Mahomet-Seymour CUSD #3 Substitute Packet

Thank you for your interest in subbing for Mahomet-Seymour CUSD #3. Substitute teachers and aides are paid $90 per day when subbing for a regular education teacher, and $95 when subbing for a special education teacher. As per the MSEA contract, (non-certified teacher) subs are not allowed to sub in any one position for more than ten continuous school days. Substitute custodians are paid $14.09 per hour. Substitute secretaries are paid $15.58 per hour. The following items are required to be completed and submitted to the Superintendent’s Office prior to being placed in our substitute database:

• Substitute Authorization Form from the Regional Office of Education. Verification of a teaching, subbing, or

aide License is required. If you do not have a substitute authorization form and/or license, contact the Regional Office of Education at 217/893-3219.

• Substitute teachers will be required to contact the Regional Office of Education for fingerprinting and will be responsible for the fee. Substitute aides, custodians, and secretaries must fill out and return the fingerprint information form. You will not be allowed to substitute until the results of your fingerprint checks are received.

• Health Examination form: Substitute teachers will be required to provide a current physical to the Regional Office of Education. All other substitutes must provide this information directly to the District. A physical form is provided for convenience, but this particular physical form is not required.

• Substitute Application form • Employee Information/Direct Deposit Authorization form. Direct deposit is required. Please attach a

voided check or a letter from your bank showing your routing and account numbers. • Federal and State tax forms • DCFS Mandated Reporter form • Employment Eligibility Verification (I-9) form (See the form instructions for specific ID requirements.) • TRS form: Required for substitute teachers only. • College transcripts are required by School Code. Substitute teachers and aides must provide copies of

all college transcripts.

Please remember that it is necessary to sign in at the school office each day when substituting. This will assure that the office staff is aware of your presence in the building and provides you the opportunity to verify the accuracy of the entry for payroll purposes. You will not complete a time card – the payroll dates page is included in this packet so you have the payroll dates. Teacher and aide substitutes are placed for the District by Aesop. Once you have been entered into the Aesop system, a login and password will be e-mailed to you. If you have any questions, contact the Superintendent’s Office at 217/586-2161.

Revised May, 2016

1301 S. Bulldog Dr., Box 229 Mahomet, IL 61853 Ofc.217-586-2161 Fax 217-586-7591

Mahomet-Seymour Schools Jennifer Farm, Substitute Coordinator

“Committed to Excellence”

2016 - 2017 Mahomet-Seymour CUSD #3

Substitute Application Name_______________________________ SSN _____________________ Address_____________________________ City/Zip _______________________ Phone (Number used to contact for jobs) ____________________________________ E-Mail Address (Required) _______________________________________________

Check the category/categories in which you want, and are qualified, to sub:

Teacher Aide Custodian Secretary

Have you previously worked for Mahomet-Seymour Schools? Yes No

In what position: _________________________________________________

Signature____________________________________ Date________________

Custodians & Secretaries ONLY

1. What days are you available to work? (Please check all that apply.) Monday Tuesday Wednesday Thursday Friday

2. In which buildings are you willing to work?

______Middletown (PreK & K) ______Junior High (6th – 8th) ______Sangamon (1st & 2nd) ______High School (9th – 12th) ______Lincoln Trail (3rd – 5th)

TEACHER and AIDE Subs ONLY

1. Are you a retired teacher? Yes No

Revised 05/2016

Employee Information

________________________________ ______________________________ Name Date of Birth ____________________________________________________________________ Street Address ________________________________ ______________________________ City, State, Zip Home Phone Race/Ethnicity Code (Required by State; enter only one code): ______________ 1 = American Indian/Alaska Native; 2 = Asian; 3 = Black African American; 4 Native Hawaiian/Other Pacific Islander; 5 = White/Non-Hispanic; 6= Hispanic/Latino

________________________________ ______________________________ Spouse’s Name Phone ________________________________ ______________________________ Emergency Contact Name Phone ________________________________ ______________________________ Alternate Emergency Contact Name Phone

Direct Deposit Authorization

NAME __________________________________ SOCIAL SECURITY # _____________________

I hereby authorize Mahomet-Seymour CUSD #3 to initiate credit entries for_______________________________, (Employee’s Name) and to initiate, if necessary, debit entries and adjustments for any credit entries in error to the account indicated below and the financial institution named below, to credit and/or debit the same to such account. NAME OF BANK/CREDIT UNION______________________________________________________ CITY_____________________________________ STATE___________ ZIP CODE_____________ ROUTING #________________________________ ACCOUNT #_____________________________ Personal E-MAIL for Direct Deposit Voucher (REQUIRED) ________________________________________ DEPOSITORY ACCOUNT TYPE: CHECKING_____ SAVINGS_____ I agree to provide to MSCUSD#3 an unused and voided personal check, or a letter from my financial institution containing my account number and their routing number, as verification for depository account stated above. This authority is to remain in full force and effect until MSCUSD#3 has received written notification from me of its termination in such time and in such manner as to afford MSCUSD#3 and my financial institution a reasonable opportunity to act on it.

