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02.20.2020
ELECTION WORKERS ONBOARDING CHECKLIST
Name: ___________________________________ Date: _____________________________
Please check off each box as completed and submitted. Return this form with
required documents.
1. Photocopy of your unexpired MA Driver’s License OR MA ID Card OR Military Card.
2. Photocopy of your U.S. Passport. If you do not have a valid U.S. Passport, you may provide
a photocopy of your Social Security Card OR Birth Certificate*. (If you do not have access to
a copy machine, please bring the required identification documents to the City Clerk’s Office
and we will make copies for you).
*If you were born in Fitchburg you do not need to provide us with a copy of your birth
certificate because we will have it on record. If you were born in Fitchburg, please
indicate below by providing your birth date, birth name and parents’ names.
YES, I WAS BORN IN FITCHBURG, MA:
Name at birth: ___________________________________________
Date of Birth: ___________________________________________
Mother’s Name: ___________________________________________
Father’s Name: ___________________________________________
3. City of Fitchburg Employment Application
4. Criminal Offender Record Information (CORI) Acknowledgement Form.
5. CORI Subject Information Form – TOP HALF ONLY. Do not write below the line entitled
“Subject Verification”
6. Employee Data Form
7. W-4 (Please note, you may complete any section of the W-4 you wish, however, the only
required sections for submission are Step 1, entitled “Enter Personal Information” and Step
5, entitled “Sign Here”.
8. Employee Eligibility Verification Form (Form I-9)
9. Massachusetts DOR – New Hire/Independent Contractor Reporting Form
10. Acknowledgement Form of Receipt of Policies (Enclosed you will find copies of the City of
Fitchburg’s Harassment, Discrimination and Sexual Harassment Policy and Drug and
Alcohol Policy for your review. Please keep these copies for your reference. Only the
Acknowledgement Form should be returned to our office).
Employment Application Form
Applicant Information
Full Name:
Date:
Last
First
M.I.
Address:
Street Address
Apartment/Unit #
City
State
Phone:
E-mail Address:
Date Available:
Position Applied for:
Are you eligible to work in the United States?
YES NO
Employment Desired?
Full
Time
Part
Time
Have you ever worked for this organization?
YES NO
Hours of work
(per week)
desired?
Have you ever been convicted of a felony?
YES NO
If yes, explain:
(Number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were committed, and sentence(s) imposed)
Education
High School
Address:
Did you graduate?
YES
NO
Degree:
College
Address:
Did you graduate?
YES
NO
Degree:
Other
Address:
Did you graduate?
YES
NO
Degree:
Source of Advertisement: _______________________________________
Please list any professional licenses, certifications or registrations you currently hold:
Rev. 05.11.2019
Previous Employment
Company:
Phone:
Address:
Supervisor:
Job Title:
Responsibilities:
From:
To:
Reason for Leaving:
May we contact your previous supervisor for a reference?
YES NO
Company:
Phone:
Address:
Supervisor:
Job Title:
Responsibilities:
From:
To:
Reason for Leaving:
May we contact your previous supervisor for a reference?
YES NO
Company:
Phone:
Address:
Supervisor:
Job Title:
Responsibilities:
From:
To:
Reason for Leaving:
May we contact your previous supervisor for a reference?
YES NO
Rev. 05.11.2019
2
Military Service
Branch:
From:
To:
Rank at Discharge:
Are you a U.S. Veteran?
YES
NO
References
Please list three professional references.
Full Name:
Relationship:
Company:
Phone/Work:
Address:
Full Name:
Relationship:
Company:
Phone/Work:
Address:
Full Name:
Relationship:
Company:
Phone/Work:
Address:
Rev. 0
5.11.2019
3
E-Mail Address: ___________________________________
Cell:________________
Cell:
__________________
E-Mail Address:
___________________________________
E-Mail Address:
Cell:
_________________
___________________________________
Disclaimer and Signature
I certify that my answers are true and complete to the best of my knowledge and that intentional misrepresentations or
omissions may be cause for the rejection of my application and that if hired I may be released from employment.
I understand that the City of Fitchburg may require me to successfully complete a pre-employment drug and alcohol test
as a condition of employment and that continued employment may be based on the successful completion of similar
tests.
I understand that the City of Fitchburg may as part of the hiring process request an investigative consumer report from a
third party entity or agency including information concerning my character, general reputation, criminal record, personal
characteristics, credit records, and mode of living. I may make a written request to the City to provide me with
additional information regarding the nature and scope of any such report.
I understand that employment with the City of Fitchburg is “at will” and nothing in the interview or hiring process, this
application, or City of Fitchburg policies are intended to create an employment contract between myself and the City of
Fitchburg. Employment may be terminated by either party at any time for any reason with or without notice.
