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Full-Time Full_Time-V1-ADA Compliant

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Instructions for Completing New Hire Paperwork – Full-time
Keep this form for your use – do not submit to Human Resources
Please use black or blue ink. Following is a list of all forms included in this packet. Please have all forms filled out
completely before coming in to meet with Human Resources for your orientation. Please call the Benefits Department
at 229.430-4623 if you have any questions prior to submitting your paperwork.
Employee Acknowledgements
Please read the Employee Acknowledgements information, and complete and sign the Acknowledgement form in the
spaces indicated.
Personal Data Sheet
The address you list will be entered into the HR and Payroll system (ADP) for University mailings, tax and insurance
records. Please make sure your address is always current and up to date in the HR and Payroll system.
W-4 Federal Tax Withholding Form
Complete and sign the lower portion of the form. Completion of the worksheet portion of this form is not required.
Note that the HR office cannot advise you on the number of allowances you should claim for tax withholding. Please
consult a tax advisor if you are unsure about the number of allowances you should claim to meet your needs.
G-4 State of Georgia Tax Withholding Form
Complete and sign the form. Completion of the worksheet is not required. Note the HR office cannot advise you on
the number of allowances you should claim for tax withholding. Please consult a tax advisor if you are unsure about
the number of allowances you should claim to meet your needs.
I-9 Employment Eligibility Verification Form
Please complete Section 1 only. A staff member from HR will complete and authorize the I-9 after you present the
appropriate documentation from the “List of Acceptable Documents”. This list has been included with the I-9 form.
You will need to present one (1) document from ‘List A’ OR one (1) document from ‘List B’ AND one (1) document
from ‘List C’ reflected on the “List of Acceptable Documents”.
Direct Deposit
The Board of Regents passed policy 7.5.1.1. This policy requires the use of direct deposit for all payroll-related
payments. All employees who are receiving their pay will be required to enroll in direct deposit. You must attach a
voided check or bank documentation that has your bank routing and account numbers on it. No counter checks (checks
without pre-printed name, address, city/state & zip information) or checking/savings deposit forms, will be accepted)
Right to Know
Please review the “Right to Know” information on line. After completion, print your Right to Know Certificate and bring
it to HR along with the attached paperwork.
ID card Authorization, Computer Access and E-mail Account Set-up and Ethics Training
All faculty will obtain their RAM ID from the Office of Academic Affairs. Your e-mail account with your username and
password will already have been set-up with OIIT. You will report to OIIT to obtain a username and password to access
computers on campus and to have your ID card made. This office is located in the James E. Pendergrast Library on the
1
st
Floor. There is not a charge for initial employee ID cards.
Revised: June 6, 2018
Regular staff’s information will be entered into the Banner System by HR Personnel following New Hire Orientation.
New employees must be in Banner to have an ID card made and to purchase a decal for parking. After your
orientation with HR, you will then need to take the “Active Directory and Email Access Request Form (AND) the
Desire2Learn Account Access Request form to the OIIT Department, to have your e-mail account set up, to obtain a
username and password to access computers on campus, to have your ID card made and to gain access to the complete
your Ethics Training. This office is located in the James E. Pendergrast Library on the 1
st
Floor. There is not a charge for
initial employee ID cards.
Parking Authorization
After your meeting with HR, you will be required to purchase your parking decal by following the instructions provided that
are enclosed in this packet. You must have your RAM ID Number to register your vehicle and purchase a parking permit.
You will also need vehicle information, including the license plate number. Any questions regarding parking on campus
should be directed to the ASU Police Department at 229.430-4711.
Mandatory Retirement Plan
All employees are required to participate in either the Teachers Retirement System of Georgia plan or the Optional
Retirement plan. If you are a bi-weekly paid employee, you are required to enroll in the Teachers Retirement System of
Georgia plan. If you are a monthly paid employee, you may choose between the Teachers Retirement System of Georgia
plans OR to enroll into the Optional Retirement plan.
Full Name: Signature: Date:
Revised: June 6, 2018
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Orientation Checklist – Full Time Regular/with Benefits
Faculty Position Staff Position
(Note: Employee must sign and return all documents below to HR)
Document Name
✓
Employment Documentation
Personal & Emergency Contact Form(s)
New Staff Information Form(s) (Note: Do not Sign if you are Faculty)
Outside Employment Form (Note: Complete if you are employed outside of ASU)
Federal (W-4) Withholding Form
State (G-4) Withholding Form
I-9 Employment Eligibility Form (Note: Include all required I-9 documents and submit within 3 days of employment)
BOR Security Questionnaire (Note: Must be Notarized by Notary)
Outstanding Wages Beneficiary Form (Note: Must be Notarized by Notary)
Direct Deposit Form (Note: Voided Check/ACH Deposit form required)
Background Check Form
Retirement Benefit Documentation
TRS Application Form ORP Enrollment Form
Board of Regents TRS/ORP Retirement Election Form
Optional Retirement Plan Certificate 60 Day Election Form
Retirement Participation Questionnaire Form
Policy Acknowledgements
Equal Opportunity Employer
Faculty and Staff Handbook Acknowledgement Statement
Classified Employment (Note: Do not Sign if you are Faculty)
Provisional Appointment (Note: Do not Sign if you are Staff)
Confidentiality & Security Access Acknowledgment Statement
Conflicts of Interest/Fiscal Misconduct Acknowledgment Statement
Fraud, Waste and Abuse Acknowledgment Statement
Drug Free Campus Acknowledgment Statement
Sexual Harassment Acknowledgment Statement
Right to Know Basic Awareness Training (Note: Complete on-line and print Certificate upon completion)
USG Ethics Policy Statement Acknowledgement & Form (Note: Complete Form and take to ITS Department)
Jeanne Clery Act (Note: Sign Both the pages)
Exit/Clearance Process
Affordable Care Act Marketplace Acknowledgment Statement
HR’s Name: Signature: Date:
Full Name: Signature: Date:
Revised: June 6, 2018
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*PERSONAL DATA 1
Name (please print)
Hire Date:
First Name:
Middle Name:
Social Security Number:
Dr.
Miss
Mister
Mrs.
Ms.
Current Address (Your first paycheck will be mailed to the address you list here.)
Permanent Address:
City
County
State
Zip Code
Phone #
*PERSONAL DATA 2
Gender:
Marital Status:
Highest Education?
Full-time
Student?
YES
NO
Male
Married
High School
Associates
Single
Bachelors
Female
Widow
Masters
Doctorate
Date of Birth:
Birth Country:
Date of Marriage:
Email Address:
How did you find out about this job?
Applicant Clearinghouse
Internet
Advertisement
Job Posting
Other (Specify)
Citizenship Status:
Native U.S.
Naturalized U.S.
Alien Temp (Alien authorized to work)
Alien Perm (Permanent Alien Resident)
White
American Indian
Asian
Black
Hispanic
Multi-racial (If you choose “Multi-racial”, please specify which races by checking the appropriate boxes above)
Other (If you choose “Other”, please specify race.)
Military Service:
None Active Active Reserves Veteran Retired Vietnam Veteran
Are you disabled? Yes No
Are you a disabled Veteran? Yes No
Do you have previous employment with the University System of Georgia? Yes No
At which Institution:
Date Last Worked:
Full Name: Signature: Date:
Revised: June 22, 2018
EMERGENCY CONTACT INFORMATION
Employee’s Name (please print)
Last Name:
First Name:
Middle Name:
Primary Contact Name:
Relationship to Employee:
Check here if contact specified has same address and phone number as employee.
If Primary Contact has a different address, please specify below.
Street
City
County
State
Zip Code
Home Phone Number:
Other Phone Number (specify type)
Business Pager Cell
SECONDARY CONTACT INFORMATION
Secondary Contact Name:
Relationship to Employee:
Check here if contact specified has same address and phone number as employee.
If Secondary Contact has a different address and/or phone number, please specify below.
Street
City
County
State
Zip Code
Home Phone Number:
Other Phone Number (specify type)
Business Pager Cell
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Full Name: Signature: Date:
Revised: June 11, 2018
NEW STAFF INFORMATION FORM
Please complete the information requested below:
NAME OF NEW STAFF (anyone hired after August 2008)
POSITION/TITLE:
COMING TO ALBANY STATE UNIVERSITY FROM:
OTHER AREAS OF INTEREST (family, hobbies, etc.)
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Full Name: Signature: Date:
Revised: June 11, 2018
OUTSIDE EMPLOYMENT
Faculty/Staff members must complete this form and receive approval before an outside employment
commitment is made. Failure to obtain prior approval may result in disciplinary actions including termination of
employment at ASU.
NAME Department
I am not currently engaging in outside employment.
I request permission to become engaged in outside employment.
TITLE LOCATION
EMPLOYER TIME/DAY(S)
ACADEMIC SEMESTER
Description of outside employment duties/responsibilities:
Approvals/Acknowledgements:
Approved
Not Approved
Acknowledged (not employed outside ASU)
Unit Vice President Date
Approved
Not Approved
Acknowledged (not employed outside ASU)
President or Designee Date
Policy 8.2.15 OUTSIDE ACTIVITIES – An employee of the University System of Georgia should avoid actual or apparent conflict of
interest between his or her college or university obligations and his or her outside activities.
Revised 12.2016
I hereby certify that the information listed above is true and complete.
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Form
W-4
(2018)
Future developments. For the latest
information about any future developments
related
to
Form W-4, such as legislation
enacted after it was published, go
to
www.irs.gov/FormW4.
