Fillable Orientation Checklist Full-time Regular/with Benefits STAFF POSITION FACULTY (Darton State College)

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Orientation Checklist Full-time Regular/with Benefits STAFF POSITION FACULTY (Darton State College)

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  • 24 check-boxes
  • 304 other fields

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Orientation Checklist – Full-time Regular/with Benefits
STAFF POSITION FACULTY POSITION
NOTE: Employee must sign and return all documents below to HR.
Employment Documentation
Personal & Emergency Contact Forms(s)
Federal (W-4) Withholding Form
State (G-4) Withholding Form
I-9 Employment Eligibility Form (Including I-9 documents) –
Submit I9 form and documents within first 3 days of Employment
BOR Security Questionnaire (Must be notarized by a Notary)
Outstanding Wages Beneficiary Form (Must be notarized by a Notary)
Direct Deposit Form (Voided check/ACH deposit form required).
(Do not Submit Counter Checks or Bank Deposit Slips )
Retirement Benefit Documentation
Board of Regents TRS/ORP Retirement Election Form
Retirement@Work Acknowledgment form – Note:
This process must be completed in OneUSG the first week of hire.
Policy Acknowledgements
Equal Opportunity Employer
Faculty and Staff Handbook Acknowledgement Statement
Classified Employment (Note: Do not sign if you are Faculty and are teaching classes)
Provisional Appointment (Note: Do not sign if you are Staff)
Confidentiality & Security Access Acknowledgment Statement
Conflicts of Interest/Fiscal Misconduct
Fraud, Waste and Abuse Acknowledgment Statement
Drug-Free Campus Acknowledgment Statement
Sexual Harassment Acknowledgement Statement
Right to Know Training –
Complete On-line (Print out Certificate)
USG Ethics Acknowledgement Statement
Jeanne Clery Act Acknowledgement Statement
Exit/Clearance Process Acknowledgement Statement
Health Benefits Enrollment
Benefits Enrollment Acknowledgement form – Note: This process must be completed in OneUSG the first week of hire.
Outside Employment Form (NOTE: Complete if you are employed outside of ASU)
HR’s Name: _______________________________ Signature: _________________________ Date: __________
Full Name: ________________________________ Signature: _________________________ Date: __________
Revised: March 3, 2020
Date of Hire:
Date I9 Due:
CLEAR ALL
*PERSONAL DATA 1
Name (please print)
Last Name:
First Name:
Hire Date:
Prefix:
Social Security Number:
Dr.
Miss
Mister
Mrs.
Ms.
Current Address
City
County
State
Zip Code
Phone #
*PERSONAL DATA 2
Gender:
Marital Status:
Highest Education?
Male
Married
Single
High School
Associates
Bachelors
Female
Widow
Masters
Doctorate
Full-time
Student?
YES
NO
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)
Ethnic Group:
White American Indian Asian African American
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:
F u l l N a m e : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ S i g n a t u r e : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ D a t e : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
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
Form W-4
2020
Employee’s Withholding Certificate
Department of the Treasury
Internal Revenue Service
▶
Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay.
▶
Give Form W-4 to your employer.
▶
Your withholding is subject to review by the IRS.
OMB No. 1545-0074
Step 1:
Enter
Personal
Information
(a) First name and middle initial Last name
Address
City or town, state, and ZIP code
(b) Social security number
▶
Does your name match the
name on your social security
card? If not, to ensure you get
credit for your earnings, contact
SSA at 800-772-1213 or go to
www.ssa.gov.
(c)
Single or Married filing separately
Married filing jointly (or Qualifying widow(er))
Head of household (Check only if you’re unmarried and pay more than half the costs of keeping up a home for yourself and a qualifying individual.)
Complete Steps 2–4 ONLY if they apply to you; otherwise, skip to Step 5. See page 2 for more information on each step, who can
claim exemption from withholding, when to use the online estimator, and privacy.
Step 2:
Multiple Jobs
or Spouse
Works
Complete this step if you (1) hold more than one job at a time, or (2) are married filing jointly and your spouse
also works. The correct amount of withholding depends on income earned from all of these jobs.
Do only one of the following.
(a) Use the estimator at www.irs.gov/W4App for most accurate withholding for this step (and Steps 3–4); or
(b)
Use the Multiple Jobs Worksheet on page 3 and enter the result in Step 4(c) below for roughly accurate withholding; or
(c)
If there are only two jobs total, you may check this box. Do the same on Form W-4 for the other job. This option
is accurate for jobs with similar pay; otherwise, more tax than necessary may be withheld . . . . .