Signature:
Date:
Rev. 05.11.2019
4
THE COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF PUBLIC SAFETY AND SECURITY
Department of Criminal Justice Information Services
200 Arlington Street, Suite 2200, Chelsea, MA 02150
TEL: 617-660-4640 | TTY: 617-660-4606 | FAX: 617-660-5973
MASS.GOV/CJIS
1
Criminal Offender Record Information (CORI)
Acknowledgement Form
is registered under the
(Organization)
provisions of M.G.L. c.6, § 172 to receive CORI for the purpose of screening current and otherwise qualified prospective
employees, subcontractors, volunteers, license applicants, current licensees, and applicants for the rental or lease of
housing.
As a prospective or current employee, subcontractor, volunteer, license applicant, current licensee, or applicant for the
rental or lease of housing, I understand that a CORI check will be submitted for my personal information to the DCJIS. I
hereby acknowledge and provide permission to
(Organization)
to submit a CORI check for my information to the DCJIS. This authorization is valid for one year from the date of my
signature. I may withdraw this authorization at any time by providing
(Organization)
with written notice of my intent to withdraw consent to a CORI check.
FOR EMPLOYMENT, VOLUNTEER, AND LICENSING PURPOSES ONLY:
The may conduct
(Organization)
subsequent CORI checks within one year of the date this Form was signed by me, provided, however, that
, must first provide me
(Organization)
with written notice of this check.
By signing below, I provide my consent to a CORI check and affirm that the information provided on Page 2 of this
Acknowledgement Form is true and accurate.
Signature of CORI Subject Date
To be used by organizations conducting CORI checks for employment, volunteer, subcontractor, licensing, and housing
purposes.
CITY OF FITCHBURG
CITY OF FITCHBURG
CITY OF FITCHBURG
CITY OF FITCHBURG
CITY OF FITCHBURG
THE COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF PUBLIC SAFETY AND SECURITY
Department of Criminal Justice Information Services
200 Arlington Street, Suite 2200, Chelsea, MA 02150
TEL: 617-660-4640 | TTY: 617-660-4606 | FAX: 617-660-5973
MASS.GOV/CJIS
2
*
First Name: Middle Initial:
*
Last Name: Suffix (Jr., Sr., etc.):
Former Last Name 1:
Former Last Name 2:
Former Last Name 3:
Former Last Name 4:
*
Date of Birth (MM/DD/YYYY): Place of Birth:
*
Last SIX digits of Social Security Number: ‐‐
Sex: Height: ft. in. Eye Color: Race:
Driver’s License or ID Number: State of Issue:
* Father’s Full Name:
* Mother’s Full Name (including Maiden Name): ________________________________________________________________
*
Street Address:
Apt. # or Suite: *City: *State: *Zip:
The above information was verified by reviewing the following form(s) of government‐issued identification:
Verified by:
Print Name of Verifying Employee
Signature of Verifying Employee Date
SUBJECT VERIFICATION
SUBJECT INFORMATION
Please complete this section using the information of the person whose CORI you are
requesting.
The fields marked with an asterisk (*) are required fields.
Current Address
City of Fitchburg
Payroll Action and
Employee Data Form
PERSONAL INFORMATION
Last Name
First Name
Middle Name:
Preferred Name:
Date of Birth(MM/DD/YYYY):
I identify my gender as:
Marital Status:
Single
Married
Civil Service
Veteran
YES
NO
YES
NO
Department
Position Title
Location Code
Org/Object
Group/Contract/Classification
Step
Position Type
# Hours per Week
Rate
Rate
Frequency
Retirement
Type:
New Hire
Documentation
attached, if any:
Birth Certificate
Form DD214
(Veterans
Only)
EMPLOYEE CONTACT INFORMATION
EMERGENCY CONTACT INFORMATION
MAILING ADDRESS:
(Number, Street)
City
State
Zip Code
Address:
(Number, Street)
Apt. #
City
State
Zip Code
)
Telephone:
Home:
)
-
Preferred:
_)
Telephone:
Home:
-
_)
-
PERSONAL E-MAIL ADDRESS:
RELATIONSHIP TO EMPLOYEE:
DEMOGRAPHIC INFORMATION
RACE: (select one or more):
Asian
American Indian
African American
Pacific Islander or Native Hawaiian
Caucasian
Department Head Name (Printed) Department Head Signature
Date
PRINT
SAVE
FORM
CLEAR
FORM
Employee #:
EFFECTIVE DATE of Hire,
Change or Annual Update:
Payroll Action Type
Choose from dropdown:
Leave of Absence Type
Choose from Dropdown:
Leave of Absence Dates:
From: To:
Hispanic or Latino
YES
NO
/ /
Rev. 06.06.2019
DISTRIBUTION:
Auditor Human Resources Payroll Retirement
Preferred:
-
Cell:
(
(
(
(
Cell:
Name:
D
river's License
Passport
Soc. Sec. Card
Other Picture ID
W - 4
Grade
Male
Female
Cell Phone Carrier:
Apt #
Suffix:
__________
_________
Soc. Sec. #
Form Completed by: _______________________________________
Alaskan Native
New Hire
NONE
None
NO CHANGE
Other:
NO CHANGE
0
0
NO CHANGE
NO CHANGE
Home
Other:
Home
Form W-4
2020
Employee’s Withholding Certificate
Department of the Treasury
Internal Revenue Service
▶
Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay.