SIGNATURE______________________________________ DATE______________________________

REQUIRED – Voided check or routing and account number verification from your bank.

9/2014

Mahomet-Seymour CUSD #3

State of Illinois – Dept. of Children & Family Services

ACKNOWLEDGEMENT OF MANDATED REPORTER STATUS I, _________________________________________ understand that when I am working and/or

(Name) volunteering for Mahomet-Seymour CUSD #3 in my official capacity and/or professional: I will become a mandated reporter under the Abused and Neglected Child Reporting Act [325 ILCS 5/4]. This means that I am required to report or cause a report to be made to the child abuse Hotline number (1-800-25A-BUSE) whenever I have reasonable cause to believe that a child known to me in my professional or official capacity may be abused or neglected. I understand that there is no charge when calling the Hotline number and that the Hotline operates 24-hours per day, 7 days per week, 365 days per year. I further understand that the privileged quality of communication between me in my professional or official capacity is not grounds for failure to report suspected child abuse or neglect, I know that if I willfully fail to report suspected child abuse or neglect, I may be found guilty of a Class A misdemeanor. I also understand that if I am subject to licensing under the Illinois Nursing Act of 1987, the Medical Practice Act of 1987, the Illinois Dental Practice Act, the School Code, the Acupuncture Practice Act, the Illinois Optometric Practice Act of 1987, the Illinois Physical Therapy Act, the Physician Assistants Practice Act of 1987, the Podiatric Medical Practice Act of 1987, the Clinical Psychologist Licensing Act, the Clinical Social Work and Social Work Practice Act, the Illinois Athletic Trainers Practice Act, the Dietetic and Nutrition Services Practice Act, the Marriage and Family Therapy Act, the Naprapathic Practice Act, the Respiratory Care Practice Act, the Professional Counselor and Clinical Professional Counselor Licensing Act, the Illinois Speech-Language Pathology and Audiology Practice Act, I may be subject to license suspension or revocation if I willfully fail to report suspected child abuse or neglect. I affirm that I have read this statement and have knowledge and understanding of the reporting requirements, which apply to me under the Abused and Neglected Child Reporting Act. _______________________________________ Signature _______________________________________ Date

Employment Eligibility Verification

Department of Hom.eland Security U.S. Citiz.enship and Immigration Services

USC IS Forml-9

OMB No. 1615-0047 Expin:s 0313112016

... START HERE. Read Instructions camully befora completing this fonn. The Instructions must be available durtng complatlon of this fonn. ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) they will accept from an employee. The refusal to hire 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 Fotm 1-9 no later than the fitSt day of employment, but not before accepting a job offer.)

Last Name (Family Neme) First Name (Given Name) Mlddle lnlUal other Names Used (If any)

Addreaa (strNt Number end Name) Apt. Number City or Town State Zip Code

El Date af Birth (mmldd/Ym) U.S. Social Sea.irtty Nunmer E-mail Addl"BH Telephone Number

[DJ-[[]-[ II IJ I I am aware that federal law provides for Imprisonment and/or ftn• for false 81.at8ments or use of falH documents In connection with the compleUon of this form.

I etlelt, under penalty of perjury, that I am (check one of the followlng):

D A citizen of the United statea

D A noncitizen national of the United States (See inatruction8)

D A lawful pennanent resident (Alien Registration Number/USCIS Number):----------

0 An alien authorized to work until (expiration date, if applicable, mmldd/yyyy) ------. Some allens may write "NIN In this flekl. (See instructions)

For a/feM autholized to WOl1c, provide your Alien Registration Number/USCIS Number OR Fotm 1-94 Admis8ion Number:

1. Allen Registration NumberlUSCIS Number: _________ _

OR 3-D Barcode

Do Not Write In Th .. Space

2. Form 1-94 Admission Number.--------------

If you obtained your admission number from CBP In connection wtth your arrtval In the United States, Include the follO'!Nlng:

Foreign Passport Number:-------------------­

Country of Issuance: ---------------------

Some aliens may write •NJA• on the Foreign Passport Number and Country of Issuance fields. (See in8troctions)

I Signature of Employee: I Date(~: Preparer and/or Translator Certification (To be oomp/flted and signed if Section 1 ;, prepared by a person other than the employee.)

I attest,, under penalty of perjury, that I have anlsted In the complatlon of this form and that to the bast of my knowledge the Information la true and correct.

Signature of Preparer or Translator: I Date(~; Last Name (Femily Name) First Name (Given Name)

Address (Street Number end Neme) City or Town State Zip Code

El Emplnyer Co111JJlda Nat P1111e

Form 1-9 03/08/13 N Pap7of9

Please refer to the "List of Acceptable Documents" that is included at the end of this packet for acceptable forms of identification.

Payroll Officer

Banta Julie Mahomet-Seymour CUSD #3

1301 S. Bulldog Dr. Mahomet IL 61853

Julie Banta, Payroll Officer

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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.