Purpose. Complete Form W-4 so that your
employer can withhold the correct federal
income tax from your pay. Consider
completing a new Form W-4 each year and
when your personal
or
financial situation
changes.
Exemption from withholding. You may
claim exemption from withholding for 2018
if
both
of
the following apply.
• For 2017 you had a right
to
a refund
of
all
federal income tax withheld because you
had
no
tax liability, and
• For 2018 you expect a refund
of
all
federal income tax withheld because you
expect
to
have no tax liability.
If you're exempt, complete
only lines 1,
2,
3,
4, and 7 and sign the form
to
validate it.
Your exemption for 2018 expires February
15, 2019. See Pub. 505, Tax Withholding
and Estimated Tax,
to
learn more about
whether you qualify for exemption from
withholding.
General Instructions
If you aren't exempt, follow the rest
of
these instructions
to
determine the number
of
withholding allowances you should claim
for withholding for 2018 and any additional
amount
of
tax
to
have withheld. For regular
wages, withholding must be based on
allowances you claimed and may not be a
flat amount or percentage
of
wages.
You can also use the calculator at
www.irs.gov/W4App
to
determine your
tax withholding more accurately. Consider
using this calculator if you have a more
complicated tax situation, such as if you
have a working spouse, more than one job,
or
a large amount
of
nonwage income
outside
of
your
job
. After your Form W-4
takes effect, you can also use this
calculator
to
see how the amount
of
tax
you're having withheld compares
to
your
projected total tax for 2018. If you use the
calculator, you
don't
need
to
complete any
of
the worksheets for Form W-4.
Note that if you have too much tax
withheld, you will receive a refund when you
file your tax return. If you have too little tax
withheld, you will owe tax when you file your
tax return, and you might owe a penalty.
Filers with multiple jobs
or
working
spouses. If you have more than one
job
at
a time,
or
if you're married and your
spouse is also working, read all
of
the
instructions including the instructions for
the Two-Earners/Multiple Jobs Worksheet
before beginning.
Nonwage
income. If you have a large
amount
of
nonwage income, such as
interest or dividends, consider making
estimated tax payments using Form 1040-
ES
, Estimated Tax for Individuals.
Otherwise, you might owe additional tax.
Or, you can use the Deductions,
Adjustments, and Other Income Worksheet
on page 3
or
the calculator at
www
.irs.gov/
W4App
to
make sure you have enough tax
withheld from your paycheck. If you have
pension or annuity income, see Pub. 505 or
use the calculator at
www.irs.gov/W4App
to
find out if you should adjust your
withholding on Form W-4 or W-4P.
Nonresident alien. If you're a nonresident
alien, see Notice 1392, Supplemental Form
W-4 Instructions for Nonresident Aliens,
before completing this form.
Specific Instructions
Personal Allowances Worksheet
Complete this worksheet on page 3 first
to
determine the number
of
withholding
allowances
to
claim.
Line C.
Head
of
household please note:
Generally, you can claim head
of
household filing status on your tax return
only if you're unmarried and pay more than
50%
of
the costs
of
keeping up a home for
yourself and a qualifying individual. See
Pub.
501
for more information about filing
status.
Line
E.
Child
tax
credit. When you file
your tax return, you might be eligible
to
claim a credit for each
of
your qualifying
children. To qualify, the child must be
under age 17 as
of
December
31
and must
be your dependent who lives with you for
more than half the year. To learn more
about this credit, see Pub. 972, Child Tax
Credit. To reduce the tax withheld from
your pay by taking this credit into account,
follow the instructions on line E
of
the
worksheet. On the worksheet you will be
asked about your total income. For this
purpose, total income includes all
of
your
wages and other income, including income
earned by a spouse, during the year.
Line
F.
Credit
for
other dependents.
When you file your tax return, you might be
eligible
to
claim a credit for each
of
your
dependents that
don't
qualify for the child
tax credit, such as any dependent children
age 17 and older. To learn more about this
credit, see Pub. 505. To reduce the tax
withheld from your pay by taking this credit
into account, follow the instructions on line
F
of
the worksheet.
On
the worksheet, you
will be asked about your total income. For
this purpose, total income includes
all
of
------------------------------ Separate here and give Form W-4 to your employer. Keep the worksheet(s) for your records.
Form W•4
Employee's Withholding Allowance Certificate
0MB
No. 1545-0074
~@18
Department
of
the Treasury
~
W~ether yo~'re entitled to claim a certain number of allowances or exemption from withholding is
sub1ect to review by the IRS. Your employer may be required to send a copy of this form to the IRS.
Internal Revenue Service
1 Your first name and middle initial
I Last name
12
Your social security number
Home address (number and street or rural route)
3
Osingle
OMarried
D Married, but withhold at higher Single rate.
Note:
If
married
filing separately, check "Married, but withhold
at
higher Single
rate
."
City or town, state, and ZIP code
4
If
your last name differs from that shown
on
your social security card,
check here. You must call
800-772-1213 for a replacement card.
~o
5 Total number
of
allowances you're claiming (from the applicable worksheet on the following pages) 5
6
Additional amount, if any, you want withheld from each paycheck
....
6 $
7 I claim exemption from withholding for 2018, and I certify that I meet both
of
the following conditions for exemption.
• Last year I had a right
to
a refund
of
all federal income tax withheld because I had
no
tax liability, and
• This year I expect a refund
of
all federal income tax withheld because I expect to have no tax liability.
If you meet both conditions, write "Exempt" here . . . . . . . . . . . . . . .
~
I 7 I
'.
Under penalties of periury, I declare that I have examined this
cert1f1cate
and,
to the best of my knowledge
and
belief, it
is
true, correct,
and
complete.
Employee's signature
(This
form
is
not valid unless
you
sign
it.)
~
8 Employer's name and
add_ress
(Employer: Complete boxes 8 and 1 O if sending to
IRS
and complete 9 First date
of
boxes 8,
9,
and 10
1f
sending
to
State Directory
of
New Hires.) employment
For Privacy Act and Paperwork Reduction Act Notice, see page 4. cat. No.
102200
Date~
10 Employer identification
number
(EIN)
Form W-4 (2018)
Form
W-4
(2018)
your wages and other income, including
income earned by a spouse, during the year.
Line G. Other credits. You might be able
to
reduce the tax withheld from your
paycheck if you expect
to
claim other tax
credits, such as the earned income tax
credit and tax credits for education and
child care expenses. If you
do
so, your
paycheck will be larger but the amount
of
any refund that you receive when you file
your tax return will be smaller. Follow the
instructions for Worksheet
1-6
in
Pub. 505
if you want
to
reduce your withholding
to
take these credits into account.
Deductions, Adjustments, and
Additional Income Worksheet
Complete this worksheet to determine if
you're able
to
reduce the tax withheld from
your paycheck
to
account for your itemized
deductions and other adjustments to
income such as IRA contributions. If you
do
so, your refund at the end
of
the year
will be smaller, but your paycheck will be
larger. You're not required to complete this
worksheet
or
reduce your withholding if
you
don't
wish
to
do
so.
You can also use this worksheet
to
figure
out how much
to
increase the tax withheld
from your paycheck if you have a large
amount
of
nonwage income, such as
interest
or
dividends.
Another option is
to
take these items into
account and make your withholding more
accurate by using the calculator at
www.irs.gov/W4App. If you use the
calculator, you
don't
need
to
complete any
of
the worksheets for Form W-4.
Two-Earners/Multiple Jobs
Worksheet
Complete this worksheet if you have more
than one job at a time
or
are married filing
jointly and have a working spouse. If you
don't
complete this worksheet, you might
have too little tax withheld. If so, you will
owe tax when you file your tax return and
might be subject
to
a penalty.
Figure the total number
of
allowances
you're entitled
to
claim and any additional
amount
of
tax
to
withhold on all jobs using
worksheets from only one Form W-4. Claim
all allowances on the W-4 that you
or
your
spouse file for the highest paying
job
in
your family and claim zero allowances on
Forms W-4 filed for all other jobs. For
example, if you earn $60,000 per year and
your spouse earns $20,000, you should
complete the worksheets
to
determine
what
to
enter on lines 5 and 6
of
your Form
W-4, and your spouse should enter zero
("-0-") on lines 5 and 6
of
his
or
her Form
W-4. See Pub.
505 for details.
Another option is
to
use the calculator at
www.irs.gov/W4App
to
make your
withholding more accurate.
Tip: If you have a working spouse and your
incomes are similar, you can check the
"Married, but withhold at higher Single
rate" box instead
of
using this worksheet. If
you choose this option, then each spouse
should fill out the Personal Allowances
Worksheet and check the "Married, but
withhold at higher Single rate" box on Form
W-4, but only one spouse should claim any
allowances for credits
or
fill out the
Deductions, Adjustments, and Additional
Income Worksheet.
Instructions for Employer
Employees, do not complete box 8, 9, or
10. Your employer will complete these
boxes if necessary.
New
hire reporting. Employers are
Page2
required by law
to
report new employees
to
a designated State Directory
of
New Hires.
Employers may use Form W-4, boxes 8,
9,
and
10
to
comply with the new hire
reporting requirement for a newly hired
employee. A newly hired employee is
an
employee who hasn't previously been
employed by the employer,
or
who was
previously employed by the employer but
has been separated from such prior
employment for at least 60 consecutive
days. Employers should contact the
appropriate State Directory
of
New Hires
to
find out
how
to
submit a
copy
of
the
completed Form W-4. For information and
links
to
each designated State Directory
of
New Hires (including for U.S. territories),
go
to
www.acf.hhs.gov/programs/css/
employers.