▶
Give Form W-4 to your employer.
▶
Your withholding is subject to review by the IRS.
OMB No. 1545-0074
Step 1:
Enter
Personal
Information
(a) First name and middle initial Last name
Address
City or town, state, and ZIP code
(b) Social security number
▶
Does your name match the
name on your social security
card? If not, to ensure you get
credit for your earnings, contact
SSA at 800-772-1213 or go to
www.ssa.gov.
(c)
Single or Married filing separately
Married filing jointly (or Qualifying widow(er))
Head of household (Check only if you’re unmarried and pay more than half the costs of keeping up a home for yourself and a qualifying individual.)
Complete Steps 2–4 ONLY if they apply to you; otherwise, skip to Step 5. See page 2 for more information on each step, who can
claim exemption from withholding, when to use the online estimator, and privacy.
Step 2:
Multiple Jobs
or Spouse
Works
Complete this step if you (1) hold more than one job at a time, or (2) are married filing jointly and your spouse
also works. The correct amount of withholding depends on income earned from all of these jobs.
Do only one of the following.
(a) Use the estimator at www.irs.gov/W4App for most accurate withholding for this step (and Steps 3–4); or
(b)
Use the Multiple Jobs Worksheet on page 3 and enter the result in Step 4(c) below for roughly accurate withholding; or
(c)
If there are only two jobs total, you may check this box. Do the same on Form W-4 for the other job. This option
is accurate for jobs with similar pay; otherwise, more tax than necessary may be withheld . . . . .
▶
TIP: To be accurate, submit a 2020 Form W-4 for all other jobs. If you (or your spouse) have self-employment
income, including as an independent contractor, use the estimator.
Complete Steps 3–4(b) on Form W-4 for only ONE of these jobs. Leave those steps blank for the other jobs. (Your withholding will
be most accurate if you complete Steps 3–4(b) on the Form W-4 for the highest paying job.)
Step 3:
Claim
Dependents
If your income will be $200,000 or less ($400,000 or less if married filing jointly):
Multiply the number of qualifying children under age 17 by $2,000
▶
$
Multiply the number of other dependents
by $500 . . . .
▶
$
Add the amounts above and enter the total here . . . . . . . . . . . . .
3 $
Step 4
(optional):
Other
Adjustments
(a)
Other income (not from jobs). If you want tax withheld for other income you expect
this year that won’t have withholding, enter the amount of other income here. This may
include interest, dividends, and retirement income . . . . . . . . . . . .
4(a) $
(b)
Deductions. If you expect to claim deductions other than the standard deduction
and want to reduce your withholding, use the Deductions Worksheet on page 3 and
enter the result here . . . . . . . . . . . . . . . . . . . . .
4(b) $
(c) Extra withholding. Enter any additional tax you want withheld each pay period .
4(c)
$
Step 5:
Sign
Here
Under penalties of perjury, I declare that this certificate, to the best of my knowledge and belief, is true, correct, and complete.
▲
Employee’s signature (This form is not valid unless you sign it.)
▲
Date
Employers
Only
Employer’s name and address First date of
employment
Employer identification
number (EIN)
For Privacy Act and Paperwork Reduction Act Notice, see page 3.
Cat. No. 10220Q
Form W-4 (2020)
Form W-4 (2020)
Page 2
General Instructions
Future Developments
For the latest information about developments related to
Form W-4, such as legislation enacted after it was published,
go to www.irs.gov/FormW4.
Purpose of Form
Complete Form W-4 so that your employer can withhold the
correct federal income tax from your pay. If too little is
withheld, you will generally owe tax when you file your tax
return and may owe a penalty. If too much is withheld, you will
generally be due a refund. Complete a new Form W-4 when
changes to your personal or financial situation would change
the entries on the form. For more information on withholding
and when you must furnish a new Form W-4, see Pub. 505.
Exemption from withholding. You may claim exemption from
withholding for 2020 if you meet both of the following
conditions: you had no federal income tax liability in 2019 and
you expect to have no federal income tax liability in 2020. You
had no federal income tax liability in 2019 if (1) your total tax on
line 16 on your 2019 Form 1040 or 1040-SR is zero (or less
than the sum of lines 18a, 18b, and 18c), or (2) you were not
required to file a return because your income was below the
filing threshold for your correct filing status. If you claim
exemption, you will have no income tax withheld from your
paycheck and may owe taxes and penalties when you file your
2020 tax return. To claim exemption from withholding, certify
that you meet both of the conditions above by writing “Exempt”
on Form W-4 in the space below Step 4(c). Then, complete
Steps 1(a), 1(b), and 5. Do not complete any other steps. You
will need to submit a new Form W-4 by February 16, 2021.
