Fillable Form 1: State of Michigan New Hire Reporting (Glen Oaks Community College)

Fill Online, Printable, Fillable, Blank Form 1: State of Michigan New Hire Reporting (Glen Oaks Community College) Form

Use Fill to complete blank online GLEN OAKS COMMUNITY COLLEGE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Form 1: State of Michigan New Hire Reporting (Glen Oaks Community College)

On average this form takes 53 minutes to complete

The Form 1: State of Michigan New Hire Reporting (Glen Oaks Community College) form is 25 pages long and contains:

0 signatures
11 check-boxes
206 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Glen Oaks Community College

BROWSE GLEN OAKS COMMUNITY COLLEGE FORMS

Related forms

Fill has a huge library of thousands of forms all set up to be filled in easily and signed.

Fill in your chosen form

Sign the form using our drawing tool

Send to someone else to fill in and sign.

find another form

Michigan Department of Treasury

Michigan New Hire

3281(Rev. 9-12)

Operations Center

P.O. Box 85010

State of Michigan New Hire Reporting Form

Lansing, MI 48908-5010

Federal law requires public (State and local) and private employers to report all newly hired or rehired employees who are working

Phone: (800) 524-9846

in Michigan to the State of Michigan.

This form is recommended for use by all employers who do not report electronically.

Fax: (877) 318-1659



A newly hired employee is an individual not previously employed by you, and

a rehired employee is an individual who was previously employed by you but

separated from employment for at least 60 consecutive days.



Reports must be submitted within 20 days of hire date (i.e., the date services

are rst performed for pay).



This form may be photocopied as necessary. Many employers preprint employer

information on the form and have the employee complete the necessary

information during the hiring process.



When reporting new hires with special exemptions, please use the MI-W4 form.



Online and other electronic reporting options are available at:

www.mi-newhire.com



Employers who report electronically and have employees working in two or

more states may register as a multi-state employer and designate a single state

to which new hire reports will be transmitted. Information regarding multi-state

registration is available online at: http://www.acf.hhs.gov/programs/cse/

newhire/employer/private/newhire.htm#multi or call

(410) 277-9470.



Reports will not be processed if mandatory information is missing. Such reports

willl be rejected and you must correct and resubmit them.



For optimum accuracy, please print neatly in all capital letters and avoid contact

with the edge of the box. See sample below.

A B C 1 2 3

OPTIONAL

First Name:

Last Name:

Address:

City:

Zip Code:

Date of Birth:

EMPLOYEE Information (Mandatory)

Driver’s License No:

Social Security Number:

Middle Initial:

State:

Hire Date:

OPTIONAL

Employer Name:

Address:

City:

Zip Code:

Contact Name:

Contact Phone:

Contact Email:

EMPLOYER Information (Mandatory)

Federal Employer Identiﬁcation Number (FEIN):

State:

Contact Fax:

Ref: Social Security Act section 453A and the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996 (P.L. 104-193), effective October 1, 1997.

3 8

F A R M I N G T O N P U B L I C S C H O O L S

6 0 0 3 0 5 1

3 2 5 0 0 S H I A W A S S E E

F A R M I N G T O N

M I

4 8 3 3 6

Checking: Savings (No check required):

(Attach a voided check to this Authorization)

Bank Routing No. *Account No. Bank Routing No. *Account No.

_________________ __________________ __________________ ________________

Name____________________________________ Five Byte ID_______________________

Building_____________________________ Date_______________________________

Direct Payroll Deposit Authorization

Employee Information

Financial Institution/Bank Name_________________________________________

Checki

ng:

Savings

(No check required):

(Attach a voided check to this Authorization)

Bank Routing No. *Account No. Bank Routing No. *Account No.

_________________ __________________ __________________ ________________

I authorize Farmington Public schools (FPS) and the bank listed above to deposit my pay automatically to my account

each payday. If funds to which I am not entitled are deposited to my account, I authorize FPS to direct my bank to return

said funds. This authority will remain in effect until I have cancelled in writing. *Please include all numbers on check.

New Setup

Change Existing Setup

Additional Comments/Instructions

Employee’s Signature __________________________________________________

It is the employee’s responsibility to verify that the information provided is accurate. FPS is not liable for any bank fees

incurred.

Return completed form to the Payroll Department

248-489-3312

When requesting a new account setup, please allow 3-5 weeks for your new account

information to be activated.

When requesting a new account setup, please allow 3-5 weeks for your new account

information to be activated.

Rev 2020-07-13

2020-2021

Initial Pay Option Election Form

Name: __________________________________________

Byte #: __________________________________________

Position: __________________________________________

Building/Location: __________________________________________

I elect the following Pay Plan for the current school year:

Teachers and 10-Month Paraprofessionals:

____ 21-Pay Plan

____ 26-Pay Plan (note: all SXI Teachers must elect this plan)

Support Staff:

____ 23-Pay Plan (available only to 10-month Office Employees)

____ 24-Pay Plan (available only to 11-month Traditional employees)

____ 26-Pay Plan (available to all employees, including 10 and 11-month Office Staff)

(note: all 12-month Office, 12-month Paraprofessional and 11-month

Alternate Support Staff must elect this plan)

Signature: __________________________________ Date: ____________

Printed Name: __________________________________

Equal Employment Opportunity Commission (E.E.O.C.)