If an employer is sending a copy
of
Form
W-4
to
a designated State Directory
of
New Hires
to
comply with the new hire
reporting requirement for a newly hired
employee, complete boxes
8,
9,
and 10 as
follows.
Box 8. Enter the employer's name and
address. If the employer is sending a copy
of
this form
to
a State Directory
of
New
Hires, enter the address where child
support agencies should send income
withholding orders.
Box 9. If the employer is sending a copy
of
this form to a State Directory
of
New Hires,
enter the employee's first date
of
employment, which is the date services for
payment were first performed by the
employee. If the employer rehired the
employee after the employee had been
separated from the employer's service for
at least 60 days, enter the rehire date.
Box 10. Enter the employer's employer
identification number
(EIN).
FORM G-4 (Rev. 01/04) STATE OF GEORGIA
EMPLOYEE’S WITHHOLDING ALLOWANCE CERTIFICATE
1. YOUR FULL NAME 2. YOUR SOCIAL SECURITY NUMBER
HOME ADDRESS
(Number, Street, or Rural Route) CITY, STATE AND ZIP CODE
PLEASE READ INSTRUCTIONS ON REVERSE SIDE BEFORE COMPLETING LINES 3 - 8
3. MARITAL STATUS
(If you do not wish to claim an allowance, enter “0” in the brackets beside your marital status.)
A. Single: enter 0 or 1 ................................... [ ] 4. DEPENDENT ALLOWANCES ........... [ ]
B. Married Filing Joint, both
spouses working: enter 0 or 1 or 2 ............. [ ]
C. Married Filing Joint, one
spouse working: enter 0 or 1 or 2 ............... [ ]
5. ADDITIONAL ALLOWANCES ........... [
(complete worksheet below)
]
D. Married Filing Separate:
enter 0 or 1 or 2 ......................................... [ ]
E. Head of Household: 6. ADDITIONAL WITHHOLDING ........... $
enter 0 or 1 or 2 ......................................... [ ]
7. LETTER USED
(Marital Status A, B, C, D, or E ) TOTAL ALLOWANCES (Total of Lines 3 - 5)
(Employer: The letter indicates the tax tables on pages 16 through 35 of the Employer’s Tax Guide)
8. EXEMPT: I claim exemption from withholding because I incurred no Georgia income tax liability last year and
I do not expect to have a Georgia income tax liability this year. Check here .
I certify under penalty of perjury that I am entitled to the number of withholding allowances or the exemption from withholding status
claimed on this Form G-4. Also, I authorize my employer to deduct per pay period the additional amount listed above.
Employee’s Signature Date
Employer: Complete Line 9 if the employee claims over 14 allowances or exempt from withholding. Mail entire form to
Georgia Department of Revenue, Withholding Tax Unit, P. O. Box 49432, Atlanta, GA 30359.
9. EMPLOYER’S NAME AND ADDRESS: EMPLOYER’S FEIN:
EMPLOYER’S WH#:
WORKSHEET FOR CALCULATING ADDITIONAL ALLOWANCES
1. COMPLETE THIS LINE ONLY IF USING STANDARD DEDUCTION:
Yourself: Age 65 or over Blind
Spouse: Age 65 or over Blind Number of boxes checked x 1300 ...........$
2. ADDITIONALALLOWANCES FOR DEDUCTIONS:
A. Federal Estimated Itemized Deductions ................................................................ $
B. Georgia Standard Deduction (enter one): Single/Head of Household $2,300
Each Spouse $1,500 $
C. Subtract Line B from Line A ........................................................................................................$
D. Allowable Deductions to Federal Adjusted Gross Income ...........................................................$
E. Add the Amounts on Lines 1, 2C, and 2D ...................................................................................$
F. Estimate of Taxable Income not Subject to Withholding..............................................................$
G. Subtract Line F from Line E (if zero or less, stop here) ...............................................................$
H. Divide the Amount on Line G by $3,000. Enter total here and on Line 5 above ............................
(This is the number of additional allowances. If the remainder is over $1,500 round up).
CREATE AS MANY COPIES AS NEEDED
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0.00
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Print Form
INSTRUCTIONS FOR COMPLETING FORM G-4
Enter your full name, address and social security number in boxes 1 and 2.
Line 3: Write the number of allowances you are claiming in the brackets beside your marital status.
A. Single - enter 1 if you are claiming yourself
B. Married Filing Joint, both spouses working - enter 1 if you claim yourself or 2 if you claim
yourself and your spouse
C. Married Filing Joint, one spouse working - enter 1 if you claim yourself or 2 if you claim
yourself and your spouse
D. Married Filing Separate - enter 1 if you claim yourself or 2 if you claim yourself and your spouse
E. Head of Household - enter 1 if you claim yourself but the individual(s) for whom you maintain a
home does not qualify as a dependent; or 2 if you claim yourself and a qualified dependent for
whom you maintain a home
Do not claim a deduction on Line 4 for a dependent used to qualify you as head of household
Line 4: Enter the number of dependent allowances you are entitled to claim.
Line 5: Use the worksheet at the bottom of Form G-4 to determine the number of additional allowances
to which you are entitled and enter the total here.
Line 6: Enter a specific dollar amount that you authorize your employer to withhold in addition to the tax
withheld based on your marital status and number of allowances.
Line 7: Enter the letter of your marital status from Line 3. Enter total of the numbers on Lines 3 - 5.
Line 8: Check the box if you qualify to claim exempt from withholding. You can claim exempt if you filed
a Georgia income tax return last year and did not have a tax liability, and you expect to file a
Georgia tax return this year and will not have a tax liability. You can not claim exempt if you did
not file a Georgia income tax return for the previous tax year.
O.C.G.A. 48-7-102 requires you to complete and submit Form G-4 to your employer in order to have tax
withheld from your wages. By correctly completing this form, you can adjust the amount of tax withheld to
meet your tax liability. Failure to submit a properly completed Form G-4 will result in your employer withholding
tax as though you are single with zero allowances.
Employers are required to mail any Form G-4 claiming more than 14 allowances or exempt from withholding
to the Georgia Department of Revenue for approval. Employers will honor the form as submitted pending
notification from the Withholding Tax Unit. Upon approval, such forms remain in effect until changed or until
February 15 of the following year.
NOTE: Employers who know that a G-4 is erroneous should not honor the form and should withhold as if the
employee is single claiming zero allowances until a corrected form has been received.
USCIS
Form I-9
OMB No. 1615-0047
Expires 08/31/2019
Employment Eligibility Verification
Department of Homeland Security
U.S. Citizenship and Immigration Services
►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)
State
Address (Street Number and Name)
Apt. Number City or Town ZIP Code
Date of Birth (mm/dd/yyyy)
U.S. Social Security Number
-
-
Employee's E-mail Address
Employee's Telephone Number
I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in
connection with the completion of this form.
I attest, under penalty of perjury, that I am (check one of the following boxes):
1. A citizen of the United States
2. A noncitizen national of the United States (See instructions)
3. A lawful permanent resident
(Alien Registration Number/USCIS Number):
4. An alien authorized to work until
(expiration date, if applicable, mm/dd/yyyy):
Some aliens may write "N/A" in the expiration date field.
(See instructions)
Aliens authorized to work must provide only one of the following document numbers to complete Form I-9:
An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.
1. Alien Registration Number/USCIS Number:
OR
2. Form I-94 Admission Number:
OR
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 07/17/17 N
Page 1 of 3
Employment Eligibility Verification
USCIS
Form I-9
Department of Homeland Security
OMB No. 1615-0047
U.S. Citizenship and Immigration Services
Expires 08/31/2019
Section 2. Employer or Authorized Representative Review and Verification
(Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You
must physically examine one document from List A OR a combination of one document from List B and one document from List C as listed on the "Lists
of Acceptable Documents.")
Employee Info from Section 1
Last Name (Family Name) First Name (Given Name) M.I. Citizenship/Immigration Status
List A
Identity and Employment Authorization
Document Title
OR
Document Title
List B
Identity
AND List C
Employment Authorization
Document Title
Issuing Authority
Document Number
Issuing Authority
Document Number
Issuing Authority
Document Number
Expiration Date (if any)(mm/dd/yyyy) Expiration Date (if any)(mm/dd/yyyy) Expiration Date (if any)(mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Additional Information
QR Code - Sections 2 & 3
Do Not Write In This Space
Expiration Date (if any)(mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any)(mm/dd/yyyy)
Certification: I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee,
(2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the
employee is authorized to work in the United States.
The employee's first day of employment (mm/dd/yyyy):
(See instructions for exemptions)
Signature of Employer or Authorized Representative
Today's Date (mm/dd/yyyy)
Title of Employer or Authorized Representative
Last Name of Employer or Authorized Representative First Name of Employer or Authorized Representative
Employer's Business or Organization Name
Employer's Business or Organization Address (Street Number and Name)
City or Town
State
ZIP Code
Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.)
A. New Name (if applicable) B. Date of Rehire (if applicable)
Last Name (Family Name)
First Name (Given Name) Middle Initial
Date (mm/dd/yyyy)
C. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes
continuing employment authorization in the space provided below.
Document Title Document Number
Expiration Date (if any) (mm/dd/yyyy)
I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if
the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual.
Signature of Employer or Authorized Representative
Today's Date (mm/dd/yyyy)
Name of Employer or Authorized Representative
Form I-9 07/17/17 N
Page 2 of 3
LISTS OF ACCEPTABLE DOCUMENTS
All documents must be UNEXPIRED
Employees may present one selection from List A
or a combination of one selection from List B and one selection from List C.