Your privacy. If you prefer to limit information provided in
Steps 2 through 4, use the online estimator, which will also
increase accuracy.
As an alternative to the estimator: if you have concerns
with Step 2(c), you may choose Step 2(b); if you have
concerns with Step 4(a), you may enter an additional amount
you want withheld per pay period in Step 4(c). If this is the
only job in your household, you may instead check the box
in Step 2(c), which will increase your withholding and
significantly reduce your paycheck (often by thousands of
dollars over the year).
When to use the estimator. Consider using the estimator at
www.irs.gov/W4App if you:
1. Expect to work only part of the year;
2. Have dividend or capital gain income, or are subject to
additional taxes, such as the additional Medicare tax;
3. Have self-employment income (see below); or
4. Prefer the most accurate withholding for multiple job
situations.
Self-employment. Generally, you will owe both income and
self-employment taxes on any self-employment income you
receive separate from the wages you receive as an
employee. If you want to pay these taxes through
withholding from your wages, use the estimator at
www.irs.gov/W4App to figure the amount to have withheld.
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
Step 1(c). Check your anticipated filing status. This will
determine the standard deduction and tax rates used to
compute your withholding.
Step 2. Use this step if you (1) have more than one job at the
same time, or (2) are married filing jointly and you and your
spouse both work.
Option (a) most accurately calculates the additional tax
you need to have withheld, while option (b) does so with a
little less accuracy.
If you (and your spouse) have a total of only two jobs, you
may instead check the box in option (c). The box must also be
checked on the Form W-4 for the other job. If the box is
checked, the standard deduction and tax brackets will be cut
in half for each job to calculate withholding. This option is
roughly accurate for jobs with similar pay; otherwise, more tax
than necessary may be withheld, and this extra amount will be
larger the greater the difference in pay is between the two jobs.
▲
!
CAUTION
Multiple jobs. Complete Steps 3 through 4(b) on only
one Form W-4. Withholding will be most accurate if
you do this on the Form W-4 for the highest paying job.
Step 3. Step 3 of Form W-4 provides instructions for
determining the amount of the child tax credit and the credit
for other dependents that you may be able to claim when
you file your tax return. To qualify for the child tax credit, the
child must be under age 17 as of December 31, must be
your dependent who generally lives with you for more than
half the year, and must have the required social security
number. You may be able to claim a credit for other
dependents for whom a child tax credit can’t be claimed,
such as an older child or a qualifying relative. For additional
eligibility requirements for these credits, see Pub. 972, Child
Tax Credit and Credit for Other Dependents. You can also
include other tax credits in this step, such as education tax
credits and the foreign tax credit. To do so, add an estimate
of the amount for the year to your credits for dependents
and enter the total amount in Step 3. Including these credits
will increase your paycheck and reduce the amount of any
refund you may receive when you file your tax return.
Step 4 (optional).
Step 4(a). Enter in this step the total of your other
estimated income for the year, if any. You shouldn’t include
income from any jobs or self-employment. If you complete
Step 4(a), you likely won’t have to make estimated tax
payments for that income. If you prefer to pay estimated tax
rather than having tax on other income withheld from your
paycheck, see Form 1040-ES, Estimated Tax for Individuals.
Step 4(b). Enter in this step the amount from the Deductions
Worksheet, line 5, if you expect to claim deductions other than
the basic standard deduction on your 2020 tax return and
want to reduce your withholding to account for these
deductions. This includes both itemized deductions and other
deductions such as for student loan interest and IRAs.
Step 4(c). Enter in this step any additional tax you want
withheld from your pay each pay period, including any
amounts from the Multiple Jobs Worksheet, line 4. Entering an
amount here will reduce your paycheck and will either increase
your refund or reduce any amount of tax that you owe.
Form W-4 (2020)
Page 3
Step 2(b)—Multiple Jobs Worksheet (Keep for your records.)
If you choose the option in Step 2(b) on Form W-4, complete this worksheet (which calculates the total extra tax for all jobs) on only ONE
Form W-4. Withholding will be most accurate if you complete the worksheet and enter the result on the Form W-4 for the highest paying job.
Note: If more than one job has annual wages of more than $120,000 or there are more than three jobs, see Pub. 505 for additional
tables; or, you can use the online withholding estimator at www.irs.gov/W4App.
