Fillable Orientation Checklist Part Time (Darton State College)

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Orientation Checklist Part Time (Darton State College)

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Full Name: ________________ Signature: ________________ Date: ________________
Revised: June 6, 2018
Orientation Checklist – Part Time
Part-Time Faculty Position Part-Time Staff Position
(Note: Employee must sign and return all documents below to HR)
Document Name
Employment Documentation
Personal & Emergency Contact Form(s)
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
Georgia Defined Exemption Form
Georgia Defined Retirement Enrollment Form
Retirement Participation Questionnaire Form
Policy Acknowledgements
Part-Time/Temporary Acknowledgment Statement
Equal Opportunity Employer
Faculty and Staff Handbook Acknowledgment Statement
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: ________________
*PERSONAL DATA 1
Name (please print)
Last Name:
First Name:
Hire Date:
Prefix:
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?
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 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:
F u l l N a m e : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ S i g n a t u r e : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ D a t e : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
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
Office of Human Resources Management
Outside Employment and Activities Form
Faculty/Staff members must complete this form and receive approval before an outside employment or any
outside activities 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 8.2.18.2 CONFLICTS OF INTEREST AND CONFLICTS OF COMMITMENT – A USG employee shall make every reasonable effort to
avoid actual or apparent conflicts of interests and also the appearance of a conflict of interest. An appearance of a conflict exists when a
reasonable person would conclude from circumstances that the employee’s ability to protect the public interest, or perform public
duties, is compromised by a personal, financial, or business interest. An appearance of conflict can exist even in the absence of a legal
conflict of interest. USG employees are referred to State Conflict of Interest Statutes O.C.G.A § 45-10-20 through § 45-10-70 and
institutional policies governing professional and outside activities.
Policy Change, Effective August 14, 2018
Form Revised, September 27, 2018
I hereby certify that the information listed above is true and complete.
Employee’s Name and Date
Form W-4 (2019)
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 2019
if both of the following apply.
• For 2018 you had a right to a refund of all
federal income tax withheld because you
had no tax liability, and
• For 2019 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 2019 expires February
17, 2020. 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 2019 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 not
subject to withholding 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
2019. 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 filing jointly 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 not subject to
withholding, 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 Additional
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 may 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 may be eligible to claim a
child tax credit for each of your eligible
children. To qualify, the child must be under
age 17 as of December 31, must be your
dependent who lives with you for more than
half the year, and must have a valid social
security number. 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 if you are filing a joint return.
Line F. Credit for other dependents.
When you file your tax return, you may be
eligible to claim a credit for other
dependents for whom a child tax credit
can’t be claimed, such as a qualifying child
who doesn’t meet the age or social
security number requirement for the child
tax credit, or a qualifying relative. To learn
more about this credit, see Pub. 972. 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
Separate here and give Form W-4 to your employer. Keep the worksheet(s) for your records.
Form W-4
Department of the Treasury
Internal Revenue Service
Employee’s Withholding Allowance Certificate
▶
Whether you’re entitled to claim a certain number of allowances or exemption from withholding is
subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.
OMB No. 1545-0074
2019
1 Your first name and middle initial Last name
Home address (number and street or rural route)
City or town, state, and ZIP code
2 Your social security number
3
Single Married Married, but withhold at higher Single rate.
Note: If married filing separately, check “Married, but withhold at higher Single rate.”
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.
▶
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 2019, and I certify that I meet both of the following conditions for exemption.
• Last year I had a right to a refund of all federal income tax withheld because I had no tax liability, and
• This year I expect a refund of all federal income tax withheld because I expect to have no tax liability.
If you meet both conditions, write “Exempt” here . . . . . . . . . . . . . . .
▶
7
Under penalties of perjury, I declare that I have examined this certificate and, to the best of my knowledge and belief, it is true, correct, and complete.
Employee’s signature
(This form is not valid unless you sign it.)
▶
Date
▶
8 Employer’s name and address (Employer: Complete boxes 8 and 10 if sending to IRS and complete
boxes 8, 9, and 10 if sending to State Directory of New Hires.)
9 First date of
employment
10 Employer identification
number (EIN)
For Privacy Act and Paperwork Reduction Act Notice, see page 4.
Cat. No. 10220Q
Form W-4 (2019)
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
0
0.00
Clear Form
Print Form
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
Form I-9 07/17/17 N
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)
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
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.
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 07/17/17 N
Page 2 of 3
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
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)
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)
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
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 07/17/17 N
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.
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.