LIST A LIST B LIST C
Documents that Establish
Documents that Establish
Documents that Establish
Both Identity and
Identity
Employment Authorization
Employment Authorization
OR AND
1. U.S. Passport or U.S. Passport Card
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
1. A Social Security Account Number
card, unless the card
includes one of
the following restrictions:
(1) NOT VALID FOR EMPLOYMENT
(2) VALID FOR WORK ONLY WITH
INS AUTHORIZATION
(3) VALID FOR WORK ONLY WITH
DHS AUTHORIZATION
2. Permanent Resident Card or Alien
Registration Receipt Card (Form I-551)
3. Foreign passport that contains a
temporary I-551 stamp or temporary
I-551 printed notation on a machine-
readable immigrant visa
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. Employment Authorization Document
that contains a photograph (Form
I-766)
2. Certification of report of birth issued
by the Department of State (Forms
DS-1350, FS-545, FS-240)
3. School ID card with a photograph
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
5. For a nonimmigrant alien authorized
to work for a specific employer
because of his or her status:
a. Foreign passport; and
b. Form I-94 or Form I-94A that has
the following:
(1) The same name as the passport;
and
(2) An endorsement of the alien's
nonimmigrant status as long as
that period of endorsement has
not yet expired and the
proposed employment is not in
conflict with any restrictions or
limitations identified on the form.
4. Voter's registration card
5. U.S. Military card or draft record
6. Military dependent's ID card
4. Native American tribal document
7. U.S. Coast Guard Merchant Mariner
Card
5. U.S. Citizen ID Card (Form I-197)
8. Native American tribal document
6. Identification Card for Use of
Resident Citizen in the United
States (Form I-179)
9. Driver's license issued by a Canadian
government authority
For persons under age 18 who are
unable to present a document
listed above:
7. Employment authorization
document issued by the
Department of Homeland Security
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
10. School record or report card
11. Clinic, doctor, or hospital record
12. Day-care or nursery school record
Examples of many of these documents appear in Part 13 of the Handbook for Employers (M-274).
Refer to the instructions for more information about acceptable receipts.
Form I-9 07/17/17 N
Page 3 of 3
NOTICE TO EMPLOYEES: The Sedition and Subversive Activities Act of 1953 (Ga. Laws, 1953), as amended, requires each employee
to complete and sign, prior to his/her employment by the State of Georgia, a questionnaire which is designed to establish that there are no
reasonable grounds to believe that he/she is a subversive person. A subversive person is defined as one who commits acts, advocates, or
teaches the overthrow of the government of the United States or government of the State of Georgia by force or violence or who is a
knowing member of a subversive organization.
INSTRUCTIONS: Prepare in original only. Fill in all items. If more space is needed for any item, or explanation, continue under Item 5.
Please type or print in ink.
Board of Regents
University System of Georgia
University System Office
SECURITY QUESTIONNAIRE
1. Name
Social Security No.
Other Names Used: (Maiden name, names by former marriages, former names changed legally or otherwise: Aliases, nicknames, etc.
Specify which, and show dates used.)
2. Address
Street and No. City State County Phone No.
3. Are you now or have you been within the last ten (10) years a member of any organization which to your knowledge at the time of
membership advocates or has as one of its objectives, the overthrow of the government of the United States or the government of the State
of Georgia by force or violence?
Yes No If “Yes,” state the name of the organization and your past and present membership
status including any offices held therein.
NOTE: If the answer to Question 3 is “yes” and the employing authority deems further inquiry is necessary, you will be notified of such
determination. No action adverse to your application will be taken because of an affirmative answer until after such an inquiry,
with notice to you and an opportunity for you to present evidence, and only if the results of such inquiry bring your application
within the prohibition within the Sedition and Subversive Activities Act of 1953, as amended.
4. (A) Have you ever been convicted or are any charges now pending against you by Federal, State, or other law-enforcement
authorities, for any violation of any federal law, state law, county or municipal law, regulation, or ordinance? (Do not include
anything that happened before your sixteenth birthday. Do not include minor traffic violations for which a fine of $35.00 or less
was imposed. All other convictions must be included even if they were pardoned.)
Yes No
(B) If the answer to 4 (A) is “yes,” state the reason convicted, the date convicted, and the place where convicted.
REASON CONVICTED
DATE
PLACE WHERE CONVICTED
5. SPACE FOR CONTINUING ANSWERS OR EXPLANATIONS: (Show item numbers to which answers or explanations apply. Attach
a separate sheet if more space is needed.)
USO/AH/11.14.07
Page 1
NOTE: Before signing this form, check all answers and explanations to see that you have answered all questions fully and correctly. This
form is to be executed under oath subject to the penalties of false swearing as prescribed in Code Section 16-11-14 of the Criminal Code of
Georgia.
AFFIDAVIT OF VERIFICATION
County State of
Personally appeared before the undersigned attesting officer, duly authorized to administer oaths, (Print your Name)
who, after being sworn, deposes and says and declares under penalties of false swearing that he or she is the person who executed the
foregoing instrument; that he or she has read and completed the same and knows and understands the contents thereof; that the matters
stated therein and the answers and information furnished by him or her in the foregoing questionnaire, including any attachments thereto,
are true and correct.
SWORN TO AND SUBSCRIBED BEFORE ME
This day of
Month
,
Year
(Signature of Employee)
____________________________________________________
Notary Public
County of My commission expires day of
month
,
year
(Affix seal)
INFORMATION TO BE FURNISHED BY EMPLOYING UNIT
INSTRUCTIONS TO UNIT: If this questionnaire is executed by applicant, insert “APPL” in the space for date of appointment, and show
date of application. If this questionnaire is executed by an individual who has been offered employment or who is already employed,
provide the information requested.
DATE OF
APPOINTMENT
TITLE OF POSITION
UNIT AND DEPARTMENT
DUTY STATION
University System
Office
Board of Regents
University System of Georgia
LOYALTY OATH
STATE OF COUNTY OF
I, (Print your Name) , a citizen of
State / Country
and being an employee of the University System of Georgia and the recipient of public funds for services rendered as such employee, do
hereby solemnly swear and affirm that I will support the Constitution of the United States and the Constitution of the State of Georgia.
This day of ,
Month Year Signature of Employee
Sworn to and subscribed before me this day and year above set out.
Notary Public
(Affix Seal)
PLEASE NOTE THAT EACH OF THE ABOVE DOCUMENTS, THE SECURITY QUESTIONNAIRE AND THE LOYALTY OATH,
MUST BE SIGNED AND NOTARIZED.
USO/AH/11.14.07
Page 2
Full Name: Signature: Date:
Revised: June 11, 2018
Outstanding Wages Beneficiary Designation
Albany State University offers its employees the option of designating a beneficiary(ies) to receive the
employee’s last check in the event of an employee’s death while an employee of the University System Office.
If you elect to name a beneficiary, you must complete the section below, Outstanding Wages Beneficiary
Designation Form, at the time of your employment and submit to Human Resources along with all of your
new hire paperwork. Should you desire to change your beneficiary at some point in the future, it will be your
responsibility to complete and submit to Human Resources another Outstanding Wages Beneficiary
Designation Form. For example, if you name your spouse and are later divorced, you would then be required
to complete a new form.
If an employee does not elect to name a beneficiary, Albany State University’s payroll office will issue the employee’s
final paycheck, including any pay for unused annual/vacation leave, to the estate of the deceased employee. If
your final check goes to your estate, please be advised that access to the funds by your family may be delayed due
to the probate process.
Albany State University - Outstanding Wages Beneficiary Designation Form
Employee’s Name:
Name of Primary Beneficiary for Outstanding Wages:
Address:
Name of Secondary Beneficiary for Outstanding Wages:
Address:
State of , County of , on this day of ,
2 , personally appeared before me, the above named and made oath that the statements made above are true.
My Commission Expires
Notary Public
(Official Seal)
Full Name: Signature: Date:
Revised: June 11, 2018
Direct Deposit
(NOTE: Your first check will be mailed to the address on your Personal Data Form)
ACH stands for automatic clearing house. It means direct deposit of a check or payment into a bank account. You will
receive a paper check. The money is electronically put into an account.
One account must be designated as the “balance” account to deposit 100% of their paycheck into.
A blank check marked “VOID” should be submitted with this direct deposit form. This account will be pre-noted the first
pay cycle after this authorization form has been received.
This means that no money is actually sent to your bank the 1
st
pay cycle. Your name and account number will be sent to
your bank to assure that no mistakes have been made in coding.
Your check will be direct deposited on your next or 2
nd
pay cycle.
You must attach (1) of the following items:
A voided check (Bank Deposit forms or courtesy checks without pre-printed name and mailing address are
not acceptable)
ACH Check Deposit form from your bank with routing and account numbers displayed.
NOTE: If you are establishing more than one bank account, please complete the sections below.
Print Name:
Direct Deposit Account I
Effective Date:
Priority:
Excess? Partial Allowed?
Bank Name:
Transit Number:
Account Number
Percent of Net Pay
Dollar Amount: $
Account Type: Checking ( ) Savings ( )
Direct Deposit Account II
Effective Date:
Priority:
Excess? Partial Allowed?
Bank Name:
Transit Number:
Account Number
Percent of Net Pay
Dollar Amount: $
Account Type: Checking ( ) Savings ( )
The Georgia Bureau of Investigation consent form is needed to complete a statewide criminal search in
Georgia.