LISTA LISTB LISTC

Documents that Establish Documents that Establish Documents that Establish Both Identity and Identity Employment Authorization

Employment Authorization OR AND

U.S. Passport or U.S. Passport Card 1. Driver's license or ID card issued by a 1. A Social Security Account Number

Permanent Resident Card or Alien state or outlying possession of the card, unless the card includes one of

Registration Receipt Card (Form 1-551) United States provided it contains a the following restrictions: photograph or information such as (1) NOT VALID FOR EMPLOYMENT

Foreign passport that contains a name, date of birth, gender, height, eye

(2) VALID FOR WORK ONLY WITH temporary 1-551 stamp or temporary

color, and address INS AUTHORIZATION

1-551 printed notation on a machine- 2. ID card issued by federal, state or local (3) VALID FOR WORK ONLY WITH readable immigrant visa government agencies or entities, DHS AUTHORIZATION provided it contains a photograph or

Employment Authorization Document information such as name, date of birth, 2. Certification of Birth Abroad issued that contains a photograph (Form gender, height, eye color, and address by the Department of State (Form 1-766) FS-545)

3. School ID card with a photograph 3. Certification of Report of Birth For a nonimmigrant alien authorized

to work for a specific employer 4. Voter's registration card issued by the Department of State because of his or her status: (Form DS-1350)

5. U.S. Military card or draft record a. Foreign passport; and 4. Original or certified copy of birth

b. Form 1-94 or Form 1-94A that has 6. Military dependenrs ID card certificate issued by a State,

the following: 7. U.S. Coast Guard Merchant Mariner county, municipal authority, or territory of the United States

(1) The same name as the passport; Card bearing an official seal and

8. Native American tribal document (2) An endorsement of the alien's 5. Native American tribal document

nonimmigrant status as long as 9. Driver's license issued by a Canadian 6. U.S. Citizen ID Card (Form 1-197) that period of endorsement has government authority not yet expired and the 7. Identification Card for Use of proposed employment is not in For persons under age 18 who are Resident Citizen in the United conflict with any restrictions or unable to present a document States (Form 1-179) limitations identified on the form. listed above:

8. Employment authorization Passport from the Federated States of 10. School record or report card document issued by the Micronesia (FSM) or the Republic of Department of Homeland Security the Marshall Islands (RMI) with Form 11. Clinic, doctor, or hospital record 1-94 or Form l-94A indicating nonimmigrant admission under the 12. Day-care or nursery school record Compact of Free Association Between the United States and the FSM or RM I

Illustrations of many of these documents appear in Part 8 of the Handbook for Employers (M-274).

Refer to Section 2 of the instructions, titled "Employer or Authorized Representative Review and Verification," for more information about acceptable receipts.

Form 1-9 03/08/13 N Page9of9

Statement Concerning Your Employment in a JobNot Covered by Social Security

Your earnings from this job are not covered under Social Security. When you retire, or if you become disabled, youmay receive a pension based on earnings from this job. If you do, and you are also entitled to a benefit from SocialSecurity based on either your own work or the work of your husband or wife, or former husband or wife, yourpension may affect the amount of the Social Security benefit you receive. Your Medicare benefits, however, willnot be affected. Under the Social Security law, there are two ways your Social Security benefit amount may beaffected.

Windfall Elimination ProvisionUnder the Windfall Elimination Provision, your Social Security retirement or disability benefit is figured using amodified formula when you are also entitled to a pension from a job where you did not pay Social Security tax. Asa result, you will receive a lower Social Security benefit than if you were not entitled to a pension from this job. Forexample, if you are age 62 in 2005, the maximum monthly reduction in your Social Security benefit as a result ofthis provision is $313.50. This amount is updated annually. This provision reduces, but does not totally eliminate,your Social Security benefit. For additional information, please refer to Social Security Publication, “WindfallElimination Provision.”

Government Pension Offset ProvisionUnder the Government Pension Offset Provision, any Social Security spouse or widow(er) benefit to which youbecome entitled will be offset if you also receive a Federal, State or local government pension based on workwhere you did not pay Social Security tax. The offset reduces the amount of your Social Security spouse orwidow(er) benefit by two-thirds of the amount of your pension.

For example, if you get a monthly pension of $600 based on earnings that are not covered under Social Security,two-thirds of that amount, $400, is used to offset your Social Security spouse or widow(er) benefit. If you areeligible for a $500 widow(er) benefit, you will receive $100 per month from Social Security ($500 - $400=$100).Even if your pension is high enough to totally offset your spouse or widow(er) Social Security benefit, you are stilleligible for Medicare at age 65. For additional information, please refer to Social Security Publication, “GovernmentPension Offset.”

For More InformationSocial Security publications and additional information, including information about exceptions to each provision,are available at www.socialsecurity.gov. You may also call toll free 1-800-772-1213, or for the deaf or hard ofhearing call the TTY number 1-800-325-0778, or contact your local Social Security office.