▶
TIP: To be accurate, submit a 2020 Form W-4 for all other jobs. If you (or your spouse) have self-employment
income, including as an independent contractor, use the estimator.
Complete Steps 3–4(b) on Form W-4 for only ONE of these jobs. Leave those steps blank for the other jobs. (Your withholding will
be most accurate if you complete Steps 3–4(b) on the Form W-4 for the highest paying job.)
Step 3:
Claim
Dependents
If your income will be $200,000 or less ($400,000 or less if married filing jointly):
Multiply the number of qualifying children under age 17 by $2,000
▶
$
Multiply the number of other dependents
by $500 . . . .
▶
$
Add the amounts above and enter the total here . . . . . . . . . . . . .
3 $
Step 4
(optional):
Other
Adjustments
(a)
Other income (not from jobs). If you want tax withheld for other income you expect
this year that won’t have withholding, enter the amount of other income here. This may
include interest, dividends, and retirement income . . . . . . . . . . . .
4(a) $
(b) Deductions. If you expect to claim deductions other than the standard deduction
and want to reduce your withholding, use the Deductions Worksheet on page 3 and
enter the result here . . . . . . . . . . . . . . . . . . . . .
4(b) $
(c) Extra withholding. Enter any additional tax you want withheld each pay period .
4(c)
$
Step 5:
Sign
Here
Under penalties of perjury, I declare that this certificate, to the best of my knowledge and belief, is true, correct, and complete.
▲
Employee’s signature (This form is not valid unless you sign it.)
▲
Date
Employers
Only
Employer’s name and address First date of
employment
Employer identification
number (EIN)
For Privacy Act and Paperwork Reduction Act Notice, see page 3.
Cat. No. 10220Q
Form W-4 (2020)
Albamy State University
2400 Gillionvile Road
Abany, Georgia 31707
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. ADDITIONAL ALLOWANCES 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
FORM G-4 (Rev. 01/04) STATE OF GEORGIA
EMPLOYEE’S WITHHOLDING ALLOWANCE CERTIFICATE
HOME ADDRESS (Number, Street, or Rural Route) CITY, STATE AND ZIP CODE
1. YOUR FULL NAME 2. YOUR SOCIAL SECURITY NUMBER
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#:
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 5. ADDITIONAL ALLOWANCES ........... [ ]
spouse working: enter 0 or 1 or 2............... [ ]
(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)
PLEASE READ INSTRUCTIONS ON REVERSE SIDE BEFORE COMPLETING LINES 3 - 8
Albany State University
2400 Gillionville Road
Albany, Georgia 31707
0
0.00
Clear Form
Print Form
USCIS
Form I-9
OMB No. 1615-0047
Expires 10/31/2022
Employment Eligibility Verification
Department of Homeland Security
U.S. Citizenship and Immigration Services
Form I-9 10/21/2019
Page 1 of 3
►START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically,
during completion of this form. Employers are liable for errors in the completion of this form.
ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an
employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the
documentation presented has a future expiration date may also constitute illegal discrimination.
Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form I-9 no later
than the first day of employment, but not before accepting a job offer.)
Last Name (Family Name)
First Name (Given Name)
Middle Initial
Other Last Names Used (if any)
Address (Street Number and Name)
Apt. Number
City or Town
State
ZIP Code
Date of Birth (mm/dd/yyyy)
-
-
Employee's E-mail Address
Employee's Telephone Number
U.S. Social Security Number
1. A citizen of the United States
2. A noncitizen national of the United States (See instructions)
3. A lawful permanent resident
4. An alien authorized to work until
(See instructions)
(expiration date, if applicable, mm/dd/yyyy):
(Alien Registration Number/USCIS Number):
Some aliens may write "N/A" in the expiration date field.
I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in
connection with the completion of this form.
I attest, under penalty of perjury, that I am (check one of the following boxes):
Aliens authorized to work must provide only one of the following document numbers to complete Form I-9:
An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.