NAME ___________________________________________________ DATE _________________________

LAST FOUR DIGITS OF SOCIAL SECURITY NO._____________________ BYTE NO.______________

Please answer BOTH parts (A & B)

Part A Are you Hispanic/Latino? (Choose only one)

 No, not Hispanic/Latino

 Yes, Hispanic/Latino (A person of Cuban,

Mexican, Puerto Rican, South or Central American

or other Spanish culture or origin, regardless of race).

Part A of the question is about ethnicity, not race. Regardless of what you selected in Part A,

please

answer Part B by marking one or more boxes to indicate what you consider your race to be.

Part B What is your race? (Choose one or more)

 American Indian or Alaska Native (Not Hispanic or Latino) (A person

having origins in any of the original peoples of North and South American,

including Central America),and who maintain tribal affiliation or community

attachment.

 Asian (Not Hispanic or Latino) (A person having origins in any of the original

peoples of the Far East, Southeast Asia, or the Indian subcontinent including,

for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the

Philippine Islands, Thailand, and Vietnam).

 Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) (A

person having origins in any of the original peoples of Hawaii, Guam, Samoa,

or other Pacific Islands).

 Black or African-American (Not Hispanic or Latino) (A person having origins

in any of the black racial groups of Africa).

 White (Not Hispanic or Latino) (A person having origins in any of the

original peoples of Europe, the Middle East or North America.)

 Two or More Races (Not Hispanic or Latino) – Persons who identify with two

or more racial categories named above.)

 I choose not to respond.

NOTE: Both Parts A and B MUST be completed. We encourage you to select an answer for both parts. If either

part (A or B) is not answered, the U.S. Department of Education requires the school district to supply an answer on

your behalf.

Submission of this form is voluntary and refusal to provide information will not subject you to any adverse

treatment. The information provided will be kept CONFIDENTIAL and will not identify any specific individual.

________________________________________________ ___________________________

SIGNATURE DATE

USCIS

Form I-9

OMB No. 1615-0047

Expires 10/31/2022

Employment Eligibility Verification

Department of Homeland Security

U.S. Citizenship and Immigration Services

Form I-9 10/21/2019

Page 1 of 3

►START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically,

during completion of this form. Employers are liable for errors in the completion of this form.

ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an

employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the

documentation presented has a future expiration date may also constitute illegal discrimination.

Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form I-9 no later

than the first day of employment, but not before accepting a job offer.)

Last Name (Family Name)

First Name (Given Name)

Middle Initial

Other Last Names Used (if any)

Address (Street Number and Name)

Apt. Number

City or Town

State

ZIP Code

Date of Birth (mm/dd/yyyy)

Employee's E-mail Address

Employee's Telephone Number

U.S. Social Security Number

1. A citizen of the United States

2. A noncitizen national of the United States (See instructions)

3. A lawful permanent resident

4. An alien authorized to work until

(See instructions)

(expiration date, if applicable, mm/dd/yyyy):

(Alien Registration Number/USCIS Number):

Some aliens may write "N/A" in the expiration date field.

I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in

connection with the completion of this form.

I attest, under penalty of perjury, that I am (check one of the following boxes):

Aliens authorized to work must provide only one of the following document numbers to complete Form I-9:

An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.

1. Alien Registration Number/USCIS Number:

2. Form I-94 Admission Number:

3. Foreign Passport Number:

Country of Issuance:

QR Code - Section 1

Do Not Write In This Space

Signature of Employee

Today's Date (mm/dd/yyyy)

Preparer and/or Translator Certification (check one):

I did not use a preparer or translator. A preparer(s) and/or translator(s) assisted the employee in completing Section 1.

(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)

I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my

knowledge the information is true and correct.

Signature of Preparer or Translator

Today's Date (mm/dd/yyyy)

Last Name (Family Name)

First Name (Given Name)

Address (Street Number and Name)

City or Town

State

ZIP Code

Employer Completes Next Page

Form I-9 10/21/2019

Page 2 of 3

USCIS

Form I-9

OMB No. 1615-0047

Expires 10/31/2022

Employment Eligibility Verification

Department of Homeland Security

U.S. Citizenship and Immigration Services

Section 2. Employer or Authorized Representative Review and Verification

(Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You

must physically examine one document from List A OR a combination of one document from List B and one document from List C as listed on the "Lists

of Acceptable Documents.")

Last Name (Family Name) M.I.

First Name (Given Name)

Employee Info from Section 1

Citizenship/Immigration Status

List A

Identity and Employment Authorization

Identity

Employment Authorization

OR List B AND List C

Additional Information

QR Code - Sections 2 & 3

Do Not Write In This Space

Document Title

Issuing Authority

Document Number

Expiration Date (if any) (mm/dd/yyyy)

Document Title

Issuing Authority

Document Number

Expiration Date (if any) (mm/dd/yyyy)

Document Title

Issuing Authority

Document Number

Expiration Date (if any) (mm/dd/yyyy)

Document Title

Issuing Authority

Document Number

Expiration Date (if any) (mm/dd/yyyy)

Document Title

Issuing Authority

Document Number

Expiration Date (if any) (mm/dd/yyyy)

Certification: I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee,

(2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the

employee is authorized to work in the United States.