I certify that I have received Form SSA-1945 that contains information about the possible effects of theWindfall Elimination Provision and the Government Pension Offset Provision on my potential future SocialSecurity benefits.

Signature of Employee Date

Form SSA-1945 (12-2004)

Employee Name Employee ID#

Employer Name Employer ID#

Information about Social Security Form SSA-1945Statement Concerning Your Employment in a Job Not Covered by Social Security

New legislation [Section 419(c) of Public Law 108-203, the Social Security Protection Act of 2004] requires Stateand local government employers to provide a statement to employees hired January 1, 2005 or later in a job notcovered under Social Security. The statement explains how a pension from that job could affect future SocialSecurity benefits to which they may become entitled.

Form SSA-1945, Statement Concerning Your Employment in a Job Not Covered by Social Security, is thedocument that employers should use to meet the requirements of the law. The SSA-1945 explains the potentialeffects of two provisions in the Social Security law for workers who also receive a pension based on their work ina job not covered by Social Security. The Windfall Elimination Provision can affect the amount of a worker’sSocial Security retirement or disability benefit. The Government Pension Offset Provision can affect a SocialSecurity benefit received as a spouse or an ex-spouse.

Employers must:

• Give the statement to the employee prior to the start of employment;

• Get the employee’s signature on the form; and

• Submit a copy of the signed form to the pension paying agency.

Social Security will not be setting any additional guidelines for the use of this form.

Copies of the SSA-1945 are available online at the Social Security website, www.socialsecurity.gov/form1945.Paper copies can be requested by email at oplm.oswm.rqct.orders@ssa.gov or by fax at 410-965-2037. Therequest must include the name, complete address and telephone number of the employer. Forms will not be sent toa post office box. Also, if appropriate, include the name of the person to whom the forms are to be delivered. Theforms are available in packages of 25. Please refer to Inventory Control Number (ICN) 276950 when ordering.

Form SSA-1945 (12-2004)

Member Information andBeneficiary Designation Form

First Name Middle Initial Last Name Maiden Name Social Security number

Date of birth Gender

Male Female

Home telephone number

( ) Street Address Work telephone number

( )Extension

City Cell phone number

( ) State Zip E-mail address

Member of other Illinois public employee retirement system (specify system’s name)

By completing this form, a TRS member or annuitant designates beneficiaries to receive death benefits. Information provided on this form will become part of the member’s permanent TRS record and will determine distribution of death and survivor benefits. Thisdesignation revokes any prior designation. If this current designation is found to be invalid, the most recent designation on file with TRS will remain in effect. Eligibility is determined by the survivor’s status at the time of the member’s death. Monthly survivor benefits can be paid only to eligible dependent beneficiaries.*

If the automatic designation is selected , do not complete the Beneficiary Refund or Survivor Benefit sections.

Automatic Designation (commonly selected by members with a spouse and/or minor children)

In lieu of designating specific beneficiaries, I elect that my dependent beneficiaries, as determined at my death, receive a beneficiary refund and/or survivor benefits. If no dependent beneficiary survives, benefits will be paid to my estate.

If automatic designation is not selected, you must complete the Beneficiary Refund and Survivor Benefits sections.

Beneficiary Refund Survivor BenefitsPrimary Beneficiaries Primary Beneficiaries

First name Last Date of birth Relationship First name Last Date of birth Relationship

Alternate Beneficiaries Alternate BeneficiariesFirst name Last Date of birth Relationship First name Last Date of birth Relationship

If additional space is required, attach a separate sheet designating primary and alternate persons for Beneficiary Refund and Survivor Benefits. Also include the last four digits of your Social Security number, signature, and date.

No faxed copies accepted. Original signature required.

Member’s signature (mandatory) Date

Signature pursuant to a General Power of Attorney is not accepted by TRS.

*See reverse for more information. 14006012 10/2008

I:\Communications\pub draft\MIBDFinalVersion2.doc

Types of Beneficiaries The member may designate a beneficiary to receive survivor benefits. If this individual is a dependent beneficiary, then he or she is eligible to receive either monthly benefits or a lump-sum payment. However, if the member designates a nondependent beneficiary, only a lump-sum benefit is payable. Monthly benefits cannot be paid to dependent beneficiaries if a nondependent beneficiary is also designated and survives the member.

Dependent beneficiary. A spouse to whom the member has been married for at least one year, except where a child is born of the marriage in which case the qualifying period is not applicable; an unmarried natural or adopted child under 18 or an unmarried child of any age who is dependent by reason of a physical or mental disability and not receiving benefits under Article III of the Illinois Public Aid Code; a dependent parent who received from the member at least half of his or her support for the 12-month period immediately prior to the member’s death; or an unmarried natural or adopted child between the ages of 18 and 22 who is a full-time student in an accredited institution.

Nondependent beneficiary. Any other designated person or entity who is not a dependent beneficiary.

