Fill - Free fillable Orientation Checklist Work Study (Darton State College) PDF form

Office of Human Resources Management

OrientationChecklist–Work‐Study

Work‐StudyStudentmustsignandreturnalldocumentsbelowtotheOfficeofHumanResources.

DocumentName



EmploymentDocumentation

PersonalDataANDEmergencyContactForm(s)

Federal(W‐4)WithholdingForm

State(G‐4)WithholdingForm

I‐9EmploymentEligibilityForm(IMP O RTA N T:Includecopiesofrequire dI‐9documents)

DirectDepositForm(Voidedcheck/ACHdepositformrequired)

EqualOpportunityEmployer

PolicyAcknowledgements

Confidentiality&SecurityAccess

PolicyConflictsofInterest/Fiscal

MisconductFraud,WasteandAbuse

Drug‐FreeCampusPolicy

SexualHarassment

USGEthicsPolicyandD2LTraining

JeanneCleryAct

Sterling Background Check Forms

UPDATED: JANUARY 24, 2019

Page 1

*PERSONAL DATA 1

Name (please print)

Last Name:

First Name:

Middle 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

Date of Birth:

Birth Country:

Date of Marriage:

Email Address:

How did you find out about this job?

Applicant Clearinghouse

Internet

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

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:

Page 2

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

Page 3

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

Single Married Married, but withhold at higher Single rate.

Note: If married filing separately, check “Married, but withhold at higher Single rate.”

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 . . . . . . . . . . . . . . .

▶

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)

Page 4

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

Page 5

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:

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

Page 6

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.

Page 7

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 ( )

Page 8

Sterling Talent Solutions / 4511 Rockside Rd. 4th Floor / Independence, OH 44131

Tel: 800-943-2589 / fax: 866-685-9426 / www.sterlingtalentsolutions.com

The Georgia Bureau of Investigation consent form is needed to complete a statewide criminal search in

Georgia.

The applicant must complete the following steps:

Step 1: The top portion of the form must be completed in its entirety and signed by the applicant.

• Full Name (last name, first name, middle name)

• Address

• Sex

• Race

• Date of Birth

• Social Security Number

• Signature

• Date

Step 2: The lower portion of the form must be completed

• Check applicable employment provisions

• Enter your first and last name to consent to periodic criminal history background checks for the

duration of your employment with this company OR authorize the validity for a designated

amount of time from the date of signature.

Step 3: Fax or Email Instructions

• Once you have completed the form, please fax or email a copy to Sterling at:

o 866-685-9426 or CrimAwaitingInfo@sterlingts.com

If you have any questions please call 800-943-2589 to speak with a client services representative.

Page 9

Sterling Talent Solutions / 4511 Rockside Rd. 4th Floor / Independence, OH 44131

Tel: 800-943-2589 / fax: 866-685-9426 / www.sterlingtalentsolutions.com

Georgia Bureau of Investigation

Georgia Crime Information Center

Consent Form

I hereby authorize Sterling Infosystems, Inc dba Sterling Talent Solutions to receive any

Georgia criminal history record information pertaining to me which may be in the files of any

state or local criminal justice agency in Georgia.

Full Name

Address

Sex Race Date of Birth Social Security Number

Signature Date

Special employment provisions (check if applicable):

 Emp

loyment with mentally disabled (Purpose code ‘M’ )

 Employment with elder care (Purpose code ‘N’ )

 Employment with children (Purpose code ‘W’ )

 Employment with criminal justice agency – non-sworn (Purpose code ‘J’ )

 Employment with criminal justice agency – sworn (Purpose code ‘Z’ )

One of the following must be checked:

This authorization is valid for 90/180/___ (circle one) days from date of signature.

I, ___________________________ give consent to the above name to perform periodic criminal

history background checks for the duration of my employment with this company

Page 10

Rev. 3.15.2015

AUTHORIZATION

I have carefully read and understand the separate background check disclosure document and the below

authorization form. I have received a copy of the “Summary of Your Rights Under the Fair Credit Reporting

Act” and any applicable state or local notices of rights provided with these documents. I have had the

opportunity to review my rights. By my signature below, I consent to the preparation of background reports

by Sterling Talent Solutions, and to the release of such reports to the Company and its designated

representatives for the purpose of assisting the Company in making a determination as to my eligibility for

employment, promotion, retention, contract assignment or for other lawful purposes.

I understand that, to the extent allowed by law, information contained in my job application or otherwise

disclosed to the Company by me before or during my employment or contract assignment, if any, may be

utilized for the purpose of obtaining such consumer reports and/or investigative consumer reports about me.

I understand that nothing herein shall be construed as an offer of employment or contract for services.

I hereby authorize law enforcement agencies, learning institutions (including public and private schools and

universities), information service bureaus, credit bureaus, record/data repositories, courts

(federal/state/local), motor vehicle record agencies, my past or present employers, the military, and other

individuals or sources to furnish any and all information on me that is requested by the consumer reporting

agency.

By my signature (including electronic) below, I certify the information provided on and in connection with this

form is true, accurate, and complete. I agree that this form in original, faxed, photocopied or electronic

form will be valid for any background reports that may be requested by or on behalf of the Company.

First Name:

Full Middle Name:

Last Name:

Social Security Number:

Date of Birth

Email Address

Signature: Date:

 CALIFORNIA, MASSACHUSETTS, MINNESOTA, NEW JERSEY, and OKLAHOMA applicants or residents:

You have a right to request a free copy of your report. Please check here if you would like [Company Name]

to provide you with a copy of your report. [NO CHANGES ALLOWED]

Page 11

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.

Page 12

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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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

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: _______________________________

Page 18

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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

Captain 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.

Page 20

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