1. Alien Registration Number/USCIS Number:
2. Form I-94 Admission Number:
3. Foreign Passport Number:
Country of Issuance:
OR
OR
QR Code - Section 1
Do Not Write In This Space
Signature of Employee
Today's Date (mm/dd/yyyy)
Preparer and/or Translator Certification (check one):
I did not use a preparer or translator. A preparer(s) and/or translator(s) assisted the employee in completing Section 1.
(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)
I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my
knowledge the information is true and correct.
Signature of Preparer or Translator
Today's Date (mm/dd/yyyy)
Last Name (Family Name)
First Name (Given Name)
Address (Street Number and Name)
City or Town
State
ZIP Code
Employer Completes Next Page
Form I-9 10/21/2019
Page 2 of 3
USCIS
Form I-9
OMB No. 1615-0047
Expires 10/31/2022
Employment Eligibility Verification
Department of Homeland Security
U.S. Citizenship and Immigration Services
Section 2. Employer or Authorized Representative Review and Verification
(Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You
must physically examine one document from List A OR a combination of one document from List B and one document from List C as listed on the "Lists
of Acceptable Documents.")
Last Name (Family Name) M.I.
First Name (Given Name)
Employee Info from Section 1
Citizenship/Immigration Status
List A
Identity and Employment Authorization
Identity
Employment Authorization
OR List B AND List C
Additional Information
QR Code - Sections 2 & 3
Do Not Write In This Space
Document Title
Issuing Authority
Document Number
Expiration Date (if any) (mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any) (mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any) (mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any) (mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any) (mm/dd/yyyy)
Certification: I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee,
(2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the
employee is authorized to work in the United States.
The employee's first day of employment (mm/dd/yyyy):
(See instructions for exemptions)
Today's Date (mm/dd/yyyy)
Signature of Employer or Authorized Representative
Title of Employer or Authorized Representative
Last Name of Employer or Authorized Representative
First Name of Employer or Authorized Representative
Employer's Business or Organization Name
Employer's Business or Organization Address (Street Number and Name)
City or Town
State
ZIP Code
Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.)
A. New Name (if applicable)
Last Name (Family Name)
First Name (Given Name)
Middle Initial
B. Date of Rehire (if applicable)
Date (mm/dd/yyyy)
Document Title Document Number
Expiration Date (if any) (mm/dd/yyyy)
C. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes
continuing employment authorization in the space provided below.
I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if
the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual.
Signature of Employer or Authorized Representative
Today's Date (mm/dd/yyyy)
Name of Employer or Authorized Representative
Albany State University
2400 Gillionville Road
Albany GA 31707
LISTS OF ACCEPTABLE DOCUMENTS
All documents must be UNEXPIRED
Employees may present one selection from List A
or a combination of one selection from List B and one selection from List C.
LIST A
2. Permanent Resident Card or Alien
Registration Receipt Card (Form I-551)
1. U.S. Passport or U.S. Passport Card
3. Foreign passport that contains a
temporary I-551 stamp or temporary
I-551 printed notation on a machine-
readable immigrant visa
4. Employment Authorization Document
that contains a photograph (Form
I-766)
5. For a nonimmigrant alien authorized
to work for a specific employer
because of his or her status:
Documents that Establish
Both Identity and
Employment Authorization
6. Passport from the Federated States
of Micronesia (FSM) or the Republic
of the Marshall Islands (RMI) with
Form I-94 or Form I-94A indicating
nonimmigrant admission under the
Compact of Free Association Between
the United States and the FSM or RMI
b. Form I-94 or Form I-94A that has
the following:
(1) The same name as the passport;
and
(2) An endorsement of the alien's
nonimmigrant status as long as
that period of endorsement has
not yet expired and the
proposed employment is not in
conflict with any restrictions or
limitations identified on the form.
