receive the application form “Request for Live Scan Services – Applicant Submission.” Fill out the middle portion of the form and take the original and a copy to Live Scan facility for fingerprint clearance.

3. When your fingerprints have cleared, we will contact you by telephone to schedule an

appointment to process your new hire paperwork.

4. Hiring is contingent upon fingerprint clearance, negative TB results, and completion of all paperwork.

http://ims.sdcoe.net/livescan/loc.asp

SAN MARCOS UNIFIED SCHOOL DISTRICT MEMORANDUM

TO: ALL NEW EMPLOYEES

FROM: HUMAN RESOURCES

RE: TUBERCULOSIS (TB) TESTS

Per Board Policy 4112.4 – no person shall be employed initially unless he/she has submitted to a tuberculosis examination within the past 60 days. It is the legal requirement of every School District employee, regular or substitute, to have a Tuberculosis (TB) test taken in the State of California before they begin work. Certification of a negative skin test is required. If your skin test is positive, a clear X-Ray certification will also be required. Please note that a TB test is a two part process:

1. Skin Test 2. Return in 48 hours for reading

LOCATIONS:

Concentra Medical Center Palomar Health 740 Nordahl Road, Suite 131 120 Craven Road, Suite 207 San Marcos, CA 92069 San Marcos, CA 92069 Phone: 760-432-9000 Phone: 760-510-7373 San Marcos Health Center Escondido Community Clinic 150 Valpreda Rd. 460 N. Elm St. San Marcos, CA 92069 Escondido, CA 92025 Phone: 760-736-6767 Phone: 760-737-2000

You may have your TB test taken at any location of your choosing.

The cost for a TB Skin Test is your responsibility, and the price can vary.

An additional fee may be applicable if it is necessary for you to see a Doctor at the facility. Chest X-Ray costs are separate, and X-Rays are only given when requested by a Doctor. The cost of

Chest X-Rays, if required, is your responsibility.

For your convenience, we have listed a few local facilities below.

SAN MARCOS UNIFIED SCHOOL DISTRICT

Human Resources and Development - August 2015

SHORT TERM EMPLOYEES EMPLOYMENT PACKET CHECK LIST

SUBMISSION CHECK (√) OFF Human Resources must receive proof of the following:

HR USE ONLY

Fingerprint Clearance for San Marcos Unified School District (see attached flyer).

COMPLETE the following documents: (bring these completed documents to your new hire orientation)

SUBMISSION CHECK (√) OFF

REQUIRED FORMS/CERTIFICATES/DOCUMENTS

HR USE ONLY

Employment Application

Emergency Notification

W-4 Form

Employment Eligibility Verification- I-9 Section 1 [1st page]

Notice of Exclusion from Public Employee Retirement System

Beneficiary Designation Form

Oath of Allegiance and Citizenship

Pre-designation of Personal Physician-Workers’ Compensation - Optional

Direct Deposit Form - Optional

Mandated Reporter Training - http://educators.mandatedreporterca.com (Completion Certificate - received by email after completion of online course)

Annual Notification Packet Acknowledgement Form

Workers’ Compensation Benefits – Acknowledgement of Information

Voluntary Information Form – Optional

Reasonable Assurance of Employment

SUBMISSION CHECK (√) OFF

BRING IN THE FOLLOWING

HR USE ONLY

Driver’s License

Signed Social Security Card

Negative TB Test Results (taken within last 60 days)

http://educators.mandatedreporterca.com/

S


T 760.752.1299 F 760.752.1138 www.smusd.org

GENERAL APPLICATION

POSITION APPLIED FOR

First Name Last Name Middle Initial

SSN

Mailing Address

City State Zip

Home Phone Cell Phone E-mail

RECORD OF EDUCATIONAL AND PROFESSIONAL PREPARATION

Name of High School

Highest Grade Completed Graduated GED

1. Name of College/University/School

Major/Field of Study

Semester Units Quarter Units

Attended From To

Degree Awarded




Attended From To

Degree Awarded




Attended From To

Degree Awarded

List languages, other than English, that you are familiar with:

RECORD OF WORK EXPERIENCE

List Most Current Employment First

1. Employer

Date From To

Current Employer Please don’t contact

Address

Name of Immediate Supervisor

Phone

Supervisor Job Title Your Job Title

Hours/Week

Job Duties

Salary Reason for Leaving

Page 1 of 3

2. Employer

Date From To


Address


Phone


Hours/Week

Job Duties


- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

3. Employer

Date From To


Address


Phone


Hours/Week

Job Duties


- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

PROFESSIONAL REFERENCES

1. Name

Organization/Company

Phone E-mail

Title

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

2. Name


Phone E-mail

Title

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

3. Name


Phone E-mail

Title

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Can you perform all essential functions of the position for which you are applying?