Types of Benefits Beneficiary Refund. This benefit is only payable upon death. The member cannot elect to receive this benefit. This refund includes a return of the member’s retirement contributions, statutorily required interest on the retirement contributions, and member contributions paid toward the annual increases in annuity. This refund is payable: to a designated beneficiary; if no beneficiary is designated, to the surviving spouse; or if no one is designated and there is no surviving spouse, to the member's estate. After retirement, this amount is reduced by the amount of retirement benefit payments made to the member.

Survivor Benefits. A beneficiary is eligible to receive a lump-sum survivor benefit if the member’s death occurs during TRS-covered employment or in the 12-month period immediately following the last day of earnings, while on a creditable leave of absence, or while receiving disability benefits.

A dependent beneficiary may also be eligible to receive monthly survivor benefits if certain requirements are met by the member before death.

Please visit the TRS Web site, trs.illinois.gov, for answers to frequently asked questions or for more copies of this form (fillable online). For instructions on designating a trust, please contact TRS. A Qualified Illinois Domestic Relations Order (QILDRO) on file with TRS when the member dies may affect distribution of survivor benefits. For more information about QILDROs, please consult the QILDRO publication available on the TRS Web site. As with all TRS benefits, death and survivor benefits must be paid in accordance with the Pension Code, 40 ILCS 5/16. If there is any discrepancy between the information on this form and applicable law, the law controls.

Bus Drivers require a DOT Medical Examination

Personal DataMI

State

Health Care Provider Performing the Examination

State

Health HistoryDo you have any of the following? Yes No Do you have any of the following? Yes No

Asthma Diabetes

Weight loss / Weight gain (circle) Palpitations or skipped beats

Fevers Chest pain or tightness

Migraine Headaches Indigestion / Heartburn

Wear lenses or glasses (circle) Abdominal pain

Dizziness / Vertigo Diarrhea / Constipation

Signature              Date

Home Phone

Name of Clinic/Doctor's Office Phone Number

Address City Zip Code

Mobile Phone Work Phone

Address City Zip Code

Date of Birth Age Male or Female

Physical Examination FormMahomet‐Seymour CUSD #3

Last Name First Name Social Security Number

I hereby state that, to the best of my knowledge, my answers are complete and correct.

Ear/Hearing problems Frequent Urinary Tract Infections

Tobacco Use (type, frequency) Kidney stones

Alcohol/Drug Use (type) Back pain

Tiredness or falling asleep Joint pain or swelling

Unable to tolerate heat/cold History of broken bones

Shortness of breath Swelling of the legs

Wheezing Skin (rash, eczema, psoriasis)

Chronic Cough Other (please list)

List any medications you are currently on:

Occupational AssessmentPlease answer the following questions regarding the job for which you have been hired:

Will you be required to wear respiratory protection (e.g. N95 mask or cartridge respirator)?

Do you anticipate working with hazardous chemicals/materials, infectious agents or laboratory animals?

Is there a chance that you will be exposed to human blood or body fluids as a result of routine job duties?

Have you had or are you experiencing discomfort, pain or numbness when working at your desk?

Will you be required to drive a vehicle for any reason?

Will you be required to move heavy objects regularly (>50lbs occasionally or > 25lbs)?

Have you ever had an occupational injury or illness before?

If yes, please explain:

Do you have any condition that would require special accommodations in order to perform your job?

If yes, please explain:

List any allergies you have:

To be completed by employee

Bus Drivers require a DOT Medical Examination

Loss of Consciousness Heart Attack Stroke

Abnormal Heart Rhythm Panic Attacks Seizure

Have you ever had: (Check each) Car Accident Injury

Loss of Vision

Head Injury Mental Health Disorder Back Injury Paralysis

Will any of the above affect your ability to perform your job duties:

Vaccination History / Communicable DiseasesHave you had:

The standard series of childhood vaccinations (to the best of your knowledge)?

The disease "chicken pox" or the chicken pox vaccine (varicella)?

A tetanus / diphtheria booster shot within the last 10 years?

Hepatitis B vaccination (this is a series of three injections spaced several months apart)?

The disease "tuberculosis"?

A positive tuberculosis test (also called a PPD or Tine test)?

Vaccination against tuberculosis with BCG (this is uncommon in the United States)?

Physical ExaminationWeight BMI Pulse

Medical Examination Normal Abnormal Findings

General Appearance

Eyes/Vision

Ears

Nose/Throat

Lymph Nodes

Heart Auscultation

L E t it P l

Height Blood Pressure Respirations Temperature

Lower Extremity Pulses

Nutritional Status

Lungs

Abdomen

Skin

Musculoskeletal ExaminationNeck

Back

Shoulder/Arm

Elbow/Forearm

Wrist/Hand

Hip/Thigh

Knee

Leg/Ankle

Foot

Medical Examiner's Comments on Health History

To be completed by the Medical ExaminerI hereby certify that I have examined the above‐named person. The above information is a complete and accurate record of such an 

examination. I further certify this person to be free from infection and contagious diseases such as tuberculosis as of this date.