1
Two jobs. If you have two jobs or you’re married filing jointly and you and your spouse each have one
job, find the amount from the appropriate table on page 4. Using the “Higher Paying Job” row and the
“Lower Paying Job” column, find the value at the intersection of the two household salaries and enter
that value on line 1. Then, skip to line 3 . . . . . . . . . . . . . . . . . . . . . 1 $
2 Three jobs. If you and/or your spouse have three jobs at the same time, complete lines 2a, 2b, and
2c below. Otherwise, skip to line 3.
a
Find the amount from the appropriate table on page 4 using the annual wages from the highest
paying job in the “Higher Paying Job” row and the annual wages for your next highest paying job
in the “Lower Paying Job” column. Find the value at the intersection of the two household salaries
and enter that value on line 2a . . . . . . . . . . . . . . . . . . . . . . . 2a
$
b
Add the annual wages of the two highest paying jobs from line 2a together and use the total as the
wages in the “Higher Paying Job” row and use the annual wages for your third job in the “Lower
Paying Job” column to find the amount from the appropriate table on page 4 and enter this amount
on line 2b . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2b $
c Add the amounts from lines 2a and 2b and enter the result on line 2c . . . . . . . . . . 2c
$
3 Enter the number of pay periods per year for the highest paying job. For example, if that job pays
weekly, enter 52; if it pays every other week, enter 26; if it pays monthly, enter 12, etc. . . . . . 3
4
Divide the annual amount on line 1 or line 2c by the number of pay periods on line 3. Enter this
amount here and in Step 4(c) of Form W-4 for the highest paying job (along with any other additional
amount you want withheld) . . . . . . . . . . . . . . . . . . . . . . . . . 4 $
Step 4(b)—Deductions Worksheet (Keep for your records.)
1
Enter an estimate of your 2020 itemized deductions (from Schedule A (Form 1040 or 1040-SR)). Such
deductions may include qualifying home mortgage interest, charitable contributions, state and local
taxes (up to $10,000), and medical expenses in excess of 7.5% of your income . . . . . . . 1 $
2 Enter:
{
• $24,800 if you’re married filing jointly or qualifying widow(er)
• $18,650 if you’re head of household
• $12,400 if you’re single or married filing separately
}
. . . . . . . . 2 $
3 If line 1 is greater than line 2, subtract line 2 from line 1. If line 2 is greater than line 1, enter “-0-” . . 3 $
4 Enter an estimate of your student loan interest, deductible IRA contributions, and certain other
adjustments (from Part II of Schedule 1 (Form 1040 or 1040-SR)). See Pub. 505 for more information 4 $
5 Add lines 3 and 4. Enter the result here and in Step 4(b) of Form W-4 . . . . . . . . . . . 5 $
Privacy Act and Paperwork Reduction Act Notice. We ask for the information
on this form to carry out the Internal Revenue laws of the United States. Internal
Revenue Code sections 3402(f)(2) and 6109 and their regulations require you to
provide this information; your employer uses it to determine your federal income
tax withholding. Failure to provide a properly completed form will result in your
being treated as a single person with no other entries on the form; providing
fraudulent information may subject you to penalties. Routine uses of this
information include giving it to the Department of Justice for civil and criminal
litigation; to cities, states, the District of Columbia, and U.S. commonwealths and
possessions for use in administering their tax laws; and to the Department of
Health and Human Services for use in the National Directory of New Hires. We
may also disclose this information to other countries under a tax treaty, to federal
and state agencies to enforce federal nontax criminal laws, or to federal law
enforcement and intelligence agencies to combat terrorism.
You are not required to provide the information requested on a form that is
subject to the Paperwork Reduction Act unless the form displays a valid OMB
control number. Books or records relating to a form or its instructions must be
retained as long as their contents may become material in the administration of
any Internal Revenue law. Generally, tax returns and return information are
confidential, as required by Code section 6103.
The average time and expenses required to complete and file this form will vary
depending on individual circumstances. For estimated averages, see the
instructions for your income tax return.
If you have suggestions for making this form simpler, we would be happy to hear
from you. See the instructions for your income tax return.