Have you ever been employed by the District?

If employed by SMUSD, what years?

Indicate any relatives employed by this district.

Do you have a valid California Drivers’ License?

Driver’s License No.

If you do not have a valid California Drivers’ License, can you acquire one if required for employment?

Page 2 of 3

LEGAL INFORMATION

The following information is REQUIRED for your application to be considered. Your answers will not necessarily disqualify you from

consideration, except for affirmative responses to certain enumerated sex and/or drug convictions and/or convictions for committing serious and/or violent felonies.

EXPLAIN ALL “YES” ANSWERS IN THE BOX BELOW THE QUESTION.

1. Have you ever been convicted of a felony of misdemeanor, or do you currently have a felony or misdemeanor charge pending?Convictions include a plea of guilty, nolo contendere (no contest) and/or a finding of guilty by a judge or a jury. (Note: Excludeconvictions for marijuana-related offenses for more than two years old.)

□ YES □ NO

If “Yes”, list all convictions including, but not limited to convictions for “driving under the influence”, and convictions for sex and/or drug offenses listed in California Education Code Sections 44010 and 44011, except for convictions related to marijuana if it is more than two years after the date of the conviction. Include any serious or violent felony conviction in any state or jurisdiction an enumerated in California Penal Code sections 667.6(c) and 1192.7(c).

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

2. Have you ever been dismissed or asked to resign from any position?

□ YES □ NO

If you answered “YES”, please explain:

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

3. This School District/County Office does not discriminate on the basis of race, color, national origin, age, religion, political affiliation,

gender, mental or physical disability, sex orientation, or any other basis protected by federal, state or local law, ordinance or regulation,in its educational program(s) or employment. No person shall be denied employment solely because of any impairment which isunrelated to the ability to engage in activities involved in the position(s) or program for which application been made.

Will you need any reasonable accommodation to participate in the hiring process?

□ YES □ NO

If you answered “Yes”, please explain.

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

1. My submission of this application authorizes the school to conduct a background investigation and authorizes release of information inconnection with my application for employment. This investigation may include such information as criminal or civil convictions, drivingrecords, previous employers and educational institutions, personal references, professional references, and other appropriate sources. Iwaive my right of access to any such information, and without limitation hereby release the school district/County Office and referencesource from any liability in connection with its release or use. This release includes the sources cited above and specific examples asfollows: The local law enforcement agencies, information from the Central Criminal Records Exchange or either data on all criminalconvictions or certification that no data on criminal convictions are maintained, information from the California or other State Departmentof Social Services Child Protective Services Unit and any locality to which they may refer for release of information to any findings ofchild abuse or neglect investigations involving me.

Furthermore, I certify that I have made true, correct and complete answers and statements on this application in the knowledge that theymay be relied upon in considering my application, and I understand that any omission or falsely answered statement made by me on thisapplication, or any supplement to it will be sufficient grounds for failure to employ or for my discharge should I become employed withthe School District/County Office.

Signature

Page 3 of 3



Human Resources


T 760.752.1299 F 760.752.1138 www.smusd.org

In order to update our personnel records, we request the following information:

MY CURRENT INFORMATION: Date:

Employee Name: Employee Birthdate:

Address:

City:

Zip:

Home Phone Number: Cell Phone Number:

E-mail Address:

EMERGENCY NOTIFICATION

IN CASE OF EMERGENCY NOTIFY:

Name:

Relationship:

Address:

City:

Zip:

Home Phone Number:

Cell Phone Number:

Please update my SMUSD records with this current information

SIGNATURE DATE

In the future, if there are any changes to the above information, please contact the school or department office where you work. They will forward the information to the District Office. Thank you for your cooperation.