DateExamined by (Signature)

Name (Print)Name (Print)

To be completed by physician

FINGERPRINTING - DISCLOSURE AND AUTHORIZATION [IMPORTANT -- PLEASE READ CAREFULLY BEFORE SIGNING AUTHORIZATION]

NOTICE REGARDING BACKGROUND INVESTIGATION

Mahomet-Seymour CUSD #3 (“the School”) may obtain information about you from a consumer reporting agency for purposes of employment, licensure, volunteering, student teaching, or any other contractual services. These reports may contain information regarding your criminal history, motor vehicle records (“driving records”), fingerprint test by state police and/or FBI, or other background checks. You have the right, upon written request made within a reasonable time after receipt of this notice, to request disclosure of the nature and scope of any consumer report. Please be advised that the nature and scope of the most common form of consumer report obtained with regard to applicants, volunteers, and contractors is a fingerprint test and photo recognition by the state police and/or FBI conducted by Bushue Human Resources, Inc., 104 N. Second St., Suite B, Effingham, IL 62401, (217) 342-3042, or toll free at (877) 342-3042, or another outside organization. The scope of this notice and authorization is all-encompassing, however, allowing Mahomet-Seymour CUSD #3 to obtain from any outside organization all manners of consumer reports and investigative consumer reports now and throughout the course of your employment or service to the district to the extent permitted by law.

New York applicants or employees only: You have the right to inspect and receive a copy of any investigative consumer report requested by Mahomet-Seymour CUSD #3 by contacting the consumer reporting agency identified above directly.

ACKNOWLEDGMENT AND AUTHORIZATION I acknowledge receipt of the DISCLOSURE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of those documents. I hereby authorize the obtaining of “consumer reports” and/or “investigative consumer reports” by the School at any time after receipt of this authorization and throughout my employment and/or service, if applicable. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, or insurance company to furnish any and all background information requested by Bushue Human Resources, Inc., 104 N. Second St., Suite B, Effingham, IL 62401, (217) 342-3042, or toll free at (877) 342-3042, another outside organization acting on behalf of Mahomet-Seymour CUSD #3, and/or the School itself. I agree that a facsimile (“fax”), electronic or photographic copy of this Authorization shall be as valid as the original. I am aware and understand that my fingerprints may be retained and will be used to check the criminal history record information files of the Illinois State Police (ISP) and/or the Federal Bureau of Investigation (FBI). In addition I authorize my photo to be taken, submitted to the ISP and/or FBI; photographic images may be shared for licensing and employment purposes only. I further understand that I have the right to challenge any state or federal criminal history record information disseminated from these criminal justice agencies regarding me that may be inaccurate or incomplete.

Last Name ______________________________ First __________________________ Middle _________________Maiden/Other Alias______________________

**Social Security # ___________________________________________**Date of Birth __________________________ Place of Birth (State): _________________

Driver’s License # ____________________________________________ State of Driver’s License ___________ Phone___________________________________

Present Address _________________________________________________ City/State/Zip ________________________________________________________

Signature: ____________________________________________________________ Date: _______________________________________________________

**This information will be used for background screening purposes only and will not be used as hiring criteria.

Gender: ____ Male Race: ____ Asian ____Pacific Islander Height:____________

____ Female ____ Black ____White Hispanic ____ White ____ Other Weight: ___________

Hair Color: ____ Bald ____ Gray Eye Color: ____ Black ____ Gray Skin Tone: ____ Black ____ Light ____ Black ____ Sandy ____ Blue ____ Hazel ____ Medium ____ Olive

____ Blonde ____ Red ____ Brown ____ Other ____ Light Brown ____ Fair ____ Brown ____ Green ____ Dark Brown

Position: ________________________________________

Per Illinois School Code you are entitled to receive a copy of your criminal background check. Would you like to receive this copy? Yes______ No_____

_

Office Use Only: Proof of Identity: DL / State I.D. / Passport / Birth Certificate / SSC / Other: __________________ ORI #: IL010003S or SB0100003

Technician: ______________________________ Technician License #: 249.000 TCN:_______________________________________

Date of Fingerprinting:________________________ Time:________________________ Location:_______________________________________

Payment Type: Cash / Money Order / Credit Card - Last 4 Digits: ___________ Amount: $___________________

Please check: Certified Non-Certified Student Teacher Bus Driver

MAHOMET-SEYMOUR COMMUNITY UNIT SCHOOL DISTRICT #3 2016 - 2017 SCHOOL CALENDAR

August 18 Thursday Institute Day - No Students August 19 August 22

Friday Monday

Institute Day – No Students First Day for Students – FULL DAY ATTENDANCE REQUIRED

September 5 Monday Labor Day - No School September 16 Friday Midquarter – 1st Quarter September 21 Wednesday Early Dismissal October 10 Monday Columbus Day – No School October 14 Friday End of First Quarter October 19 Wednesday Early Dismissal October 20 Thursday Regular Attendance Day, Parent-Teacher Conferences