The applicant must complete the following steps:
Step 1: The top portion of the form must be completed in its entirety and signed by the applicant.
• Full Name (last name, first name, middle name)
• Address
• Sex
• Race
• Date of Birth
• Social Security Number
• Signature
• Date
Step 2: The lower portion of the form must be completed
• Check applicable employment provisions
• Enter your first and last name to consent to periodic criminal history background checks for the
duration of your employment with this company OR authorize the validity for a designated
amount of time from the date of signature.
Step 3: Fax or Email Instructions
• Once you have completed the form, please fax or email a copy to Sterling at:
o 866-685-9426 or CrimAwaitingInfo@sterlingts.com
If you have any questions please call 800-943-2589 to speak with a client services representative.
Sterling Talent Solutions / 4511 Rockside Rd. 4th Floor / Independence, OH 44131
Tel: 800-943-2589 / fax: 866-685-9426 / www.sterlingtalentsolutions.com
Georgia Bureau of Investigation
Georgia Crime Information Center
Consent Form
I hereby authorize Sterling Infosystems, Inc dba Sterling Talent Solutions to receive any
Georgia criminal history record information pertaining to me which may be in the files of any
state or local criminal justice agency in Georgia.
Full Name
Address
Sex Race Date of Birth Social Security Number
Signature Date
Special employment provisions (check if applicable):
Employment with mentally disabled (Purpose code ‘M’)
Employment with elder care (Purpose code ‘N’)
Employment with children (Purpose code ‘W’)
Employment with criminal justice agency – non-sworn (Purpose code ‘J’)
Employment with criminal justice agency – sworn (Purpose code ‘Z’)
One of the following must be checked:
This authorization is valid for 90/180/ (circle one) days from date of signature.
I, give consent to the above name to perform periodic criminal
history background checks for the duration of my employment with this company
Sterling Talent Solutions / 4511 Rockside Rd. 4th Floor / Independence, OH 44131
Tel: 800-943-2589 / fax: 866-685-9426 / www.sterlingtalentsolutions.com
AUTHORIZATION
I have carefully read and understand the separate background check disclosure document and the below
authorization form. I have received a copy of the “Summary of Your Rights Under the Fair Credit Reporting Act”
and any applicable state or local notices of rights provided with these documents. I have had the opportunity
to review my rights. By my signature below, I consent to the preparation of background reports by Sterling
Talent Solutions, and to the release of such reports to the Company and its designated representatives for the
purpose of assisting the Company in making a determination as to my eligibility for employment, promotion,
retention, contract assignment or for other lawful purposes.
I understand that, to the extent allowed by law, information contained in my job application or otherwise
disclosed to the Company by me before or during my employment or contract assignment, if any, may be
utilized for the purpose of obtaining such consumer reports and/or investigative consumer reports about me.
I understand that nothing herein shall be construed as an offer of employment or contract for services.
I hereby authorize law enforcement agencies, learning institutions (including public and private schools and
universities), information service bureaus, credit bureaus, record/data repositories, courts
(federal/state/local), motor vehicle record agencies, my past or present employers, the military, and other
individuals or sources to furnish any and all information on me that is requested by the consumer reporting
agency.
By my signature (including electronic) below, I certify the information provided on and in connection with this
form is true, accurate, and complete. I agree that this form in original, faxed, photocopied or electronic form
will be valid for any background reports that may be requested by or on behalf of the Company.
First Name:
Full Middle Name:
Last Name:
Social Security Number:
Date of Birth
Email Address
Signature: Date:
CALIFORNIA, MASSACHUSETTS, MINNESOTA, NEW JERSEY, and OKLAHOMA applicantsor residents:
You have a right to request a free copy of your report. Please check here if you would like [Company Name] to
provide you with a copy of your report. [NO CHANGES ALLOWED]
Rev. 3.15.2015
Full Name: Signature: Date:
Revised: June 11, 2018
Teachers Retirement System of Georgia
Election Form
Non-Exempt (hourly paid):
I have been informed that, as a non-exempt Benefitted Employee of Albany State University, I
am required to participate in the Teachers Retirement System of Georgia.
Exempt (monthly paid):
I am choosing to elect TRS as my retirement plan. My contributions into the plan will be 6.00%
of my gross salary before federal and state taxes. Albany State University will contribute (16.81%)
of my gross salary to TRS. I understand that there is a ten-year vesting period under TRS.
I, further, understand that I correspondence will be mailed to me by TRS to set-up my account
on-line and to input my beneficiary information.
Name of Primary Beneficiary:
Address:
Name of Secondary Beneficiary:
Address:
Full Name: Signature: Date:
Revised: June 11, 2018
OPTIONAL RETIREMENT PLAN ENROLLMENT FORM
This is to certify that I have received the information regarding the Board of Regent’s Retirement Plan.
I, the undersigned understand that I have sixty (60) days from the date of my initial appointment date to make an election
to participate in the Board of Regents Retirement Plan (ORP) with Fidelity, TIAA-Cref or VALIC. I understand that I will
automatically be enrolled as a participant in the Teachers Retirement System of Georgia for the remainder of my
employment with the University System of Georgia, if I do not make an election to participate in the Board of Regents
Optional Retirement Plan (ORP) within the first 60 days of my employment.
Retirement participation is a condition of employment with the University System of Georgia. You are REQUIRED to submit
the proper retirement application(s). Contributions will be deducted from your paycheck for your retirement plan retro to
your employment date. The rate for the employee’s portion in the Optional Retirement Plan is 6%. The current employer
contribution rate is 9.24%. The employee and employer contribution rates for both retirement plans are reviewed and
adjusted yearly, if appropriate.
Company Allocation
VALIC/formerly - AIG-American International Group
TIAA-CREF Teachers Insurance and Annuity Association
Fidelity
Total Should Be: 100%
This agreement shall remain in force during my continued employment except if amended in writing by me during our annual
Open Enrollment period. I understand the allocation of retirement contributions shall remain as selected above and that I
am responsible for all investment decisions regarding this plan.
I, the undersigned, do hereby certify that I have read and fully understand the above statements regarding the Board of
Regents, University System of Georgia’s Optional Retirement Plan.
0%
0%
0%
click to sign
signature
click to edit
Full Name: Signature: Date:
Revised: June 11, 2018
TRS/ORP RETIREMENT ELECTION FORM
Teachers Retirement System (TRS) Defined Benefit Plan
In this type of plan, your retirement benefits is “defined” based on a pre-designated formula:
2% x Years of Membership Service x Average of 24 Highest Consecutive Months Salary
Optional Retirement Plan (ORP) Defined Contributions Plan
This type of plan is similar to a 401(k) in which you have your own account and make your own investment
For more information regarding the plans above, visit the University System of Georgia’s website at:
http://www.usg.edu/hr/benefits/retirement_plan_information
You have 60 days from your date of hire to make a decision regarding your retirement plan. Otherwise, you will
be automatically enrolled in the TRS plan. This decision is irrevocable. It is your responsibility to ensure that
Human Resources has received your completed paperwork.
I elect to participate in: (Choose One)
Teachers Retirement System (TRS) Defined Benefit Plan
Optional Retirement Plan (ORP) Defined Contribution Plan
Company Allocation (Of Total Contributions)
Fidelity
%
TIAA-CREF
%
VALIC
%
ORP Participants are responsible for setting up an account and making investment elections directly with their
vendors(s) of choice. Changes to vendor allocations may be made quarterly in writing with Human Resources.
Please contact the ORP Vendors directly to set up an account(s).
I do hereby certify that I have read and fully understand the above statements regarding the University System
of Georgia retirement plans. In making this election, I understand that under current law, my decision is
irrevocable.
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0%
0%
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signature
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Full Name: Signature: Date:
Revised: June 11, 2018
ALBANY STATE UNIVERSITY
OPTIONAL RETIREMENT PLAN CERTIFICATE
This is to certify that I have received the information regarding the Board of Regent’s Retirement Plan.
I, the undersigned understand that I have sixty (60) days from the date of my initial appointment date to make
an election to participate in the Board of Regents Retirement Plan (ORP) with Fidelity, TIAA-Cref or VALIC. I
understand that I will automatically be enrolled as a participant in the Teachers Retirement System of Georgia
for the remainder of my employment with the University System of Georgia, if I do not make an election to
participate in the Board of Regents Optional Retirement Plan (ORP) within the first 60 days of my employment.
Retirement participation is a condition of employment with the University System of Georgia. You are REQUIRED
to submit the proper retirement application(s). Contributions will be deducted from your paycheck for your
retirement plan retro to your employment date.
The current employee contribution to the Teachers Retirement System of Georgia is 6%. The rate for the
employee’s portion in the Optional Retirement Plan is 6%. The current employer contribution rate for TRS is
(16.81%) while the employer contribution rate for the ORP Plan is 9.24%. The employee and employer
contribution rates for both retirement plans are reviewed and adjusted yearly, if appropriate.
NOTE: If you elect the Optional Retirement Plan, you may only change the company you chose during Open
Enrollment. Changes will take effect the 1
st
day of January following Open Enrollment
Full Name: Signature: Date:
Revised: June 11, 2018
RETIREMENT PARTICIPATION QUESTIONNAIRE
1. Are you currently employed and participating in Payroll Deduction in a public school retirement plan
Example: Employees Retirement System (ERSGA) or Teachers Retirement System (TRS of Georgia)?
Yes No
If yes, which school system are you employed with? .
Please provide documentation showing deductions with ERSGA or TRS.