The employee's first day of employment (mm/dd/yyyy):

(See instructions for exemptions)

Today's Date (mm/dd/yyyy)

Signature of Employer or Authorized Representative

Title of Employer or Authorized Representative

Last Name of Employer or Authorized Representative

First Name of Employer or Authorized Representative

Employer's Business or Organization Name

Employer's Business or Organization Address (Street Number and Name)

City or Town

State

ZIP Code

Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.)

A. New Name (if applicable)

Last Name (Family Name)

First Name (Given Name)

Middle Initial

B. Date of Rehire (if applicable)

Date (mm/dd/yyyy)

Document Title Document Number

Expiration Date (if any) (mm/dd/yyyy)

C. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes

continuing employment authorization in the space provided below.

I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if

the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual.

Signature of Employer or Authorized Representative

Today's Date (mm/dd/yyyy)

Name of Employer or Authorized Representative

Driver's License

Social Security

United States

Human Resource Specialist

Farmington Public Schools

32500 Shiawassee

Farmington

48336

LISTS OF ACCEPTABLE DOCUMENTS

All documents must be UNEXPIRED

Employees may present one selection from List A

or a combination of one selection from List B and one selection from List C.

LIST A

2. Permanent Resident Card or Alien

Registration Receipt Card (Form I-551)

1. U.S. Passport or U.S. Passport Card

3. Foreign passport that contains a

temporary I-551 stamp or temporary

I-551 printed notation on a machine-

readable immigrant visa

4. Employment Authorization Document

that contains a photograph (Form

I-766)

5. For a nonimmigrant alien authorized

to work for a specific employer

because of his or her status:

Documents that Establish

Both Identity and

Employment Authorization

6. Passport from the Federated States

of Micronesia (FSM) or the Republic

of the Marshall Islands (RMI) with

Form I-94 or Form I-94A indicating

nonimmigrant admission under the

Compact of Free Association Between

the United States and the FSM or RMI

b. Form I-94 or Form I-94A that has

the following:

(1) The same name as the passport;

and

(2) An endorsement of the alien's

nonimmigrant status as long as

that period of endorsement has

not yet expired and the

proposed employment is not in

conflict with any restrictions or

limitations identified on the form.

a. Foreign passport; and

For persons under age 18 who are

unable to present a document

listed above:

1. Driver's license or ID card issued by a

State or outlying possession of the

United States provided it contains a

photograph or information such as

name, date of birth, gender, height, eye

color, and address

9. Driver's license issued by a Canadian

government authority

3. School ID card with a photograph

6. Military dependent's ID card

7. U.S. Coast Guard Merchant Mariner

Card

8. Native American tribal document

10. School record or report card

11. Clinic, doctor, or hospital record

12. Day-care or nursery school record

2. ID card issued by federal, state or local

government agencies or entities,

provided it contains a photograph or

information such as name, date of birth,

gender, height, eye color, and address

4. Voter's registration card

5. U.S. Military card or draft record

Documents that Establish

Identity

LIST B

OR AND

LIST C

7. Employment authorization

document issued by the

Department of Homeland Security

1. A Social Security Account Number

card, unless the card

includes one of

the following restrictions:

2. Certification of report of birth issued

by the Department of State (Forms

DS-1350, FS-545, FS-240)

3. Original or certified copy of birth

certificate issued by a State,

county, municipal authority, or

territory of the United States

bearing an official seal

4. Native American tribal document

6. Identification Card for Use of

Resident Citizen in the United

States (Form I-179)

Documents that Establish

Employment Authorization

5. U.S. Citizen ID Card (Form I-197)

(2) VALID FOR WORK ONLY WITH

INS AUTHORIZATION

(3) VALID FOR WORK ONLY WITH

DHS AUTHORIZATION

(1) NOT VALID FOR EMPLOYMENT

Page 3 of 3

Form I-9 10/21/2019

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

Refer to the instructions for more information about acceptable receipts.

FARMINGTON PUBLIC SCHOOLS

Michigan Public Act 189 & 397

To provide to the Farmington Public School District information regarding my employment history and, in addition, to disclose

any other information which is job related, including all items within my personnel file and pursuant to Public Act 189 of the

Public Acts of 1996 begin section 380.1230b of Michigan Compiled Laws, I authorize current or former employer(s) to

disclose any unprofessional conduct and provide copies of all documents in my personnel record maintained by my current

or former employer(s) relating to any unprofessional conduct as defined by Public Act 189 of 1996 which states:

“Unprofessional conduct” means one or more acts of misconduct; one or more acts of immorality, moral turpitude, or

inappropriate behavior involving a minor; or commission of a crime involving a minor. A criminal conviction is not an

essential element of determining whether or not a particular act constitutes unprofessional conduct. MCL 380.1230 (8b).

I ac

knowledge the Farmington Public School District’s right to investigate any and all references and secure additional

information regarding my employment history, including any and all disciplinary action and/or the events surrounding the

termination of employment.

Pur

suant to Public Act 189 of 1996, I waive my right of prior notice under the Bullard-Plawecki Employee Right to Know Act,

Act No. 397 of the Public Acts of 1978, being section 423.506 of Michigan Compiled Laws and I hereby release my

current/former employer, and employees acting on behalf of my current/former employer, from any liability for providing

information regarding connection with this employment history verification. I understand that if I am employed after signing

this form, but before the disclosures are received, my continued employment is contingent upon the District’s receipt of

disclosures satisfactory to the District, in its sole discretion.

plicant’s Signature: __________________________________________Date:_________________________

int Name: _________________________________________Social Security # (Last 4 digits): ____________

Please complete this section, providing us with the name and complete address and phone/fax numbers of a

present or immediate past employer. Please print legibly.