a. Foreign passport; and
For persons under age 18 who are
unable to present a document
listed above:
1. Driver's license or ID card issued by a
State or outlying possession of the
United States provided it contains a
photograph or information such as
name, date of birth, gender, height, eye
color, and address
9. Driver's license issued by a Canadian
government authority
3. School ID card with a photograph
6. Military dependent's ID card
7. U.S. Coast Guard Merchant Mariner
Card
8. Native American tribal document
10. School record or report card
11. Clinic, doctor, or hospital record
12. Day-care or nursery school record
2. ID card issued by federal, state or local
government agencies or entities,
provided it contains a photograph or
information such as name, date of birth,
gender, height, eye color, and address
4. Voter's registration card
5. U.S. Military card or draft record
Documents that Establish
Identity
LIST B
OR AND
LIST C
7. Employment authorization
document issued by the
Department of Homeland Security
1. A Social Security Account Number
card, unless the card
includes one of
the following restrictions:
2. Certification of report of birth issued
by the Department of State (Forms
DS-1350, FS-545, FS-240)
3. Original or certified copy of birth
certificate issued by a State,
county, municipal authority, or
territory of the United States
bearing an official seal
4. Native American tribal document
6. Identification Card for Use of
Resident Citizen in the United
States (Form I-179)
Documents that Establish
Employment Authorization
5. U.S. Citizen ID Card (Form I-197)
(2) VALID FOR WORK ONLY WITH
INS AUTHORIZATION
(3) VALID FOR WORK ONLY WITH
DHS AUTHORIZATION
(1) NOT VALID FOR EMPLOYMENT
Page 3 of 3
Form I-9 10/21/2019
Examples of many of these documents appear in the Handbook for Employers (M-274).
Refer to the instructions for more information about acceptable receipts.
USO/AH/11.14.07
Page 1
Board of Regents
University System of Georgia
University System Office
SECURITY QUESTIONNAIRE
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.
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 2
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
State of County
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
(Signature of Employee)
This day of ,
Month Year
____________________________________________________
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.
F u l l N a m e : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ S i g n a t u r e : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ D a t e : _________ _______
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:
ALBANY STATE UNIVERSITY
OPTIONAL RETIREMENT PLAN ENROLLMENT FORM
I have elected to participate in the Optional Retirement Plan (ORP) of the University System of Georgia. In
making this election, I understand that under current law, my decision is irrevocable. My contributions to the
Optional Retirement Plan should be sent to the following company.
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)
Office of Human Resources Management
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.
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 ( )
TRS/ORP RETIREMENT ELECTION FORM
Teachers Retirement System (TRS) Defined Benefit Plan
In this type of plan, your retirement benefit 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 Contribution Plan
This type of plan is similar to a 401(k) in which you have your own account and make your own investment
decisions.
For more information regarding the plans above, visit the University System of Georgia’s website at:
http://retirement.usg.edu
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 %
Valic %
ORP Participants are responsible for setting up an account and making investment elections directly with their
vendor(s) of choice. Changes to vendor allocations can be made via the Retirement@Work tile in the OneUSG
system after 7/3/2019. 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.
Print Name Date
Signature
Revised 5.06.2019
"Creating A More Educated Georgia"
www.usg.edu
Retirement@Work
USG Mandatory Retirement Plan
I acknowledge and understand that I am responsible for logging into the OneUSG
Connect Self-Service System and enrolling into my retirement plan with one of the
two mandatory retirement plans. The two retirement plans are Teachers
Retirement System of Georgia and the Optional Retirement Plan.
I understand that I will receive an e-mail giving me instructions on how to enroll
into my retirement plan.
I understand that my enrollment must take place within the first week of hire and
I will notify Human Resources upon completion of my enrollment.
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F u l l N a m e : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ S i g n a t u r e : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ D a t e : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
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.
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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.
F u l l N a m e : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ S i g n a t u r e : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ D a t e : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
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.
F u l l N a m e : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ S i g n a t u r e : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ D a t e : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
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.
F u l l N a m e : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ S i g n a t u r e : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ D a t e : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
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.
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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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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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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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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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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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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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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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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.
F u l l N a m e : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ S i g n a t u r e : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ D a t e : _________ _______
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.
F u l l N a m e : _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ S i g n a t u r e : _ _ _ _ __ _ _ _ _ _ _ _ __ _ D a t e : _ _ __ _ _ _ _ _ _ _ _ _ _ _ _
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.
OneUSG Connect Benefits
Benefits Enrollment
I acknowledge and understand that I am responsible for logging into the OneUSG
Connect Benefits Portal within the OneUSG Connect Self-Service System and
enrolling into my health benefits the first week of hire.
I understand that I will receive an e-mail giving me instructions on how to enroll
into my health benefit plan from Human Resources.
I understand that my enrollment must take place within the first week of hire and
I will notify Human Resources upon completion of my enrollment.
F
u l l N a m e : _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ S i g n a t u r e : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ D a t e : _________ _______
Revise 12.15.19
Purpose: This form should be completed by Albany State University (ASU) employees
(faculty and staff) seeking approval to engage in compensated outside activities that relate to
their expertise or responsibilities as an ASU employee. Such activities include consulting,
teaching, speaking, and participating in business, professional, or service enterprises.