2. Are you currently retired from the State of Georgia and receiving retirement benefits from Employees’
Retirement System (ERSGA) or Teachers Retirement System of Georgia (TRS of Georgia)?
Yes No
NOTE: If you are not participating in one of the above retirement plans, please complete the appropriate forms for
Teachers Retirement System of Georgia (6% of Gross Pay), or elect an Optional Retirement Plan (6% of Gross Pay
VALIC, FIDELITY or TIAA-CREF) available to you.
Georgia Defined is a Retirement Plan that is only available to part-time/temporary employees.
Full Name: Signature: Date:
Revised: June 11, 2018
Equal Opportunity Employer
Albany State University provides equal employment opportunities (EEO) to all employees and applicants for
employment without regard to race, color, religion, sex, national origin, age, disability or genetics. In addition
to federal law requirements, Albany State University complies with applicable state and local laws governing
nondiscrimination in employment in every location in which the University has facilities. This policy applies to
all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff,
recall, transfer, leaves of absence, compensation, and training.
Albany State University expressly prohibits any form of workplace harassment based on race, color, religion,
gender, sexual orientation, gender identity or expression, national origin, age, genetic information, disability,
or veteran status. Improper interference with the ability of Albany State University’s employees to perform
their job duties may result in discipline up to and including discharge.
The University shall take action, to the extent allowed under state and federal law, to ensure fulfillment of this
policy. For questions or more detailed information regarding this policy, or to file a complaint regarding violation
of this policy, please contact the Albany State University Office of Human Resources, 504 College Drive, Billy C.
Black Building, Room 382, Albany, Georgia 31705, Director of Human Resources, (229) 430-4623. Students
requiring disability-related accommodations for participation in any event or to obtain print materials in an
alternative format, please contact the Student Disability Services Center, New Student Center, 2nd Floor, Green
Zone, Room 2-140, Dr. Stephanie Harris-Jolly, Director of Counseling and Student Disability Services, (229) 903-
3610.
Full Name: Signature: Date:
Revised: June 11, 2018
Faculty/Staff Handbook for Employees of
Albany State University
Employee Acknowledgment Form
(Note: Please sign on the line below and return this form to the Office of Human Resources Management).
Location of the Handbook – I acknowledge that I have been informed that the Faculty/Staff Handbook for
employees of Albany State University is available on the university’s website at:
https://www.asurams.edu/administration/human-resources-home/employee-handbook/
Notification of Future Changes – It is my responsibility to read and comply with the policies and procedures contained in the
handbook. I understand that the policies and procedures contained in it may change without prior notice and that notification
of changes or additions to these policies and procedures will be made to the employees. I understand that efforts will be made
to communicate significant changes in a timely manner and that such revisions may supersede, modify, or eliminate existing
policies, procedures and benefits. The handbook may be updated from time to time, and I will be notified via e-mail, without
the need to sign this form again. No Contract Implied & Rights of Employment Termination –
I acknowledge that the Faculty/Staff Handbook for employees of Albany State University is not a contract of employment. I
understand that neither the handbook, nor any other communications by a university representative, either written or oral,
made prior to employment or during the course of employment, is intended in any way to create an employment contract. I
further understand that either Albany State University or the employee can terminate their employment relationship at any
time, so long as no violations of applicable federal or state laws exist. Authority of the Handbook – I understand that the
handbook is not a legal document, for it is an official publication of the Board of Regents of the University System of Georgia.
In case of divergence from or conflict with the By-laws and Policies of the Board of Regents, the official By-laws and Policies will
prevail. I understand that I should consult my supervisor or the Office of Human Resources Management regarding any
questions not answered in the handbook. Pledge to Read and Understand It – I hereby acknowledge that I will read the
Faculty/Staff Handbook for employees of Albany State University and become familiar with its contents.
Full Name: Signature: Date:
Revised: June 11, 2018
803.04 NOTICE OF EMPLOYMENT AND RESIGNATION
TO BE SIGNED BY FACULTY ONLY
The following notification requirements apply to those members of the faculty who have been awarded the ranks
of instructor, assistant professor, associate professor, or professor:
Tenured Faculty: All tenured faculty members employed under written contract for the fiscal or academic year
shall give at least sixty days written notice of their intention to resign to the president of the institution or to
his/her authorized representative.
Non-tenured Faculty with Academic Ranks of Instructor, Assistant Professor, Associate Professor, Professor: All
non-tenured faculty who have been awarded academic rank (instructor, assistant professor, associate
professor, professor), are employed under written contract, and who served full-time for the entire previous
year have the presumption of renewal of the next academic year unless notified in writing, by the president of
an institution or his/her authorized representative, of the intent not to renew. Written notice of intent not to
renew shall be delivered by hand or by certified mail, to be delivered to the addressee only, with receipt to
show to whom and when delivered and the address where delivered (BR Minutes, October 2008).
Notice of intention not to renew a non-tenured faculty member who has been awarded academic rank
(instructor, assistant professor, associate professor, professor) shall be furnished, in writing, according to the
following schedule:
A. At least three months before the date of termination of an initial one-year contract;
B. At least six months before the date of termination of a second one-year contract;
C. At least nine months before the date of termination of a contract after two or more years of service in
the institution.
This schedule of notification does not apply to persons holding temporary, limited-term, or part-time positions,
or persons with courtesy appointments such as adjunct appointments.
I have read and acknowledge the above Notice of Employment and Resignation.
Full Name: Signature: Date:
Revised: June 11, 2018
Personnel Policies and Procedures
Volume 3A Revised. November 12, 1985
Section II: Classified Employment
TO BE SIGNED BY STAFF ONLY
“All classified employees are required to serve the first six (6) months of employment in the University System
on a provisional basis to provide the employer an opportunity to evaluate the employee’s performance. If the
work of the employee is unsatisfactory, the employee will be notified in writing prior to the completion of this
six (6) months provisional period and the employee may be terminated at that time without right of appeal or
any of the procedural protections provided for in Section II – I (Dismissal, Demotion or Suspension) and K
(Appeals) of these policies.”
I have read and understand the above.
Full Name: Signature: Date:
Revised: June 11, 2018
CONFIDENTIALITY AND SECURITY ACCESS AGREEMENT
Albany State University has a legal and ethical responsibility to safeguard and to protect all confidential information. Confidential information
includes employee information, student records, business information, financial information and other information relating to Albany State
University. In the course of my employment and/or association with Albany State University, I understand that I will come into contact with
confidential information. Confidential information may be spoken, written or electronic. The purpose of this agreement is to clarify my duties
regarding confidential information. By signing this document, I understand and agree to comply with Albany State University Policies & Procedures
on Confidentiality and Security Access and the GA Computer Systems Protection Act, copies of which I have received for my records. In addition:
1. I agree not to disclose confidential information to others who do not have a need-to-know. Need-to-know is defined as that which is
necessary for one to adequately perform one's specific job responsibilities as they relate to Albany State University.
2. I agree not to access or attempt to access any information, or utilize equipment, other than that which is required to do my job.
3. I agree not to discuss confidential information where others can overhear the conversation, e.g., in hallways, on elevators, in the
cafeterias, at restaurants, at social events. I understand that it is not acceptable to discuss any confidential information inside or
outside the organization, while on or off duty, even if specific names are not used, other than as permitted in this agreement.
4. I agree not to access any confidential information for any person who does not have a need-to-know.
5. I understand that my user name and password are the equivalent of my signature and that I am accountable for all entries and actions
recorded during their use.
6. I agree that I will not disclose my user name and password to any person for any reason.
7. I agree not to access any confidential information using someone else's user name and password.
8. I agree not to send or take any confidential information outside Albany State University in any form (including PDAs) without
authorization.
9. I agree not to make any additions, modifications or deletions to any confidential information without authorization.
10. I agree to respect the limitations and usage of the information system network and not to interfere unreasonably with the activity usage
of other authorized persons.
11. I understand that my access to all computer systems may be monitored and audited without notice to me.
12. I agree to log out of any computer session opened under my user name and password prior to leaving any computer or terminal
unattended.
13. I understand that if authorized to use Internet and/or email, I will use it only for authorized job responsibilities. Any misuse or abuse
(e.g., pornographic material, chain letters, etc.) of these privileges could be grounds for disciplinary action.
14. I understand that I must participate in periodic training, as determined by Albany State University.
15. I agree to respect the ownership of proprietary software (e.g., I will not operate any unauthorized software on Albany State University
computers or make unauthorized copies of any software for my own use).
16. I understand that confidential papers should be picked up as soon as possible from copiers, mail boxes, fax machines, printers and other
publicly accessible locations. Confidential papers, reports, and computer printouts should be kept in a secure place. When they are no
longer needed, confidential papers should be deposited in the document destruction bins to be destroyed.
17. I understand that my obligation under this agreement will continue after my termination of employment and/or association with Albany
State University and that my privileges are subject to periodic review, revision, renewal and termination.
18. I agree to notify my supervisor or the Department of Human Resources immediately of any unauthorized access or use of confidential
information or of violation by anyone of any of the rules above.
I understand that violation of this agreement may result in the following: Denial of access to University computer systems;
Disciplinary action as stated in University Policies and Procedures up to and including termination; Penalties under State and Federal laws and
regulations; Denial of entry into University facilities; Notification to State and/or national professional licensing departments or organizations; any
combination of the above.