Form W-4 (2020)
Page 4
Married Filing Jointly or Qualifying Widow(er)
Higher Paying Job
Annual Taxable
Wage & Salary
Lower Paying Job Annual Taxable Wage & Salary
$0 -
9,999
$10,000 -
19,999
$20,000 -
29,999
$30,000 -
39,999
$40,000 -
49,999
$50,000 -
59,999
$60,000 -
69,999
$70,000 -
79,999
$80,000 -
89,999
$90,000 -
99,999
$100,000 -
109,999
$110,000 -
120,000
$0 - 9,999 $0 $220 $850 $900 $1,020 $1,020 $1,020 $1,020 $1,020 $1,210 $1,870 $1,870
$10,000 - 19,999
220 1,220 1,900 2,100 2,220 2,220 2,220 2,220 2,410 3,410 4,070 4,070
$20,000 - 29,999 850 1,900 2,730 2,930 3,050 3,050 3,050 3,240 4,240 5,240 5,900 5,900
$30,000 - 39,999
900 2,100 2,930 3,130 3,250 3,250 3,440 4,440 5,440 6,440 7,100 7,100
$40,000 - 49,999
1,020 2,220 3,050 3,250 3,370 3,570 4,570 5,570 6,570 7,570 8,220 8,220
$50,000 - 59,999 1,020 2,220 3,050 3,250 3,570 4,570 5,570 6,570 7,570 8,570 9,220 9,220
$60,000 - 69,999
1,020 2,220 3,050 3,440 4,570 5,570 6,570 7,570 8,570 9,570 10,220 10,220
$70,000 - 79,999
1,020 2,220 3,240 4,440 5,570 6,570 7,570 8,570 9,570 10,570 11,220 11,240
$80,000 - 99,999 1,060 3,260 5,090 6,290 7,420 8,420 9,420 10,420 11,420 12,420 13,260 13,460
$100,000 - 149,999
1,870 4,070 5,900 7,100 8,220 9,320 10,520 11,720 12,920 14,120 14,980 15,180
$150,000 - 239,999
2,040 4,440 6,470 7,870 9,190 10,390 11,590 12,790 13,990 15,190 16,050 16,250
$240,000 - 259,999 2,040 4,440 6,470 7,870 9,190 10,390 11,590 12,790 13,990 15,520 17,170 18,170
$260,000 - 279,999
2,040 4,440 6,470 7,870 9,190 10,390 11,590 13,120 15,120 17,120 18,770 19,770
$280,000 - 299,999
2,040 4,440 6,470 7,870 9,190 10,720 12,720 14,720 16,720 18,720 20,370 21,370
$300,000 - 319,999 2,040 4,440 6,470 8,200 10,320 12,320 14,320 16,320 18,320 20,320 21,970 22,970
$320,000 - 364,999
2,720 5,920 8,750 10,950 13,070 15,070 17,070 19,070 21,290 23,590 25,540 26,840
$365,000 - 524,999
2,970 6,470 9,600 12,100 14,530 16,830 19,130 21,430 23,730 26,030 27,980 29,280
$525,000 and over
3,140 6,840 10,170 12,870 15,500 18,000 20,500 23,000 25,500 28,000 30,150 31,650
Single or Married Filing Separately
Higher Paying Job
Annual Taxable
Wage & Salary
Lower Paying Job Annual Taxable Wage & Salary
$0 -
9,999
$10,000 -
19,999
$20,000 -
29,999
$30,000 -
39,999
$40,000 -
49,999
$50,000 -
59,999
$60,000 -
69,999
$70,000 -
79,999
$80,000 -
89,999
$90,000 -
99,999
$100,000 -
109,999
$110,000 -
120,000
$0 - 9,999 $460 $940 $1,020 $1,020 $1,470 $1,870 $1,870 $1,870 $1,870 $2,040 $2,040 $2,040
$10,000 - 19,999
940 1,530 1,610 2,060 3,060 3,460 3,460 3,460 3,640 3,830 3,830 3,830
$20,000 - 29,999 1,020 1,610 2,130 3,130 4,130 4,540 4,540 4,720 4,920 5,110 5,110 5,110
$30,000 - 39,999
1,020 2,060 3,130 4,130 5,130 5,540 5,720 5,920 6,120 6,310 6,310 6,310
$40,000 - 59,999
1,870 3,460 4,540 5,540 6,690 7,290 7,490 7,690 7,890 8,080 8,080 8,080
$60,000 - 79,999 1,870 3,460 4,690 5,890 7,090 7,690 7,890 8,090 8,290 8,480 9,260 10,060
$80,000 - 99,999
2,020 3,810 5,090 6,290 7,490 8,090 8,290 8,490 9,470 10,460 11,260 12,060
$100,000 - 124,999
2,040 3,830 5,110 6,310 7,510 8,430 9,430 10,430 11,430 12,420 13,520 14,620
$125,000 - 149,999 2,040 3,830 5,110 7,030 9,030 10,430 11,430 12,580 13,880 15,170 16,270 17,370
$150,000 - 174,999
2,360 4,950 7,030 9,030 11,030 12,730 14,030 15,330 16,630 17,920 19,020 20,120
$175,000 - 199,999
2,720 5,310 7,540 9,840 12,140 13,840 15,140 16,440 17,740 19,030 20,130 21,230
$200,000 - 249,999 2,970 5,860 8,240 10,540 12,840 14,540 15,840 17,140 18,440 19,730 20,830 21,930
$250,000 - 399,999
2,970 5,860 8,240 10,540 12,840 14,540 15,840 17,140 18,440 19,730 20,830 21,930
$400,000 - 449,999
2,970 5,860 8,240 10,540 12,840 14,540 15,840 17,140 18,450 19,940 21,240 22,540
$450,000 and over
3,140 6,230 8,810 11,310 13,810 15,710 17,210 18,710 20,210 21,700 23,000 24,300
Head of Household
Higher Paying Job
Annual Taxable
Wage & Salary
Lower Paying Job Annual Taxable Wage & Salary
$0 -
9,999
$10,000 -
19,999
$20,000 -
29,999
$30,000 -
39,999
$40,000 -
49,999
$50,000 -
59,999
$60,000 -
69,999
$70,000 -
79,999
$80,000 -
89,999
$90,000 -
99,999
$100,000 -
109,999
$110,000 -
120,000
$0 - 9,999 $0 $830 $930 $1,020 $1,020 $1,020 $1,480 $1,870 $1,870 $1,930 $2,040 $2,040
$10,000 - 19,999