}

{

Form W-4 (2015)

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 2015 expires February 16, 2016. 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 cannot claim exemption from withholding if your 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 do not apply to supplemental wages greater than $1,000,000.

Basic instructions. If you are not 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 2015. 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 www.irs.gov/w4.

Personal Allowances Worksheet (Keep for your records.)

A Enter “1” for yourself if no one else can claim you as a dependent . . . . . . . . . . . . . . . . . . A

B Enter “1” if: { • You are single and have only one job; or

• You are married, have only one job, and your spouse does not work; or

• Your wages from a second job or your spouse’s wages (or the total of both) are $1,500 or less.

. . . B

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 $65,000 ($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 $65,000 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

For accuracy, complete all worksheets that apply.

• If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions and Adjustments Worksheet on page 2.

• If you are single and have more than one job or are married and you and your spouse both work and the combined earnings from all jobs exceed $50,000 ($20,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2 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.

Form W-4 Department of the Treasury Internal Revenue Service

Employee's Withholding Allowance Certificate ▶ Whether you are entitled to claim a certain number of allowances or exemption from withholding is

subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.

OMB No. 1545-0074

2015 1 Your first name and middle initial Last name 2 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 1-800-772-1213 for a replacement card. ▶

5 Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2)

6 Additional amount, if any, you want withheld from each paycheck . . . . . . . . . . . . . .

5 6 $

7 I claim exemption from withholding for 2015, 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 . . . . . . . . . . . . . . . ▶ 7 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 Act and Paperwork Reduction Act Notice, see page 2. Cat. No. 10220Q Form W-4 (2015)

http://www.irs.gov/w4

Form W-4 (2015) Page 2 Deductions and Adjustments Worksheet

Note. Use this worksheet only if you plan to itemize deductions or claim certain credits or adjustments to income.1 Enter an estimate of your 2015 itemized deductions. These include qualifying home mortgage interest, charitable contributions, state

and local taxes, medical expenses in excess of 10% (7.5% if either you or your spouse was born before January 2, 1951) of your income, and miscellaneous deductions. For 2015, you may have to reduce your itemized deductions if your income is over $309,900 and you are married filing jointly or are a qualifying widow(er); $284,050 if you are head of household; $258,250 if you are single and not head of household or a qualifying widow(er); or $154,950 if you are married filing separately. See Pub. 505 for details . . . . 1 $

2 Enter: { $12,600 if married filing jointly or qualifying widow(er)$9,250 if head of household . . . . . . . . . . .$6,300 if single or married filing separately

} 2 $

3 Subtract line 2 from line 1. If zero or less, enter “-0-” . . . . . . . . . . . . . . . . 3 $4 Enter an estimate of your 2015 adjustments to income and any additional standard deduction (see Pub. 505) 4 $5 Add lines 3 and 4 and enter the total. (Include any amount for credits from the Converting Credits to

Withholding Allowances for 2015 Form W-4 worksheet in Pub. 505.) . . . . . . . . . . . . 5 $6 Enter an estimate of your 2015 nonwage income (such as dividends or interest) . . . . . . . . 6 $7 Subtract line 6 from line 5. If zero or less, enter “-0-” . . . . . . . . . . . . . . . . 7 $8 Divide the amount on line 7 by $4,000 and enter the result here. Drop any fraction . . . . . . . 89 Enter the number from the Personal Allowances Worksheet, line H, page 1 . . . . . . . . . 9

10 Add lines 8 and 9 and enter the total here. If you plan to use the Two-Earners/Multiple Jobs Worksheet, also enter this total on line 1 below. Otherwise, stop here and enter this total on Form W-4, line 5, page 1 10

Two-Earners/Multiple Jobs Worksheet (See Two earners or multiple jobs on page 1.)Note. Use this worksheet only if the instructions under line H on page 1 direct you here.1 Enter the number from line H, page 1 (or from line 10 above if you used the Deductions and Adjustments Worksheet) 12 Find the number in Table 1 below that applies to the LOWEST paying job and enter it here. However, if

you are married filing jointly and wages from the highest paying job are $65,000 or less, do not enter more than “3” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

3 If line 1 is more than or equal to line 2, subtract line 2 from line 1. Enter the result here (if zero, enter “-0-”) and on Form W-4, line 5, page 1. Do not use the rest of this worksheet . . . . . . . . . 3

Note. If line 1 is less than line 2, enter “-0-” on Form W-4, line 5, page 1. Complete lines 4 through 9 below to figure the additional withholding amount necessary to avoid a year-end tax bill.