3:30 - 8:40 PM October 21 Friday No School November 11 November 16

Friday Wednesday

Midquarter – 2nd Quarter & End of 1st Elementary Trimester Early Dismissal

November 22 Tuesday One Hour Early Dismissal November 23-25 Wed.-Fri. Thanksgiving Vacation - No School December 7 Wednesday Early Dismissal December 16 Friday One Hour Early Dismissal December 19 Monday First Day of Winter Vacation January 2 Monday Institute Day - End of Second Quarter, First Semester January 3 Tuesday Classes Resume January 16 Monday M.L. King Birthday Observance - No School January 18 Wednesday Early Dismissal February 10 Friday Midquarter-3rd Quarter February 15 Wednesday Early Dismissal February 17 Friday End of 2nd Elementary Trimester February 20 Monday Presidents’ Day - No School March 8 Wednesday Early Dismissal March 10 Friday End of Third Quarter March 16 Thursday Regular Attendance Day, Parent-Teacher Conferences

3:30 – 8:40 PM March 17 Friday No School March 20-24 Mon.-Fri. No School – Spring Break April 12 Wednesday Early Dismissal April 14 Friday Board Approved Holiday April 21 Friday Midquarter – 4th Quarter May 10 Wednesday Early Dismissal May 26 Friday Last Official Day for Students; End of Fourth Quarter & 3rd

Elementary Trimester, Second Semester – One Hour Early Dismissal

May 29 Monday Memorial Day – No School May 30 Tuesday Institute Day – No Students June 6* Tuesday Last day of school (Teacher Institute) if all 5 emergency

days are used

*Schedule if all 5 Emergency Days are used. Board approved 12/7/2015

2016-2017Payroll Dates

The following are payroll dates, pay period ending dates, and time card due dates.Time cards must be signed by the employee and his/her principal or director.

Please make sure job duty, location, dates (including year) , days and lunch hoursare listed and time card is totaled. If the time card is not filled out correctly, it will be returned.

Time cards & sub sheets must be in the Business Office by 12:00 p.m. on thenext business day following the pay period ending date.

Payroll Date Pay Period Start Date Pay Period End Date Time Cards DueJuly 15th June 12th July 2nd July 5thJuly 29th July 3rd July 16th July 18th

August 15th July 17th July 30th August 1stAugust 30th July 31st August 13th August 15th

September 15th August 14th August 27th August 29thSeptember 30th August 28th September 10th September 12th

October 14th September 11th September 24th September 26thOctober 28th September 25th October 8th October 11th

November 15th October 9th October 22nd October 24thNovember 30th October 23rd November 5th November 7thDecember 15th November 6th November 19th November 21stDecember 16th November 20th December 3rd December 5thJanuary 13th December 4th December 17th January 3rdJanuary 30th December 18th January 14th January 17thFebruary 15th January 15th January 28th January 30thFebruary 28th January 29th February 11th February 13th

March 15th February 12th February 25th February 27thMarch 30th February 26th March 11th March 13thApril 13th March 12th April 1st April 3rdApril 28th April 2nd April 15th April 17thMay 15th April 16th April 29th May 1stMay 30th April 30th May 13th May 15thJune 15th May 14th May 27th May 30thJune 30th May 28th June 10th June 12th

Para información en español, visite www.consumerfinance.gov/learnmore o escribe a laConsumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552.

A Summary of Your Rights Under the Fair Credit Reporting Act

The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy ofinformation in the files of consumer reporting agencies. There are many types of consumerreporting agencies, including credit bureaus and specialty agencies (such as agencies that sellinformation about check writing histories, medical records, and rental history records). Here is asummary of your major rights under the FCRA. For more information, including informationabout additional rights, go to www.consumerfinance.gov/learnmore or write to: ConsumerFinancial Protection Bureau, 1700 G Street N.W., Washington, DC 20552.

• You must be told if information in your file has been used against you. Anyone who uses acredit report or another type of consumer report to deny your application for credit, insurance, oremployment – or to take another adverse action against you – must tell you, and must give youthe name, address, and phone number of the agency that provided the information.

• You have the right to know what is in your file. You may request and obtain all theinformation about you in the files of a consumer reporting agency (your “file disclosure”). Youwill be required to provide proper identification, which may include your Social Securitynumber. In many cases, the disclosure will be free. You are entitled to a free file disclosure if:

• a person has taken adverse action against you because of information in your credit report;• you are the victim of identify theft and place a fraud alert in your file;• your file contains inaccurate information as a result of fraud;• you are on public assistance;• you are unemployed but expect to apply for employment within 60 days.

In addition, all consumers are entitled to one free disclosure every 12 months upon request fromeach nationwide credit bureau and from nationwide specialty consumer reporting agencies. Seewww.consumerfinance.gov/learnmore for additional information.