Full Name: Signature: Date:
Revised: June 11, 2018
Conflict of Interest
In accordance with Georgia Law (Section 45-10-26 of the Official Code of Georgia Annotated) all University
employees are required to disclose any business transactions made between the employee and the State of
Georgia or any agency of the State of the State of Georgia occurring during a calendar year. Employees are also
required to disclose any transactions made between the employee and the State of Georgia on behalf of any
business, or any business that the employee has a substantial interest. Failure to disclose such business
transactions will subject an employee to a civil fine not to exceed $10,000 restitution to the State of Georgia
and removal from employment.
Fiscal Misconduct Policy
REQUEST FOR ACTION: WHEREAS, federal and state statues define and prescribe penalties for actions that are
criminal in nature; and WHEREAS, State of Georgia administrative rules and University policies set out guidelines
for the behavior of University employees in the conduct of University business; and WHEREAS, the Board of
Regents establishes Standards of Conduct expected of those who serve the University System of Georgia; and
WHEREAS, it is essential to the effective operation of Albany State University that administrative officers and
other employees of the University be independent and impartial in all actions involving the University, that
public office not be used for private gain, and that there be complete public confidence in the integrity of the
University; now, therefore, be it resolved that it is the policy of the Board of Regents that the University shall
conduct its affairs so that no member of the University community shall derive private gain from his/her
association with the University except as provided by explicit policies of the University; and WHEREAS, in
recognition of the negative impact that fiscal misconduct may have on the financial resources and reputation
of Albany State University, the University wishes to make an additional statement of policy regarding Fiscal
Misconduct; NOW THEREFORE BE IT RESOLVED, that the attached policy on Fiscal Misconduct be approved
within the Fiscal Affairs Policy and Procedure Manual.
I have read and acknowledge the above Conflict of Interest and Fiscal Misconduct policies.
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Full Name: Signature: Date:
Revised: June 11, 2018
FRAUD, WASTE AND ABUSE
ACKNOWLEDGEMENT STATEMENT
The University System of Georgia (USG) is committed to the highest standards of excellence, integrity, accountability and respect
throughout all of its operations and institutions. Dedicated to its mission of transforming the System, changing lives, and
strengthening the state, the USG both expects and requires its employees to report suspected malfeasance or wrongdoing on the
part of any USG employee or member of the USG community. Additionally, USG institutions are required to report suspected
malfeasance and other violations of federal and state law or BOR policy.
All suspected or known employee malfeasance shall be reported. Examples of employee malfeasance include but are not limited to
embezzlement, misappropriation, alteration or falsification of documents, false claims or reimbursement requests, theft of any
asset, inappropriate use of computer systems, violation of state or federal laws, violation of the USG Ethics Policy or any misuse of
federal funds to include funds provided pursuant to the American Recovery and Reinvestment Act of 2009. Additionally, violations
of policies and procedures often must be reported to the appropriate USG office.
WHO IS RESPONSIBLE FOR REPORTING INCIDENTS?
The USG Ethics Policy mandates reporting wrongdoing to the proper authority while protecting those who do report violations from
retaliation.
•
Individual USG employees should report suspected malfeasance on the part of a USG employee using any of the options outlined
below.
•
USG institutions are also required to report suspected employee malfeasance in a timely manner to the USG Office of Internal
Audit. Additionally, incidents involving misuse of information technology assets or involving computer/network security breaches
must be reported to the USG Office of Information Security.
HOW SHOULD INCIDENTS BE REPORTED?
•
Anonymously
by
phone
or
internet
using
the
USG
Ethics
and
Compliance
Hotline
available
online
24/7
at
https://asurams.alertline.com/gcs/welcome or toll-free by calling 1-877-516-3415.
•
Directly to any of the following Albany State University departments:
Legal Affairs:
229-430-0577
Internal Audit:
229-430-3494
Human Resources:
229-430-4623
Dean of Students:
229-903-3607
Information Technology:
229-430-0538
Police Department:
229-430-4711
Location of the Policy – I acknowledge that I have been informed that the USG Fraud, Waste and Abuse Reporting Policy information
is available at: http://www.usg.edu/organizational_effectiveness/ethics_compliance/fraud_waste_and_abuse_reporting.
Notification of Future Changes – It is my responsibility to read and comply with the policies and procedures contained in the USG
Fraud, Waste and Abuse Reporting Policy. I understand that the policies and procedures contained in it may change without prior
notice.
Acknowledgement of Policy – I hereby acknowledge the USG Fraud, Waste and Abuse Reporting Policy for all Albany State University
Community members which includes but is not limited to employees, students, and volunteers. I recognize and understand that
Violations of USG and ASU policies may result in disciplinary action including dismissal or termination. I acknowledge that I will abide
by the policy.
Email Address:
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Full Name: Signature: Date:
Revised: June 11, 2018
DRUG-FREE CAMPUS
ACKNOWLEDGEMENT STATEMENT
The University System of Georgia (USG) is committed to the highest ethical and professional standards of conduct in
pursuit of its mission to create a more educated Georgia. Accomplishing this mission demands integrity, good judgment
and dedication to public service from all members of the USG community. While the USG affirms each person’s
accountability for individual actions, it also recognizes that the shared mission and the shared enterprise of its institutions
require a shared set of core values and ethical conduct to which each member of the USG community must be held
accountable. Furthermore, the USG acknowledges that an organizational culture grounded in trust is essential to
supporting these core values and ethical conduct.
The University System of Georgia promotes and requires a drug-free work place among its employees.
Albany State University (ASU) complies with and supports federal, state and local laws, and policies of the Board
of Regents of the University System of Georgia, with respect to the unlawful manufacture, distribution, sale use
or possession of marijuana, a controlled substance or other illegal or dangerous drugs on college campuses and
elsewhere.
Albany State University prohibits the unlawful manufacture, distribution, sale, use or possession or use of illegal
drugs by students and employees on the Albany State University campus or as any part of its activities, where
on or off campus.
Location of the Policy – I acknowledge that I have been provided a copy of the ASU Drug-Free Campus Policy
and informed that the Policy is available on the Human Resources Department website at
https://www.asurams.edu/albany-state-university/administration/human-resources-home/.
Notification of Future Changes – It is my responsibility to read and comply with the policies and procedures
contained in the ASU Drug-Free Campus Policy. I understand that the policies and procedures contained in it
may change without prior notice.
Acknowledgement of Policy – I hereby acknowledge the ASU Drug-Free Campus Policy for all ASU Community
members which includes but is not limited to employees, students, and volunteers. I recognize and understand
that Violations of the USG and ASU policies may result in disciplinary action including dismissal or termination.
I acknowledge that I will abide by the policy.
Email Address:
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Full Name: Signature: Date:
Revised: June 11, 2018
SEXUAL HARASSMENT
ACKNOWLEDGEMENT STATEMENT
The University System of Georgia (USG) is committed to the highest ethical and professional standards of conduct in pursuit of its
mission to create a more educated Georgia. Accomplishing this mission demands integrity, good judgment and dedication to public
service from all members of the USG community. While the USG affirms each person’s accountability for individual actions, it also
recognizes that the shared mission and the shared enterprise of its institutions require a shared set of core values and ethical conduct
to which each member of the USG community must be held accountable. Furthermore, the USG acknowledges that an organizational
culture grounded in trust is essential to supporting these core values and ethical conduct.
8.2.16
Sexual Harassment
Federal law provides that it shall be an unlawful discriminatory practice for any employer, because of the sex of any person, to
discharge without cause, to refuse to hire, or otherwise discriminate against any person with respect to any matter directly or
indirectly related to employment or academic standing. Harassment of an employee on the basis of sex violates this federal law.
Sexual harassment of USG employees or students is prohibited and shall subject the offender to dismissal or other
sanctions after compliance with procedural due process requirements.
Unwelcome sexual advancements, requests for sexual favors, and other verbal or physical conduct of a sexual nature
constitutes sexual harassment when:
1. Submission to such conduct is made explicitly or implicitly a term or condition of an individual’s employment or
academic standing; or,
2. Submission to or rejection of such conduct by an individual is used as a basis for employment or academic
decisions affecting an individual; or,
3. Such conduct unreasonably interferes with an individual’s work or academic performance or creates an
intimidating, hostile or offensive working or academic environment.
(Last Modified on July 28, 2009)
(BoR Minutes, 1980-81, p. 237-38)
Location of the Policy – I acknowledge that I have been informed that the USG Sexual Harassment Policy is available at
http://www.usg.edu/policymanual/section8/C224/#p8.2.16_sexual_harassment.
Notification of Future Changes – It is my responsibility to read and comply with the policies and procedures contained in
the USG Sexual Harassment Policy. I understand that the policies and procedures contained in it may change without
prior notice.
Acknowledgement of Policy – I hereby acknowledge the USG Sexual Harassment Policy for all Albany State University
Community members which includes but is not limited to employees, students, and volunteers. I recognize and
understand that Violations of USG and ASU policies may result in disciplinary action including dismissal or termination. I
acknowledge that I will abide by the policy.
Email Address:
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Full Name: Signature: Date:
Revised: June 11, 2018
Right to Know Training
Albany State University has incorporated policies to ensure that all faculty/staff acquire training and information
about hazardous chemicals in their work environment.
Click on (http://www.usg.edu/facilities/rtk-ghs/) for access to the "Right to Know Training." At the end of the
training, please complete the online form and print the certificate of completion. Note: If you are not able to
print the online certificate, please print out the page at the end of the training that states, 'Congratulations!
You have completed the Right-to Know Online Training program."
Either that page or the certificate MUST be brought to Human Resources to verify your Right to Know Training.