Nam

e of Company/School: ____________________________________________________________________

dress: ______________________________________________ Phone: ______________________________

ty: _____________________________ State: _______ Zip: _____________ Fax: _______________________

**To be completed by employer **

Public Act 189 of 1996 requires you to provide the Farmington Public School District with copies of information relating to

unprofessional conduct contained within the above named person’s personnel file with 20 days of the receipt of request.

The Act provides that, “an employer or an employee acting on behalf of the employer that discloses information under the

section in good faith is immune from civil liability for the disclosure.”

ease fax or mail copies of all such documents along with a signed copy of this request to the address listed below. If no

documentation of unprofessional conduct is contained with the personnel file, please note it at the bottom of this form and

return. Maintain one copy for your records. Thank you for your assistance. If you have any questions or concerns, please

contact Dina Ascenzo, HR Specialist at (248) 489-3356.

____ I

certify that no documentation of unprofessional conduct exists within the above named person’s personnel file.

____ I have enclosed items relating to unprofessional conduct.

_______

_________________________ ______________________________ ____________________

Authorized Employer Signature Title Date

_______

_________________________

Print Name

Thank

you.

Kathy Smith, Assistant Superintendent, Human Resources & Talent Development

Farmington Public School District, 32500 Shiawassee, Farmington, MI 48331

Phone: (248) 489-3356 FAX: (248) 489-3318

REASONABLE ASSURANCE OF EMPLOYMENT

ACKNOWLEDGEMENT FORM

During the course of your employment with the district, you will experience

regularly scheduled breaks in work during the school year. These breaks occur

when school is not in session or in recess. At the beginning of each break, you

have a “reasonable assurance” that the same or similar work will be available at

the end of the break or recess. Unless you are notified to the contrary, you

should expect that the reasonable assurance is in place.

I have received, read, and acknowledge this notice.

_____________________________ _________________________

PRINTED NAME DATE

_____________________________

SIGNATURE

8001

GUIDELINE

FARMINGTON PUBLIC SCHOOL DISTRICT

NETWORK REGISTRATION AGREEMENT FOR ALL USERS

I, ______________________________________, a student or employee of Farmington Public School

District, understand and agree to comply with the Network Acceptable Use Policy Terms and Conditions.

Further, I understand, agree and shall comply with the following terms and conditions:

1. The u

se of the District’s network is a privilege and responsible use is required. Some examples of

irresponsible use would include, but not be limited to, unapproved software, unlicensed software, key

logging software or hardware devices, the placing of unlawful information on the system, or

information which conveys an offensive, profane, sexually suggestive message, or harasses or disturbs

by pestering or tormenting, including, but not limited to, intimidation because of a person’s race, color,

religion, gender, sexual orientation or ethnicity in either public or, upon registration of complaint,

private messages or other systems that are accessed through the District’s network. The District will

be the sole arbiter of what constitutes irresponsible use.

2. The District’s network may not be used for conduct or communication that embarrasses, harms or in

any way distracts from the good reputation of the District, its staff, students or any organizations,

groups, or institutions with which the District’s network is affiliated. The District will be the sole

arbiter of what constitutes unacceptable behavior. It also includes illegal or unauthorized entry or

attempt to gain access to another’s files, computers, or computer systems.

3. The D

istrict reserves the right to review any material stored in files to which any users have access and

will edit or remove any material which the District, in its sole discretion, believes may be unlawful, or

constitutes irresponsible use as set forth in paragraph one, above. Any individual, who uses, sends,

receives or stores information via the District’s network has no expectation of privacy associated with

such actions.

4. All i

nformation services and features on the District’s network are intended for educational or

professional use. Any commercial or unauthorized use of those features or services, in any form, is

expressly forbidden.

5. In cons

ideration of the privilege of using the District’s network and in consideration of access to it, I

release the District’s network, its operators and sponsors, the District and its staff, and all organizations,

groups and institutions with which the District is affiliated, from any liability and from any claims I may

have, of any nature, arising from my use, my inability to use and from others’ use of the District’s

network.

6. My access to

the District’s network is subject to such rules and regulations of system usage as may be

established by the administrators of the system, which may be changed from time to time. Violation of

this network agreement may result in disciplinary action.

______________________

______ ___________________________ ____________________________

Signature of Staff Member Signature of Student Signature of Parent/Guardian

(if student is under age 18)

____________________

____________________ ____________________

Date Date Date

cc: Student or Personnel file

Revised 9/18/20

BOARD POLICIES & ADMINISTRATIVE REGULATIONS

CORPORAL PUNISHMENT

NO SMOKING POLICY

POLICY & AR 2003

POLICY & AR 2007

POLICY 6006

POLICY 6007

DRUG FREE WORKPLACE

NOTICE OF NONDISCRIMINATION AND

ANTI-HARASSMENT POLICY

COMPLAINT PROCEDURE FOR HARASSMENT

OR DISCRIMINATION STUDENT OR EMPL

POLICY & AR 8008

COMPLAINT PROCEDURE FOR SEXUAL

HARASSMENT TITLE VI, IX, SECTION 504

EMPLOYEES AND STUDENTS

KEEPING STUDENT RECORDS

SECURE

certify that I have received and am responsible for the contents of the above-

listed Board Policies and Administrative

Regulations material distributed by the

Farmington

Board of Education.