Completed forms should be forwarded through your supervisor to the appropriate Dean,
Department Head, Vice President, Associate Provost, or Director of your college, school, or
unit for approval. An employee is not required to obtain written approval prior to engaging in
compensated outside activities that do not relate to the employee’s expertise or responsibility
as an ASU employee.
Policy Requirement: In accordance with Board of Regents Policy 8.2.18.2 Conflicts of Interest,
Conflicts of Commitment, and Outside Activities, each ASU employee with a work commitment
of 30 or more hours per week must obtain written approval in advance from the Dean,
Department Head, Vice President, Associate Provost, or Director of the employee’s college,
school, or unit of primary employment prior to engaging in compensated outside activities that
relate to the employee’s expertise or responsibilities as a ASU employee. Non-faculty employees
must take annual leave when engaged in outside activities during work hours.
Please provide the information requested below:
Name:
Title:
School/College/Unit:
Department:
Email:
1. Information Regarding the Business or Organization that is the Subject of this Request
(Organization):
Name:
Primary Contact:
Email:
Phone:
Albany State University
Compensated Outside Activities
Approval Form
Revise 12.15.19
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
Address:
2. Dates of Proposed Outside Work
Note: All dates must fall within a single fiscal year ending on June 30.
Starting Date (MM/DD/YYYY):
Ending Date (MM/DD/YYYY):
Note: If work is expected to extend beyond June 30, a separate Approval Form must be
submitted for the next fiscal year.
Total # of hours:
Total # of months:
Avg. # of hours per month:
3. What services or activities will you engage in on behalf of this organization? Check all
that apply.
_____ Consulting Board of Directors
Officer/Manager Instruction
Other
Provide details regarding any activities you will engage in on behalf of this
organization:
4. What compensation will you receive from this organization for the proposed outside
activities? Check all that apply:
Salary Expense Reimbursements
Honoraria Royalties
_____ Travel Costs _____ Loans
_____ Gifts or other things of Value _____ Equity/Ownership Interest
Revise 12.15.19
_____
_____
_____
_____
_____
_____
Provide details to include amounts of anything of value to be received:
5. Missed University Work
Identify any ASU classes, meeting, or responsibilities that will be missed because of this
proposed Outside Work, and what arrangements are proposed to cover any missed
responsibilities:
6. Is the organization a for-profit organization? Yes No
7. Do you have any intellectual property that will be used or licensed to this organization?
Yes No N/A If yes, please provide relevant details:
8. To your knowledge, does the organization receive federal funding as it relates to the
work you would be performing? Yes No
9. Is the organization a vendor of Albany State University? Yes No
Revise 12.15.19
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
“Vendor” means any person who sells to or contracts with ASU for the provision of any goods
or services.
10. Do you or anyone you supervise participate in or approve of the purchase of products
or services from this organization in the role of a ASU employee?
Yes No
If yes, please provide relevant details:
11. Do you, or members of your immediate family, have any ownership in this
organization?
Yes No
12. Is the organization owned by a member of the institution’s faculty or staff?
Yes No
If yes, please provide details:
13. In the past 12 months, have you received any of the following from this organization?
Check all that apply.
Salary Loans
Honoraria Travel Costs
Royalties Gifts or other things of value
Expense Reimbursements
Provide details of anything of value received:
14. Will ASU students, interns, trainees, post-doctoral students or other ASU employees
participate in the activities of this organization?
Yes No N/A
Revise 12.15.19
_____
_____
______
______
______
If yes, please provide relevant details:
15. Will any ASU property or resources be used in the execution of your activities with this
organization?
Yes No
If yes, please provide relevant details, including your plan to reimburse the institution:
I hereby swear or affirm that the information provided below is true and correct to the best
of my knowledge.
Signature of submitting employee Date
To be completed by authorizing representatives:
Review by employee’s immediate supervisor: Completed
Supervisor’s Name:
Review by ASU President or Designee:
Approved
Approved with below-listed restrictions
Disapproved
Revise 12.15.19
Restrictions:
Name
Title
Authorized Signature Date
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Orientation Checklist Full-time Regularwith Benefits STAFF POSITION FACULTY (Darton State College)

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Completed 25 July 2020

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