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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:
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 ( )
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Revised: June 11, 2018
Exemption from Participation in the
Georgia Defined Contribution Plan
The Georgia Defined Contribution Plan (GDCP) was created by the 1992 Georgia Law, Under Georgia Law 996, and became effective
on July 1, 1997. The administration and responsibility for the GDCP is under the Board of Trustees of the Employees’ Retirement
System (ERS). The contributions to the Georgia Defined Contribution Plan are mandatory for any State Employee not covered under
a Retirement Plan sanctioned by the State (ERS or TRS).
Exclusion:
I meet requirements for exemption from the Defined Contribution plan because:
Yes No
I am an active member of Employee’s Retirement System of Georgia (ERS). Please provide a copy of
Paycheck stub from current employer or TRS Statement showing ongoing contributions are being made
I am an active member contributing to Teachers Retirement System of Georgia (TRS). Please provide a copy
Of paycheck stub from current employer or TRS Statement showing ongoing contributions are being made.
I am a retiree of Employee’s Retirement System of Georgia (ERS – Retiree).
I am a retiree of Teachers Retirement System of Georgia (TRS Retiree).
I am a person qualified as bona fide independent contractor. (Please provide contract).
I am a non-resident alien with F-1, J-1, or J-2 visas.
I am working for an institution in which that person is regularly enrolled and attending classes and meets IRS
Student exclusion criteria.
If you answered YES to any of the statements, you do not have to enroll in the Georgia Defined Contribution Plan.
If you answered NO to all the statements, you are required to enroll in the Georgia Defined Contribution Plan. Please proceed with
completing the attached Georgia Defined Enrollment Form on the next page.
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Revised: June 11, 2018
Georgia Defined Contributions
Enrollment Form
I have been informed that, as a temporary, seasonal, and part time (less than 50%) employee
of the State of Georgia, I am required to enroll into the Georgia Defined Retirement Plan
unless I meet one of the Exclusions Rule for enrollment.
I also confirm that I am not eligible for membership in the ERSGA (Employees Retirement
System of Georgia), the TRSGA (Teachers Retirement System of Georgia) or the ORP Optional
Retirement Plan at one of the University System of Georgia’s colleges or universities.
By enrolling into the Georgia Defined Contributions plan, my contributions will be 7.50% of my
gross salary before federal and state taxes. I further understand that if I terminate
employment, I may apply for a lump sum refund of contributions plus interest that has been
credited to my ERSGA Account online.
Name of Primary Beneficiary:
Address:
Name of Secondary Beneficiary:
Address:
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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.
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Revised: June 11, 2018
Part-time/Temporary Acknowledgment Statement
I am applying to work in a temporary position with Albany State University. I fully understand the following conditions of
employment as outlined:
1. If a temporary employee exceeds an average 30 or more hours per week and meets the definition of healthcare
eligibility under ACA, if they continue employment in a regular position, they will become eligible to enroll in
healthcare benefits. Otherwise, temporary employees are NOT eligible for healthcare benefits.
2. I am required to participate in the Georgia Defined Contribution Plan (GDCP), the state retirement plan for part time
employees. The required participation is 7.5% of my gross salary.
3. I am eligible to participate in the Deferred Compensation Plan (457b) and/or the Tax Sheltered Annuity Plan (403b).
I am interested in additional information for the Deferred Compensation Plan
I am interested in additional information for the Tax Sheltered Annuity Plan
I am not interested at this time
4. I will not accrue Annual or Sick Leave.
5. I have been approved for temporary employment not to exceed a total of 1,300 hours worked in a 12-consecutive
month period. The 1,300 hours can be accumulated in any combination during the 12 month period. Once a
temporary employee has worked 1,300 hours or has been employed for 12 consecutive months, whichever comes
first, the temporary employee must have a break in service of 26 weeks (6 ½ months).
6. As a temporary employee I may not work more than the total number of weekly hours approved for my temporary
position by the Human Resources Department at the time of my hire. I will only be scheduled for hours required to
meet the needs of the department. I will not necessarily be guaranteed a specific schedule or specific number of
hours. The department may decide not to schedule me for any hours.
7. To obtain regular employment with Albany State University, I understand that I must apply for regular positions
posted on university’s employment web page and must be selected for that position through the regular recruitment
process.
I accept this position with full understanding and acknowledgement of the conditions outlined.
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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.
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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.
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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.
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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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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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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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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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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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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: _______________________________
F u l l N a m e : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ S i g n a t u r e : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ D a t e : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
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
F u l l N a m e : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ S i g n a t u r e : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ D a t e : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
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.
F u l l N a m e : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ S i g n a t u r e : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ D a t e : ________________
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.
F u l l N a m e : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ S i g n a t u r e : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ D a t e : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
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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