In addition,

acknowledge that

am required to comply with all Board

Policies

and Administrative Regulations available on the District website

www.farmington.k12.mi.us.

(Signature) (Printed Name)

(Date)

9/21/20

AR 8008.1

AR 8008.2

AR 8008.3

FARMINGTON PUBLIC SCHOOLS

NEW HIRE RETIREMENT PLAN ELECTION

PUBLIC SCHOOL EMPLOYEES WHO FIRST WORK ON OR AFTER SEPTEMBER 4, 2012

AND ARE BRAND NEW TO THE PUBLIC SCHOOLS RETIREMENT SYSTEM

I __________________________________________ HAVE RECEIVED THE NEW HIRE RETIREMENT PLAN

(NAME PRINTED)

ELECTION FORM ON__________________________________. I UNDERSTAND IT IS MY RESPONSIBILITY

(DATE RECEIVED)

TO READ OVER THE RETIREMENT INFORMATION I WAS GIVEN AND RETURN WITHIN 75 DAYS FROM

THE DATE OF MY FIRST PAYCHECK. I UNDERSTAND THAT MY DECISION WILL BE RETROACTIVE FROM

THE DATE I RETURN MY PAPERWORK. BY RETURNING THIS FORM AS SOON AS POSSIBLE I WILL AVOID

A LARGE DEDUCTION ON ONE PAY. I UNDERSTAND THAT IF I DO NOT RETURN THIS ELECTION FORM MY

RETIREMENT OPTION WILL DEFAULT TO THE PENSION PLUS PLAN, AND THE SELECTION I DO MAKE IS

IRREVOCABLE.

_________________________________ ______________________

(SIGNATURE) (POSITION)

______________________

(LAST FOUR DIGITS OF SOCIAL)

RI-030 (01/2019)

Michigan State Police

Page 1 of 2

AUTHORITY: MCL 28.162, MCL 28.214, MCL 28.248, & MCL 28.273

COMPLIANCE: Voluntary. However, failure to complete this form will

result in denial of request.

LIVE SCAN FINGERPRINT BACKGROUND CHECK REQUEST

Purpose: To conduct a civil fingerprint-based background check for employment, to volunteer, or for licensing purposes as authorized by law.

Instructions: See page two.

I. Authorizing Information

1. Fingerprint Reason Code

2. Requestor/Agency ID

1837T

3. Agency Name

Farmington Public School District

4. Individual ID (MNU-OA)

II. Applicant Information: Type or clearly print answers in all fields before going to be fingerprinted.

1a. Last Name 1b. First Name

1c. Middle Initial 1d. Suffix

2. Any Alternative Names, Last Names, or Aliases 3.

Social Security Number (Optional)

4. Place of Birth (State or Country) 5. Date of Birth 6.

Phone Number

Driver's License / State ID Number

ssuing State

9. Home Address 10.

Cit

y 11.

tate 12.

ZIP Code

13. Sex 14. Race 15.

eight 16. Weight 17.

Eye Color

18. Hair Color

III. Live Scan Information

1. Date Printed 2.

Picture ID Type Presented

3. Transaction C

ontrol Number (TCN)

Live Scan Operat

or*

* When an individual ID is provided, please enter the ID into the Miscellaneous Number (MNU) field on the Live Scan device. Select OA - Originating

Agenc

y Identifier and then enter the unique identifier in the Identification Code field.

IV. Privacy Act Statement

Authority: Acquisition, preservation, and exchange of fingerprints and associated information by the Federal Bureau of Investigation

(FBI) is generally authorized under 28 U.S.C. 534. Depending on the nature of your application, supplemental authorities include

Federal statutes, State statutes pursuant to Pub. L. 92-544, Presidential Executive Orders, and federal regulations. Providing your

fingerprints and associated information is voluntary; however, failure to do so may affect completion or approval of your application.

Principal Purpose: Certain determinations, such as employment, licensing, and security clearances, may be predicated on

fingerprint-based background checks. Your fingerprints and associated information/biometrics may be provided to the employing,

investigating, or otherwise responsible agency, and/or the FBI for the purpose of comparing your fingerprints to other fingerprints in

the FBI's Next Generation Identification (NGI) system or its successor systems (including civil, criminal, and latent fingerprint

repositories) or other available records of the employing, investigating, or otherwise responsible agency. The FBI may retain your

fingerprints and associated information/biometrics in NGI after the completion of this application and, while retained, your fingerprints

may continue to be compared against other fingerprints submitted to or retained by NGI.

Routine Uses: During the processing of this application and for as long thereafter as your fingerprints and associated

information/biometrics are retained in NGI, your information may be disclosed pursuant to your consent, and may be disclosed

without your consent as permitted by the Privacy Act of 1974 and all applicable Routine Uses as may be published at any time in the

Federal Register, including the Routine Uses for the NGI system and the FBI's Blanket Routine Uses. Routine Uses include, but are

not limited to, disclosures to: employing, governmental or authorized non-governmental agencies responsible for employment,

contracting, licensing, security clearances, and other suitability determinations; local, state, tribal, or federal law enforcement

agencies; criminal justice agencies; and agencies responsible for national security or public safety.