830 1,920 2,130 2,220 2,220 2,680 3,680 4,070 4,130 4,330 4,440 4,440
$20,000 - 29,999 930 2,130 2,350 2,430 2,900 3,900 4,900 5,340 5,540 5,740 5,850 5,850
$30,000 - 39,999
1,020 2,220 2,430 2,980 3,980 4,980 6,040 6,630 6,830 7,030 7,140 7,140
$40,000 - 59,999
1,020 2,530 3,750 4,830 5,860 7,060 8,260 8,850 9,050 9,250 9,360 9,360
$60,000 - 79,999 1,870 4,070 5,310 6,600 7,800 9,000 10,200 10,780 10,980 11,180 11,580 12,380
$80,000 - 99,999
1,900 4,300 5,710 7,000 8,200 9,400 10,600 11,180 11,670 12,670 13,580 14,380
$100,000 - 124,999
2,040 4,440 5,850 7,140 8,340 9,540 11,360 12,750 13,750 14,750 15,770 16,870
$125,000 - 149,999 2,040 4,440 5,850 7,360 9,360 11,360 13,360 14,750 16,010 17,310 18,520 19,620
$150,000 - 174,999
2,040 5,060 7,280 9,360 11,360 13,480 15,780 17,460 18,760 20,060 21,270 22,370
$175,000 - 199,999
2,720 5,920 8,130 10,480 12,780 15,080 17,380 19,070 20,370 21,670 22,880 23,980
$200,000 - 249,999 2,970 6,470 8,990 11,370 13,670 15,970 18,270 19,960 21,260 22,560 23,770 24,870
$250,000 - 349,999
2,970 6,470 8,990 11,370 13,670 15,970 18,270 19,960 21,260 22,560 23,770 24,870
$350,000 - 449,999
2,970 6,470 8,990 11,370 13,670 15,970 18,270 19,960 21,260 22,560 23,900 25,200
$450,000 and over 3,140 6,840 9,560 12,140 14,640 17,140 19,640 21,530 23,030 24,530 25,940 27,240
USCIS
Form I-9
OMB No. 1615-0047
Expires 10/31/2022
Employment Eligibility Verification
Department of Homeland Security
U.S. Citizenship and Immigration Services
Form I-9 10/21/2019
Page 1 of 3
►START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically,
during completion of this form. Employers are liable for errors in the completion of this form.
ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an
employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the
documentation presented has a future expiration date may also constitute illegal discrimination.
Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form I-9 no later
than the first day of employment, but not before accepting a job offer.)
Last Name (Family Name)
First Name (Given Name)
Middle Initial
Other Last Names Used (if any)
Address (Street Number and Name)
Apt. Number
City or Town
State
ZIP Code
Date of Birth (mm/dd/yyyy)
-
-
Employee's E-mail Address
Employee's Telephone Number
U.S. Social Security Number
1. A citizen of the United States
2. A noncitizen national of the United States (See instructions)
3. A lawful permanent resident
4. An alien authorized to work until
(See instructions)
(expiration date, if applicable, mm/dd/yyyy):
(Alien Registration Number/USCIS Number):
Some aliens may write "N/A" in the expiration date field.
I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in
connection with the completion of this form.
I attest, under penalty of perjury, that I am (check one of the following boxes):
Aliens authorized to work must provide only one of the following document numbers to complete Form I-9:
An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.
1. Alien Registration Number/USCIS Number:
2. Form I-94 Admission Number:
3. Foreign Passport Number:
Country of Issuance:
OR
OR
QR Code - Section 1
Do Not Write In This Space
Signature of Employee
Today's Date (mm/dd/yyyy)
Preparer and/or Translator Certification (check one):
I did not use a preparer or translator. A preparer(s) and/or translator(s) assisted the employee in completing Section 1.
(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)
I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my
knowledge the information is true and correct.
Signature of Preparer or Translator
Today's Date (mm/dd/yyyy)
Last Name (Family Name)
First Name (Given Name)
Address (Street Number and Name)
City or Town
State
ZIP Code
Employer Completes Next Page
Form I-9 10/21/2019
Page 2 of 3
USCIS
Form I-9
OMB No. 1615-0047
Expires 10/31/2022
Employment Eligibility Verification
Department of Homeland Security
U.S. Citizenship and Immigration Services
Section 2. Employer or Authorized Representative Review and Verification
(Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You
must physically examine one document from List A OR a combination of one document from List B and one document from List C as listed on the "Lists
of Acceptable Documents.")