• You have the right to ask for a credit score. Credit scores are numerical summaries of yourcredit-worthiness based on information from credit bureaus. You may request a credit scorefrom consumer reporting agencies that create scores or distribute scores used in residential realproperty loans, but you will have to pay for it. In some mortgage transactions, you will receivecredit score information for free from the mortgage lender.

• You have the right to dispute incomplete or inaccurate information. If you identifyinformation in your file that is incomplete or inaccurate, and report it to the consumerreporting agency, the agency must investigate unless your dispute is frivolous. Seewww.consumerfinance.gov/learnmore for an explanation of dispute procedures.

• Consumer reporting agencies must correct or delete inaccurate, incomplete, orunverifiable information. Inaccurate, incomplete or unverifiable information must be removed

or corrected, usually within 30 days. However, a consumer reporting agency may continue toreport information it has verified as accurate.

• Consumer reporting agencies may not report outdated negative information. In mostcases, a consumer reporting agency may not report negative information that is more than sevenyears old, or bankruptcies that are more than 10 years old.

• Access to your file is limited. A consumer reporting agency may provide information aboutyou only to people with a valid need – usually to consider an application with a creditor, insurer,employer, landlord, or other business. The FCRA specifies those with a valid need for access.

• You must give your consent for reports to be provided to employers. A consumer reportingagency may not give out information about you to your employer, or a potential employer,without your written consent given to the employer. Written consent generally is not required inthe trucking industry. For more information, go to www.consumerfinance.gov/learnmore.

• You may limit “prescreened” offers of credit and insurance you get based on informationin your credit report. Unsolicited “prescreened” offers for credit and insurance must include atoll-free phone number you can call if you choose to remove your name and address from thelists these offers are based on. You may opt-out with the nationwide credit bureaus at 1-888-567-8688.

• You may seek damages from violators. If a consumer reporting agency, or, in some cases, auser of consumer reports or a furnisher of information to a consumer reporting agency violatesthe FCRA, you may be able to sue in state or federal court.

• Identity theft victims and active duty military personnel have additional rights. For moreinformation, visit www.consumerfinance.gov/learnmore.

States may enforce the FCRA, and many states have their own consumer reporting laws.In some cases, you may have more rights under state law. For more information, contactyour state or local consumer protection agency or your state Attorney General. Forinformation about your federal rights, contact:

TYPE OF BUSINESS: CONTACT:1.a. Banks, savings associations, and credit unions with total assets ofover $10 billion and their affiliates.

b. Such affiliates that are not banks, savings associations, or creditunions also should list, in addition to the CFPB:

a. Consumer Financial Protection Bureau1700 G Street NWWashington, DC 20552

b. Federal Trade Commission: Consumer Response Center – FCRAWashington, DC 20580(877) 382-4357

2. To the extent not included in item 1 above:

a. National banks, federal savings associations, and federal branchesand federal agencies of foreign banks

b. State member banks, branches and agencies of foreign banks (otherthan federal branches, federal agencies, and Insured State Branches ofForeign Banks), commercial lending companies owned or controlled byforeign banks, and organizations operating under section 25 or 25A of theFederal Reserve Act

c. Nonmember Insured Banks, Insured State Branches of ForeignBanks, and insured state savings associations

d. Federal Credit Unions

a. Office of the Comptroller of the CurrencyCustomer Assistance Group1301 McKinney Street, Suite 3450Houston, TX 77010-9050

b. Federal Reserve Consumer Help CenterP.O. Box 1200Minneapolis, MN 55480

c. FDIC Consumer Response Center1100 Walnut Street, Box #11Kansas City, MO 64106

d. National Credit Union AdministrationOffice of Consumer Protection (OCP)Division of Consumer Compliance and Outreach (DCCO)1775 Duke StreetAlexandria, VA 22314

3. Air carriers Asst. General Counsel for Aviation Enforcement & ProceedingsAviation Consumer Protection DivisionDepartment of Transportation1200 New Jersey Avenue, SEWashington, DC 20590

4. Creditors Subject to Surface Transportation Board Office of Proceedings, Surface Transportation BoardDepartment of Transportation395 E Street S.W.Washington, DC 20423

5. Creditors Subject to Packers and Stockyards Act, 1921Nearest Packers and Stockyards Administration area supervisor

6. Small Business Investment Companies Associate Deputy Administrator for Capital AccessUnited States Small Business Administration409 Third Street, SW, 8th FloorWashington, DC 20416

7. Brokers and Dealers Securities and Exchange Commission100 F St NEWashington, DC 20549

8. Federal Land Banks, Federal Land Bank Associations, FederalIntermediate Credit Banks, and Production Credit Associations

Farm Credit Administration1501 Farm Credit DriveMcLean, VA 22102-5090

9. Retailers, Finance Companies, and All Other Creditors Not ListedAbove

FTC Regional Office for region in which the creditor operates orFederal Trade Commission: Consumer Response Center – FCRAWashington, DC 20580(877) 382-4357