V. Procedure to Obtain a Change, Correction, or Update of Identification Records

If, after reviewing his/her identification record, the subject thereof believes that it is incorrect or incomplete in any respect and wishes

changes, corrections, or updating of the alleged deficiency; he/she should make application directly to the agency which contributed

the questioned information. The subject of a record may also direct his/her challenge as to the accuracy or completeness of any

entry on his/her record to the FBI, Criminal Justice Information Services (CJIS) Division, ATTN: SCU, Mod. D2, 1000 Custer Hollow

Road, Clarksburg, WV 26306. The FBI will then forward the challenge to the agency which submitted the data requesting that agency

to verify or correct the challenged entry. Upon the receipt of an official communication directly from the agency which contributed the

original information, the FBI CJIS Division will make any changes necessary in accordance with the information supplied by that

agency. (28 CFR § 16.34)

VI. Consent

I understand that my personal information and biometric data being submitted by Live Scan, will be used to search against

identification records from both the Michigan State Police (MSP) and the FBI for the purpose listed above. I hereby authorize the

release of my personal information for such purposes and release of any records found to the authorized requesting agency listed

above.

Signature: Date:

RI-030 (01/2019)

Michigan State Police

Page 2 of 2

INSTRUCTIONS

Section I:

Authorizing Information:

This section is to be completed by the agency authorized to request civil fingerprint-based background checks.

Fingerprint Code:

The fingerprint code identifies the authorizing purpose in law allowing the agency to request the civil fingerprint-based

background check. For example, School Employment (SE), Child Protection Volunteer (CPV), Health Care employment

(HC).

Requesting Agency Identification (ID):

The requesting agency ID is assigned to your agency by the MSP. No request for fingerprinting can be completed without an

agency ID. Please ensure the correct fingerprinting reason code and agency Identification is used. The MSP will charge for

second requests due to incorrect codes.

Agency Name:

The agency name is the legal name of the authorized agency. For schools specifically, the agency name is the name

recognized by the Michigan Department of Education.

Individual ID (MNU-OA)

The Individual ID is a unique identifier specific to the individual requested to submit fingerprints. An ID such as a state

issued licensing number, a Personnel Identification Code (PIC) number, or other similar uniquely issued identifier/number.

Section II:

Applicant Information:

This section can be completed by the authorized agency, the individual, or as a joint effort by both. Section II specifically pertains

to the demographic information needed in order to obtain the biometric data of the applicant and is a unique identifier specific to

the applicant.

Section III:

Live Scan Information:

This section is required to be completed by the Live Scan vendor operator and must be completed at the time of fingerprinting.

After fingerprinting, the applicant shall return this signed and completed document to the requesting agency. The Live Scan

operator must return a completed copy of the form to the applicant.

RI-088A (02/2017)

MICHIGAN STATE POLICE

Criminal Justice Information Center

MICHIGAN WAIVER AGREEMENT AND STATEMENT FOR SCHOOLS

An Individual Applicant’s Request for a Fingerprint-Based Criminal History Record Information (CHRI)

Background Check Result for a Qualified Entity in Accordance with the

Michigan School Volunteer & Employee Criminal History Program

Pursuant to the National Child Protection Act (NCPA) of 1993, as amended by the Volunteers for Children Act (VCA),

this form should be completed and signed by every current or prospective employee, volunteer, and contractor/vendor,

for whom criminal history records are requested by a qualified entity (i.e. school or management company) under these

laws.

I hereby authorize (enter name of Qualified Entity)

Farmington Public Schools

to receive the results of my state and federal fingerprint-based CHRI background check result for the purpose of

evaluating and determining my fitness to have responsibility for the safety and well-being of children or individuals with

disabilities. Prior to submitting my fingerprints to the Michigan State Police to conduct a CHRI background check, I will

complete, sign, and return this form and a Livescan Fingerprint Background Check Request form (RI-030). I

understand the Qualified Entity will retain all required documentation for a period of time no less than prescribed by

state or federal laws. By signing this Michigan Waiver Agreement and Statement, it is my intent to authorize the

dissemination of any state and national CHRI that may pertain to me to the Qualified Entity with which I am, or am

seeking to be, employed or to serve as a volunteer, pursuant to the NCPA VCA.

I understand that until the criminal history background check is completed, the Qualified Entity may choose to deny me

unsupervised access to children or individuals with disabilities. I further understand that upon request the Qualified

Entity will provide me a copy of the CHRI background results, if any, and that I am entitled to challenge the accuracy

and completeness of any information contained in such results. I may obtain a prompt determination as to the validity

of my challenge before the Qualified Entity makes a final decision about my status; as an employee, volunteer,

contractor, or subcontractor.

Printed/Typed Name

Date of Birth

Address

City

State

ZIP Code

What is your current or prospective status (check one)?

Employee Volunteer Contractor/Vendor

Have you ever been convicted of a crime?

Yes No

If yes, please provide a description of the crime and the particulars of the conviction.

I understand that I may be asked to assist with obtaining any and all official disposition documentation regarding my conviction.

If you are an employee, prospective employee, or a volunteer of a public school academy, do you authorize release of your CHRI results to another

qualified entity (i.e. school or management company) for a like purpose? If yes, indicate the name of the other qualified entity below.