4 Enter the number from line 2 of this worksheet . . . . . . . . . . 45 Enter the number from line 1 of this worksheet . . . . . . . . . . 56 Subtract line 5 from line 4 . . . . . . . . . . . . . . . . . . . . . . . . . 67 Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here . . . . 7 $8 Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed . . 8 $9 Divide line 8 by the number of pay periods remaining in 2015. For example, divide by 25 if you are paid every two

weeks and you complete this form on a date in January when there are 25 pay periods remaining in 2015. Enter the result here and on Form W-4, line 6, page 1. This is the additional amount to be withheld from each paycheck 9 $

Table 1Married Filing Jointly

If wages from LOWEST paying job are—

Enter on line 2 above

$0 - $6,000 06,001 - 13,000 1

13,001 - 24,000 224,001 - 26,000 326,001 - 34,000 434,001 - 44,000 544,001 - 50,000 650,001 - 65,000 765,001 - 75,000 875,001 - 80,000 980,001 - 100,000 10

100,001 - 115,000 11115,001 - 130,000 12130,001 - 140,000 13140,001 - 150,000 14

150,001 and over 15

All Others

If wages from LOWEST paying job are—


$0 - $8,000 08,001 - 17,000 117,001 - 26,000 226,001 - 34,000 334,001 - 44,000 444,001 - 75,000 575,001 - 85,000 685,001 - 110,000 7

110,001 - 125,000 8125,001 - 140,000 9140,001 and over 10

Table 2Married Filing Jointly

If wages from HIGHEST paying job are—


$0 - $75,000 $60075,001 - 135,000 1,000

135,001 - 205,000 1,120205,001 - 360,000 1,320360,001 - 405,000 1,400405,001 and over 1,580

All Others

If wages from HIGHEST paying job are—


$0 - $38,000 $60038,001 - 83,000 1,00083,001 - 180,000 1,120

180,001 - 395,000 1,320395,001 and over 1,580

Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this form to carry out the Internal Revenue laws of the United States. Internal Revenue Code sections 3402(f)(2) and 6109 and their regulations require you to provide this information; your employer uses it to determine your federal income tax withholding. Failure to provide a properly completed form will result in your being treated as a single person who claims no withholding allowances; providing fraudulent information may subject you to penalties. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation; to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their tax laws; and to the Department of Health and Human Services for use in the National Directory of New Hires. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism.

You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by Code section 6103.

The average time and expenses required to complete and file this form will vary depending on individual circumstances. For estimated averages, see the instructions for your income tax return.

If you have suggestions for making this form simpler, we would be happy to hear from you. See the instructions for your income tax return.

Priscilla

Personnel Data Technician

San Marcos Unified School DistrictMadrid Lopez

255 Pico Ave., Ste. 250 San Marcos CA 92026

, ,

California Public Employees’ Retirement System www.calpers.ca.gov

NOTICE OF EXCLUSION FROM CalPERS MEMBERSHIP

1. SOCIAL SECURITY NUMBER Your employer has contracted with the California Public Employees’ Retirement System (CalPERS) to provide an employee benefit package which includes service retirement, death, and disability benefits.

2. CURRENT NAME (LAST) (FIRST) (MIDDLE)

3. NAME OF PUBLIC AGENCY 4. DEPARTMENT OR SCHOOL DISTRICT 5. JOB OR POSITION TITLE

6. TERM OF APPOINTMENT

PERMANENT TEMPORARY

7. IF TEMPORARY, ENTER NEAREST NUMBEROF WHOLE MONTHS THE APPOINTMENT ISEXPECTED TO LAST.

MONTHS

8. APPOINTMENT DATEMM DD YYYY

9. TIME BASE

FULL-TIME INDETERMINATE PART-TIME IF PART TIME, ENTER THE FRACTION OF FULL TIME:

In your present position with this agency, you are excluded from CalPERS membership because:

1. Your full-time seasonal or limited term appointment is limited to 6 months or less.

2. Your part-time appointment is limited to less than an average of 20 hours per week for less thanone year.

3. Your appointment is an on-call, intermittent, emergency, substitute, or other irregular basis whichexcludes you from membership until you have worked 1,000 hours (or 125 days if paid on perdiem basis) this fiscal year.