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Full Name: Signature: Date:
Revised: June 11, 2018
USG ETHICS POLICY AND TRAINING
ACKNOWLEDGEMENT STATEMENT
The University System of Georgia (USG) is committed to the highest ethical and professional standards of conduct in pursuit of its
mission to create a more educated Georgia. Accomplishing this mission demands integrity, good judgment and dedication to public
service from all members of the USG community. While the USG affirms each person’s accountability for individual actions, it also
recognizes that the shared mission and the shared enterprise of its institutions require a shared set of core values and ethical conduct
to which each member of the USG community must be held accountable. Furthermore, the USG acknowledges that an organizational
culture grounded in trust is essential to supporting these core values and ethical conduct.
The USG Ethics Policy applies to all members of the USG community. The USG community includes:
1.
All members of the Board of Regents;
2.
All individuals employed by, or acting on behalf of, the USG or one of the USG institutions, including volunteers, vendors,
and contractors; and,
3.
Members of the governing boards and employees of all cooperative organizations affiliated with the USG or one of its
institutions.
Members of the Board of Regents and all individuals employed by the USG or one of its institutions in any capacity shall participate in
USG Ethics Policy training, and shall certify compliance with the USG Ethics Policy on a periodic basis as provided in the USG Business
Procedures Manual. The USG Ethics Policy governs only official conduct performed by or on behalf of the USG. Violations of the USG
Ethics Policy may result in disciplinary action including dismissal or termination.
Training Requirement
All new employees are required to complete the USG Ethics Training course online in GeorgiaView. Completion of the training module
must be completed within thirty (30) days of your start date.
If you experience difficulties accessing the USG Ethics Training course in GeorgiaView, please contact asuonline@asurams.edu or call
317-6241. If you are unable to access your email account or need password assistance please email helpdesk@asurams.edu, visit the
ITS Help Desk (West campus: Building A or East campus: 1
st
floor JP Library) or call 229-430-4909.
Location of the Policy – I acknowledge that I have been informed that the USG Ethics Policy which is available on the USG website at:
http://www.usg.edu/audit/compliance/ethics/.
Notification of Future Changes – It is my responsibility to read and comply with the policies and procedures contained in the USG
Ethics Policy. I understand that the policies and procedures contained in it may change without prior notice.
Acknowledgement of Policy – I hereby acknowledge the USG Ethics Policy for all Albany State University (ASU) Community members
which includes but is not limited to employees, students, and volunteers. I recognize and understand that Violations of USG and ASU
policies may result in disciplinary action including dismissal or termination. I acknowledge that I will abide by the policy.
Email Address:
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Full Name: Signature: Date:
Revised: June 11, 2018
Jeanne Clery Act
Crime Statistics and Report Training for Campus Security Authorities
The Jeanne Clery Disclosure of Campus Security Policy and Campus Crime Statistics Act is the landmark federal law, originally
known as the Campus Security Act that requires colleges and universities across the United States to disclose information about
crime on and around their campuses. The directly relates to participation in federal student financial aid programs, therefore it
applies to most institutions of higher education both public and private. It is enforced by the U.S. Department of Education
(DOE).
The “Clery Act” is named in memory of 19-year-old Lehigh University freshman Jeanne Ann Clery who was raped and murdered
while asleep in her residence hall room on April 5, 1986. Jeanne’s parents discovered that students hadn’t been told about 38
violent crimes on the campus in the three years before her murder. They joined with other campus crime victims and persuaded
Congress to enact this law, which was originally known as the “Crime Awareness and Campus Security Act of 1990”. The law
was amended in 1992 to add a requirement that schools afford the victims of campus sexual assault certain basic rights, and
was amended again in 1998 to expand the reporting requirements. The 1998 amendments also formally named the law in
memory of Jeanne Clery.
What is a CSA?
CSA stands for “Campus Security Authority.” CSA’s are usually found in departments responsible for, but not limited to, student
and campus activities, safety/security, discipline, housing, human resources, or judicial proceedings. This designation also
includes any individual who has been specified by ASUPD to receive and report offenses. CSA’s are responsible for reporting
the number of crimes and incidents as described in the Clery Act that occur in their department to the ASU Police Department.
These numbers are then included in the federally-mandated Clery Report, which is distributed every year by October 1st.
How do I know what to report?
You must report all allegations of crimes that you determine are made in good faith as a statistic that will be included in the
Annual Security Report. Although law enforcement personnel may conclude after further investigation that some allegations
are not substantiated by the facts or the law, you must report information that is a reported to you. Neither a formal police
report nor an investigation is needed in order for a crime report to be included in these statistics. Your responsibility is to
provide as accurate and complete a description as possible of what happened, including the location and whether the victim or
alleged perpetrator was a student.
What crimes must I report?
The Annual Security Report must include statistics on nine types of crime:
Criminal Homicide - (A) Murder and Non- Negligent Manslaughter, and (B) Negligent Manslaughter;
Sex Offenses - (A) Forcible Sex Offenses and (B) Non-Forcible Sex Offenses;
Robbery;
Aggravated Assault;
Burglary;
Motor Vehicle Theft;
Arson;
Arrests and Disciplinary Referrals for liquor law violations, drug law violations, and illegal weapons possession; and
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Revised: June 11, 2018
Hate Crimes/bias.
Campus Police will ensure that crimes are properly classified.
Who must report campus crime?
In addition to the Police Department, Campus Security Authorities must report any crimes or incidents that may be crimes that
are reported to them. You are a Campus Security Authority if you fit any the following descriptions: 1. Individuals with Campus
Security responsibility staff assigned to security functions. 2. Designated Individuals – any individual or organization identified
on the campus as Clery Coordinator to which crimes must be reported.
If you are a pastoral counselor or professional counselor, use your judgement. When appropriate, you may tell a person you
are counseling about campus procedures for reporting crimes and confidentially for inclusion in the annual disclosure of crime
statistics report even if the person does not want to press charges or participate in an investigation. Procedures for reporting
crimes confidentially must be included in the Annual Safety and Fire Report.
What about timely warnings?
Immediate reporting of crimes allows the police to act in a timely fashion to investigate or otherwise address alleged crimes
that may present a clear danger to the campus community. All you need do is report the crime by calling the police. The ASU
Police Department is responsible for gathering the data for all crimes reported, and soliciting information from local police
agencies concerning crimes reported to them.
A copy of the Annual Safety and Fire Report and Compliance Statement can be found on the ASU website at www.asurams.edu.
Clery Coordinator
Sgt. LaShawnda Ethridge
Phone: (229) 894-0606
Lashawnda.ethridge@asurams.edu
Officials with Significant Responsibility for Student and Campus Activities campus officials who manage or otherwise oversee
students and campus activities, for example, staff responsible for campus student housing, a student center, or student extra-
curricular activities; a director of athletics or a team coach; faculty advisors to a student groups; staff responsible for student
discipline; campus judicial staff. Each campus must identify these individuals. The Clery Coordinator is responsible for ensuring
that they are aware of their responsibilities and report periodically. If you are a Campus Security Authority you must report
unless you are one of those whom the regulations define as exempt.
What about confidentiality?
The crime statistics included in the Annual Security Report do not include any information that would identify the victim or the
person accused of committing the crime. Your report to the Clery Coordinator should not include personally identifying
information. Make sure you advise the student that you will not release that information but that you are obligated to report
the alleged criminal conduct.
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Full Name: Signature: Date:
Revised: June 11, 2018
CLEARANCE PROCESS AND
EXIT INTERVIEW
PLEASE BE AWARE THAT IF YOU ARE TERMINATED OR IF YOU RESIGN FROM ALBANY STATE UNIVERSITY, YOU
MUST COMPLETE THE EXIT INTERVIEW PROCESS.
IMPORTANT: FINAL REVIEW OF ANY OUTSTANDING BALANCES OR ITS EQUIPMENT OWED MUST BE SETTELED
BEFORE AN EMPLOYEE RECEIVES HIS/HER FINAL VACATION PAYOUT. IN ADDITION, THE EMPLOYEE’S LAST PAY-
CHECK IS MAILED TO THE ADDRESS INDICATED IN ADP.
I UNDERSTAND THAT I AM REQUIRED TO COMPLETE THE EXIT/CLEARANCE PROCESS WITH THE OFFICE OF
HUMAN RESOURCES IF I SEVER EMPLOYMENT WITH THE UNIVERSITY.
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Full Name: Signature: Date:
Revised: June 11, 2018
New Health Insurance Marketplace Coverage
Affordable Care Act
Under the Affordable Care Act, the University System of Georgia, as your employer, is required to provide you this
notice.
If you have questions about the Health Insurance Marketplace, please visit the Federal Health Insurance Marketplace
website at https://www.healthcare.gov/families/. The State of Georgia has opted not to operate a Health Insurance
Marketplace and therefore, individuals in Georgia will use the federal Health Insurance Marketplace to enroll in
coverage.
The University System of Georgia’s Consumer Choice H.S.A. plan meets the Affordability Requirement under the
Affordable Care Act. Therefore, in general, University System of Georgia employees who are eligible for health
insurance will not be eligible for a tax credit in 2014 through the Health Insurance Marketplace (or Exchanges)
created under the Affordable Care Act.
I have read and understand that the University System of Georgia offer’s the Consumer Choice H.S.A. plan, which
meets the affordability requirement under the Affordable Care Act. I also understand that if I opt out of enrollment
into this plan at the time of hire, that I will be ineligible for any tax credit through the Marketplace. I also forfeit my
opportunity to enroll into a healthcare plan with Albany State University and must wait until Open Enrollment to
elect coverage, where coverage will not take effect until January 1
st
of the following year.
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