Yes No

Name of Other Qualified Entity

Signature

Date Signed

ORIGINAL - MUST BE RETAINED BY QUALIFIED ENTITY

AUTHORITY: MCL 28.242

COMPLIANCE: Voluntary; however, failure to complete

this Agreement will result in denial of request.

FARMINGTON PUBLIC SCHOOL DISTRICT

32500 Shiawassee, Farmington MI 48336 Phone: 248.489.3356 Fax: 248.489.3318

CRIMINAL CONVICTION HISTORY FORM

I understand that I have been conditionally offered a position as an employee by the Farmington Public School District,

subject to a fingerprinting / criminal conviction history check and a pre-employment physical.

I understand that the information below is required by the Michigan State Police and FBI, for the criminal conviction history

check. I authorize the Farmington Public School District to utilize this information for the sole purpose of obtaining a

conviction-only history file search.

Name: ____________________________________________________________________________________________

Last First Middle

Maiden Name and/or additional last names used: _________________________________________________________

Date of Birth: ________/______/________ Gender: M / F Race:  Am. Indian/Alaskan Native

(circle one)  Asian/Pacific Islander

 Black/African American

 Hispanic

 White

Driver's License #:________________________________________ State Issued From: ______________________

Position applied for: _______________________________________ Building/Department_____________________

Pursuant to 2005 Public Act 129 & 138, I represent that (you must check one):

______ I have not been convicted of, or pled guilty or nolo contenderes (no contest) to any crimes.

______ I have been convicted of or pled guilty or nolo contenderes (no contest) to the following crimes (use separate

sheet to explain the nature of conviction, date and court):

_____________________________________________________________________________________________

I understand and agree that pursuant to the School Safety Initiative Legislation of 2005:

1. The Board of Education must request a criminal history check on me from the Central Records Division of the

Michigan Department of State Police and FBI for all full time and part time employees, or for any individual who is

assigned to regularly and continuously work under contract in the district’ s schools.

2. Until that report is received and reviewed by the District, I am regarded as a conditional employee; and if the report

received from the Department of State Police or the FBI are not the same as my representation(s) above respecting

either the absence of any conviction(s) or any crimes of which I have been convicted, my employment and/or

employment contract is voidable at the option of the School District.

3. I have been told by an agent of Farmington Public School District that I am to be fingerprinted prior to my first

day of employment. I authorize release of my prints and/or criminal history report received from these prints to

any Michigan public school district personnel department.

4. I have been fingerprinted pursuant to Public Act 129 & 138 for employment with

(Name and address of District

previously printed with)

_____________________________________________________________________________________________

and authorize the release of my prints and/or criminal history report.

______________________________________________ ___________________________________

Signature Date

FARMINGTON PUBLIC SCHOOL DISTRICT

HEPATITIS B

ACCEPTANCE OR DECLINATION STATEMENT

I have been informed about Hepatitis B and the vaccine and at this time I am

choosing:

_____ To accept and complete the vaccination series (3 shots – first shot, then

second shot is 30 days from the first, the third shot is six months from the

first shot.) If you choose to get vaccinated, you must go to the

Concentra location in Novi since they hold our vaccine.

_____ To decline the vaccinated series at the time. I understand that due to my

occupational exposure to blood or other potentially infectious materials, I

may be at risk of acquiring Hepatitis B virus (HBV) infection. I have been

given the opportunity to be vaccinated with the Hepatitis B vaccine, at no

charge to myself. However, I decline Hepatitis B vaccination at this time. I

understand that by declining this vaccine, I continue to be at risk of

acquiring Hepatitis B, a serious disease. If, in the future, I continue to have

occupational exposure to blood or other potentially infectious materials

and I want to be vaccinated with the Hepatitis B vaccine, I can receive the

vaccination series at no charge to me.

Employee Name (print): _______________________________________________________

Employee Signature: _______________________________________________________

Date: _______________________________________________________

BB Hep B Declination form

Special instructions/comments:

_______________________________________________________________________________________________

_______________________________________________________________________________________________________________________________

Authorized by: Title:

______________________________________________________

___________________________________________________________

Please print

Phone:

______________________________________________________________

______________________________________________________

Date

( ___________________________________________________ )

Authorization for Examination or Treatment

Patient Name:

___________________________________________________

Social Security Number:

___________________________________________

Employer:

___________________________________

Date of Birth:

Location Number:

__________________________________________________

Work Related

Physical Examination

Injury

Illness

Preplacement

Baseline

Annual

Exit

Date of Injury

DOT Physical Examination

___________________________________

Special Examination

Breath alcohol

Substance Abuse Testing (check all that apply)

Preplacement

Recertification

Regulated drug screen

Collection only

Hair collect

Asbestos

Respirator

HAZMAT

Medical Surveillance

Audiogram

Human Performance Evaluation

Non-regulated drug screen

Rapid drug screen

_________________

Other

_________________

Other

Preplacement

Reasonable cause

Employee to pay charges

Post-accident

Random

Follow-up

+Due to the nature of these specific services, only the

patient and staff are allowed in the testing/treatment

area. Please alert your employee so that they can make

arrangements for children or others that might otherwise

be accompanying them to the medical center.

Street Address:

___________________________________

Temporary Staffing Agency:

___________________________________

Billing (check if applicable)

Type of Substance Abuse Testing

(Copies of this form are available at www.concentra.com)

(Patient Must Present Photo ID at Time of Service)

Concentra now offers urgent care services for non-work related illness and injury. We accept many insurance plans.