4. Your position is excluded by law or by contract agreement which excludes:

5. You are an independent contractor.

6. You are employed to render professional legal service to a city.Exceptions: Persons holding the office of city attorney, deputy city attorney, or assistant city attorney.

7. You are employed as a student aide by a school district in a position established for studentsonly and you are attending school in the same district (for County Schools only).

NOTE: If you are a member of CalPERS by previous employment (either you have funds on deposit or service credit), exclusions 1, 2, and 3 do not apply to you and you should be a member in your present position. Be sure to notify your employer to complete a (PERS-1) Member Action Request Form or appoint via ACES to report your employment to CalPERS.

If you believe that your employment does qualify you for CalPERS membership, ask your employer for an explanation. If you still have doubts, you may appeal directly to CalPERS by sending a letter to the Actuarial & Employer Services Branch, Membership Analysis & Design Unit, P.O. Box 942709, Sacramento, CA 94229-2709, stating the reasons why you feel you should be a member.

SIGNATURE OF CERTIFYING OFFICER TITLE DATE

SIGNATURE OF EMPLOYEE DATE

NOTE: Benefits provided by CalPERS are described in the “CalPERS Benefits” information booklet available from your employer.

PERS-AESD-139 (3/08)

Enter contract exclusion (for Public Agencies only).

SAN MARCOS UNIFIED SCHOOL DISTRICT

EMPLOYEE’S DESIGNATION OF BENEFICIARY UNDER GOVERNMENT CODE SECTION 53245*

INSTRUCTIONS: Please complete this form and return it to the Human Resources Department.

From: XXX-XX- Employee Name Social Security Number (Last 4 numbers only)

To: SMUSD Human Resources & Development Department

Re: Designation of Person to Receive and Negotiate Warrants After Death Under Government Code Section 53245

This is to inform you that in the event of my death, I hereby designate:

Name of Designee

as the person entitled to receive and negotiate all warrants or checks that will be payable to me from the Superintendent of Schools, San Diego County Office of Education.

This designee is: □ Husband □ Wife □ Parent □ Child □ Other

He/she may be identified as follows:

XXX – XX - Date of Birth Place of Birth Social Security Number

(Last 4 numbers only)

Address, this date:

I understand that it is my responsibility to keep this designation current, and further, I understand that the designation is in addition to, and separate from, the beneficiary designation filed with the State Teachers’ Retirement System, the Public Employees’ Retirement System, the County Employees’ Retirement System, or in any other will, codicils or like documents.

Date Filed Signature

*Government Code, Section 53245

“Any person now or hereafter employed by a county, city, municipal corporation, district or other public agency may file with his appointing power a designation of a person who, notwithstanding any other provision of law, shall, on the death of the employee, be entitled to receive all warrants or checks that would have been payable to the decedent had he survived. The employee may change the designation from time to time. A person so designated shall claim such warrants or checks from the appointing power. On sufficient proof of identity, the appointing power shall deliver the warrants or checks to the claimant. A person who received a warrant or check pursuant to this section is entitled to negotiate it as if he were the payee.”

OATH OF ALLEGIANCE AND CITIZENSHIP

FOR PERSONS EMPLOYED BY A SCHOOL DISTRICT

OF THE STATE OF CALIFORNIA

(Required by Section 3107 Title 1 Government Code)

(State of California, County of San Diego)

I, do solemnly swear (or affirm) that I will support and

defend the Constitution of the United States of American and the Constitution of the

State of California against all enemies, foreign and domestic; that I will bear true faith

and allegiance to the Constitution of the United States and the Constitution of the State

of California; that I take this obligation freely, without any mental reservation or purpose

of evasion and that I will well and faithfully discharge the duties upon which I am about

to enter.

Signature of Employee

Taken, subscribed and sworn to before me this_____ day of ______________, 20____.

Signature of Authorized Official

Title San Marcos Unified School District San Marcos, CA 92069

ss

Personnel Data Technician

PREDESIGNATION OF PERSONAL PHYSICIANIn the event you sustain an injury or illness related to your employment, you may be treated for such injury or illness by your personal medical doctor (M.D.), doctor of osteopathic medicine (D.O.) or medical group if:

on the date of your work injury you have health care coverage for injuries or illnesses that are not workrelatedthe doctor is your regular physician, who shall be either a physician who has limited his or her practice ofmedicine to general practice or who is a board-certified or board-eligible internist, pediatrician,obstetrician-gynecologist, or family practitioner, and has previously directed your medical treatment, andretains your medical records;your “personal physician” may be a medical group if it is a single corporation or partnership composed oflicensed doctors of medicine or osteopathy, which operates an integrated multispecialty medical groupproviding comprehensive medical services predominantly for nonoccupational illnesses and injuries;prior to the injury your doctor agrees to treat you for work injuries or illnesses;prior to the injury you provided your employer the following in writing: (1) notice that you want yourpersonal doctor to treat you for a work-related injury or illness, and (2) your personal doctor's name andbusiness address.

You may use this form to notify your employer if you wish to have your personal medical doctor or a doctor of osteopathic medicine treat you for a work-related injury or illness and the above requirements are met.

NOTICE OF PREDESIGNATION OF PERSONAL PHYSICIAN Employee: Complete this section.

To: ____________________________ (name of employer) If I have a work-related injury or illness, I choose to be treated by:_________________________________________________________________ (name of doctor)(M.D., D.O., or medical group)_________________________________________________________________ (street address, city, state, ZIP)

__________________________________________________ (telephone number)

Employee Name (please print): _____________________________________________________________________________________________

Employee's Address:_____________________________________________________________________________________________

Name of Insurance Company, Plan, or Fund providing health coverage for nonoccupational injuries or illnesses:

Employee's Signature ________________________________Date: __________

Physician: I agree to this Predesignation:

Signature: _________________ ___________________________Date: __________(Physician or Designated Employee of the Physician or Medical Group)

The physician is not required to sign this form, however, if the physician or designated employee of the physician or medical group does not sign, other documentation of the physician's agreement to be predesignated will be required pursuant to Title 8, California Code of Regulations, section 9780.1(a)(3).

Title 8, California Code of Regulations, section 9783.

- OPTIONAL -

DIRECT DEPOSIT AUTHORIZATION

PRINT or TYPE

Name ______________________________________ Social Security No./employee iD No. ____________________

DiStrict ___________________________________ work Site ______________________________________________

i hereby authorize the above named District and the San Diego county office of education (SDcoe) and/or thier agents, to initiate electronic deposits via the automated clearing House (acH) and, as necessary, debit corrections to previous deposits, to the folowing account(s).

I understand:

• Directdepositstatusisnotactivateduntilmyregularpayrollcyclefollowinga$0testtransaction(approx.30days).• ImustsubmitanewauthorizationformifIclose/changemyaccount(name,branch,,etc.);failuretodosomayresultinadepositdelay.• Directdepositstatuswillbetemporarilysuspendedifwagesaregarnishedand/ortheCredentialsUnit,SDCOE,placesaholdonthewarrant.• Itismyresponsibilitytokeepapprisedofanydeposit(s)madetomyaccount(s)includingdatesandamountsofanysuchdeposit(s).

i agree to hold harmless and indemnify the District and SDcoe and their officers, employees and agents from any claim or demand of whatever nature, includingthosebaseduponnegligenceoftheDistrictandSDCOEandtheirofficers,employees,andagentsforfailureordelayinmakingdepositsand/orcorrections to deposits as herein authorized.

this authorization replaces any previously made by me and is to remain in effect until changed or canceled by submission of a new Direct Deposit authorization form.

Signature: _______________________________________________________________ Date: __________________________________________

Name of Financial institution _________________________________________________________________________________________________

address of Financial institution _______________________________________________________________________________________________

Financial institution transit routing No.