Auth Pad FT CUC.pdf 3/18/09 9:56:47 AM

Farmington Public School District

Claudia Coyle

Human Resources Secretary

248

489-3355

$32 with Lift Test

Ascension Michigan at Work

Employer Authorization

For Treatment/Billing

Date

Employee Name

Job Title/Duties

Employer Farmington Public Schools Phone

Address

Street City State Zip

MINORS MUST BE ACCOMPANIED BY PARENT OR LEGAL GUARDIAN

Injury Care: (Describe)

a.m.

Date of Injury: Time: p.m.

Controlled Substance Test with this injury: Urine Drug Screen Breath Alcohol Test

Patients treated after hours in Urgent Care or Emergency Department should return

for follow-up care at the nearest occupational health office.

Physical Exam (bring eyeglasses and/or contact lenses and case)

Post-offer/Pre-hire

Annual

Return to Work

DOT – new hire

DOT – renewal

Hazmat

MCOLES

Preventative Well Exam

Silica Exam

Other Lift test – Employee to pay charges

Drug and Alcohol Testing (photo identification required)

DOT Urine Drug Screen

DOT Collection Only

DOT Breath Alcohol

Urine Drug Screen

Collection Only

Hair Testing

Breath Alcohol

Reason:

Pre-hire Random Post accident Reasonable Suspicion Return to duty Follow Up Other

Screening/Immunization

Audiogram

Audiogram w/Analysis

EKG

Respirator Questionnaire

TB Test (PPD)

Hepatitis B Vaccination

Hepatitis B Titer

Travel Medicine (Rochester)

Lift Test

Pulmonary Function Test (PFT)

Vision Screen

Hepatitis A Vaccination

Respirator Fit Test (No facial hair. No tobacco, food or drink (except water) one hour prior to test)

Other

AUTHORIZED BY: Claudia Giampa-Coyle 248-489-3355

Phone (Please print)

AUTHORIZED SIGNATURE:

Ascension.org/Michigan

Your Partner in Workplace Health & Wellness

34030-66980-020 REVISED 3/20/19

Ascension Michigan at Work

Locations to Serve Your Workplace

DETROIT/GROSSE POINTE WOODS

Ascension St. John Hospital

19251 Mack Ave., Suite 100

Grosse Pointe Woods, Ml 48326

313-343-3740

• Fax: 313-343-7864

Monday - Friday 7:30 a.m.- 4 p.m.

MADISON HEIGHTS

Ascension Macomb-Oakland Hospital, Madison Heights

27351 Dequindre Rd.

Madison Heights, Ml 48071

248-967-7715

• Fax: 248-967-7716

Monday - Friday 7:30 a.m. - 4 p.m.

EAST CHINA

Ascension River District Hospital

4100 River Rd.

East China, Ml 48054

810-329-8912

• Fax:810-329-8913

Monday - Friday 7:30 a.m.-

p.m.

NOVI

Ascension Providence Hospital, Novi Campus

Outpatient Center, northeast entrance

47601Grand River Ave., Suite B230

Novi, Ml 48374

248-465-4800

• Fax: 248-465-4872

Monday - Friday 7:30 a.m. - 4 p.m.

HOWELL

Ascension Medical Center

1225 S. Latson Rd., Suite130

Howell, Ml 48843

517-338-2370

• Fax: 517-338-2371

Monday - Friday 7:30 a.m. - 4 p.m., after hours injury

care

available in Urgent Ca re daily until 9 p.m. and

holidays

a.rn.-

p.m.

ROCHESTER

Ascension Providence Rochester Hospital

South entrance, second level parking structure

11 0 1 W. University Dr.

Rochester, Ml 48307

248-652-5203

• Fax: 248-652-5128

Monday - Friday 7:30 a.m.- 4 p.m.

LIVONIA

Ascension Providence Health Center

37595 Seven Mile Rd.

Livonia, Ml 48152

734-432-6668

• Fax: 734-542-6108

Monday - Friday 7:30 a.m. - 4 p.m., after hours injury care

available in Urgent Care daily until 10 p .m.

SOUTHFIELD

Ascension Providence Health Pavilion

22255 Greenfield Rd., Suite 422

Southfield, Ml 48075

248-849-3195

• Fax: 248-849-3390

Monday - Friday 7:30 a.m.- 4 p.m.

MACOMB TOWNSHIP

Ascension St. John Hospital Health Center

17700 23 Mile Rd.

Macomb Township, Ml 48044

586-868-9120

• Fax: 586-868-9136

Monday - Friday 7:30 a.m. - 4 p.m.

AFTER HOURS INJURY CARE IS AVAILABLE

IN THE EMERGENCY ROOM AT

ASCENSION MICHIGAN HOSPITALS

Download
Save PDF to desktop

Email
Email completed PDF

Send for Signing
Email for others to sign

Print
Print document

NAME

Form 1: State of Michigan New Hire Reporting (Glen Oaks Community College)

View Audit Log
Print With Audit Log
Duplicate Document

Fillable Form 1: State of Michigan New Hire Reporting (Glen Oaks Community College)

Fill Online, Printable, Fillable, Blank Form 1: State of Michigan New Hire Reporting (Glen Oaks Community College) Form

Related forms

First 20 documents completely FREE!