IF DEPOSITING TO A CHECKING/SHARE DRAFT ACCOUNT, ATTACH A VOIDED CHECK TO THIS FORM.IF DEPOSITING TO A SAVINGS ACCOUNT, FINANCIAL INSTITUTION PROVIDES TRANSIT ROUTING NUMBER.

DEPOSIT INSTRUCTIONS: q New ACH Set Up q ACH Amount Change q ACH Cancellation (Prenote Needed) (No Prenote needed)

Checking

NetCheck,or

$________________

CheckingAccountNumber

Savings

NetCheck,or

$________________

Savings account Number

ATTAch voIdEd blANk

chEck hERE

if required

Jane A. Doe1000 Main St.Anywhere, U.S.A. 10001

__________________20_____PAy to the orDer of____________________________________________________________$________________

_______________________________________________________________________________ DollArS

MeMo____________________________ ____________________________________________________

transit routing No. Account No. Check No.

Form 224 - BuSSDCOE11/08

white - Districtyellow - employee

- OPTIONAL -




T 760.752.1299 F 760.471.4928 www.smusd.org

AB 1432 – California Educator: Mandated Reporter Training

As an employee of the San Marcos Unified School District, you are considered a mandated child abuse reporter. The Child Abuse and Neglect Reporting Act requires a mandated reporter, which includes a teacher or one of certain other types of school employees, to report whenever he or she, in his or her professional capacity or within the scope of his or her employment, has knowledge of or has observed a child whom the mandated reporter knows or reasonably suspects has been the victim of child abuse or neglect.

The State Department of Education, in consultation with the Office of Child Abuse Prevention in the State Department of Social Services, has developed an online training module for all persons required to receive the training, and to provide proof of completing the training.

Upon successful completion of the training, you will receive an email with your Certificate.

PLEASE BRING IN YOUR COMPLETION CERTIFICATE TO HUMAN RESOURCES WHEN YOU BRING IN YOUR NEW HIRE PACKET

As a District employee, you are required to complete the Mandated Reporter Training once each school year.

To complete the training, please visit the following website:

http://educators.mandatedreporterca.com

http://educators.mandatedreporterca.com/

_____________________________________ Employee Name (please print)

_____________________________________ __________________ Employee Signature Date

on the San Marcos Unified School District website: www.SMUSD.org

I understand how to access and have reviewed the district policies / documents listed above

SMUSD POLICY ACKNOWLEDGEMENT

I understand that I am legally obligated to review the following:

Access the SMUSD website at: www.SMUSD.org

1. Go to “DEPARTMENTS”2. Click on “Human Resources”3. Click on “Non-Classified,

Substitute Classified,Short Term Personnel” on theleft side of the page

4. SCROLL DOWN to “Documentsand Forms for SHORT-TERM

NEW HIRES ONLY 5. Click on:

New Hire Packet Annual Notification Package Employee Handbook Mandated Reporter Training Safety Manual

Annual Notification Package Employee HandbookMandated Reporter Training Safety Manual



Human Resources


T 760.752.1299 F 760.752.1138 www.smusd.org

HUMAN RESOURCES

VOLUNTARY INFORMATION FORM

Section 1233 of the California Government Code permits public employers to solicit from employees and applicants a voluntary declaration of sex and racial/ethnic group membership. Information provided will assist the San Marcos Unified School District (SMUSD) in accurately compiling required statistical reports for federal and state agencies. None of the information will be used to discriminate against or give preference to any individual in any personnel transaction. Other information requested is for the SMUSD use only and is also voluntary.

PLEASE PRINT

Full legal name:

Position:

Birthdate: Gender:

School site/Work location:

The following questions are required to be in compliance with new Federal/State laws. Please mark the appropriate area:

Ethnic Background: Are you Hispanic or Latino? □ NO □ YES

Please continue to answer the following by marking one or more to indicate your race:

□Alaskan Native □Chinese □Hmong □Other Asian □Vietnamese

□American Indian □Filipino □Japanese□Other Pacific

Islander □White

□Black/African

American □Guamanian □Korean □Samoan

□Cambodian □Hawaiian □Laotian □Tahitian