Last Name (Family Name) M.I.
First Name (Given Name)
Employee Info from Section 1
Citizenship/Immigration Status
List A
Identity and Employment Authorization
Identity
Employment Authorization
OR List B AND List C
Additional Information
QR Code - Sections 2 & 3
Do Not Write In This Space
Document Title
Issuing Authority
Document Number
Expiration Date (if any) (mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any) (mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any) (mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any) (mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any) (mm/dd/yyyy)
Certification: I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee,
(2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the
employee is authorized to work in the United States.
The employee's first day of employment (mm/dd/yyyy):
(See instructions for exemptions)
Today's Date (mm/dd/yyyy)
Signature of Employer or Authorized Representative
Title of Employer or Authorized Representative
Last Name of Employer or Authorized Representative
First Name of Employer or Authorized Representative
Employer's Business or Organization Name
Employer's Business or Organization Address (Street Number and Name)
City or Town
State
ZIP Code
Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.)
A. New Name (if applicable)
Last Name (Family Name)
First Name (Given Name)
Middle Initial
B. Date of Rehire (if applicable)
Date (mm/dd/yyyy)
Document Title Document Number
Expiration Date (if any) (mm/dd/yyyy)
C. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes
continuing employment authorization in the space provided below.
I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if
the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual.
Signature of Employer or Authorized Representative
Today's Date (mm/dd/yyyy)
Name of Employer or Authorized Representative
LISTS OF ACCEPTABLE DOCUMENTS
All documents must be UNEXPIRED
Employees may present one selection from List A
or a combination of one selection from List B and one selection from List C.
LIST A
2. Permanent Resident Card or Alien
Registration Receipt Card (Form I-551)
1. U.S. Passport or U.S. Passport Card
3. Foreign passport that contains a
temporary I-551 stamp or temporary
I-551 printed notation on a machine-
readable immigrant visa
4. Employment Authorization Document
that contains a photograph (Form
I-766)
5. For a nonimmigrant alien authorized
to work for a specific employer
because of his or her status:
Documents that Establish
Both Identity and
Employment Authorization
6. Passport from the Federated States
of Micronesia (FSM) or the Republic
of the Marshall Islands (RMI) with
Form I-94 or Form I-94A indicating
nonimmigrant admission under the
Compact of Free Association Between
the United States and the FSM or RMI
b. Form I-94 or Form I-94A that has
the following:
(1) The same name as the passport;
and
(2) An endorsement of the alien's
nonimmigrant status as long as
that period of endorsement has
not yet expired and the
proposed employment is not in
conflict with any restrictions or
limitations identified on the form.
a. Foreign passport; and
For persons under age 18 who are
unable to present a document
listed above:
1. Driver's license or ID card issued by a
State or outlying possession of the
United States provided it contains a
photograph or information such as
name, date of birth, gender, height, eye
color, and address
9. Driver's license issued by a Canadian
government authority
3. School ID card with a photograph
6. Military dependent's ID card
7. U.S. Coast Guard Merchant Mariner
Card
8. Native American tribal document
10. School record or report card
11. Clinic, doctor, or hospital record
12. Day-care or nursery school record
2. ID card issued by federal, state or local
government agencies or entities,
provided it contains a photograph or
information such as name, date of birth,
gender, height, eye color, and address
4. Voter's registration card
5. U.S. Military card or draft record
Documents that Establish
Identity
LIST B
OR AND
LIST C
7. Employment authorization
document issued by the
Department of Homeland Security
1. A Social Security Account Number
card, unless the card
includes one of
the following restrictions:
2. Certification of report of birth issued
by the Department of State (Forms
DS-1350, FS-545, FS-240)
3. Original or certified copy of birth
certificate issued by a State,
county, municipal authority, or
territory of the United States
bearing an official seal
4. Native American tribal document
6. Identification Card for Use of
Resident Citizen in the United
States (Form I-179)
Documents that Establish
Employment Authorization
5. U.S. Citizen ID Card (Form I-197)
(2) VALID FOR WORK ONLY WITH
INS AUTHORIZATION
(3) VALID FOR WORK ONLY WITH
DHS AUTHORIZATION
(1) NOT VALID FOR EMPLOYMENT
Page 3 of 3
Form I-9 10/21/2019
Examples of many of these documents appear in the Handbook for Employers (M-274).
Refer to the instructions for more information about acceptable receipts.
Massachusetts Department of Revenue
Form NHR
New Hire and Independent Contractor Reporting Form
Rev. 3/15
Employee information
First name Middle initial (optional) Last name
Mailing address
City/Town State Zip
Social Security number Date of hire or reinstatement (mm/dd/yyyy)
Employer information
Name of corporation Account ID number
Payroll address City/Town State Zip
Social Security number Date of hire or reinstatement (mm/dd/yyyy)
Important notice
Massachusetts regulations require employers with 25 or more employees to report their new hires and independent contractors at mass.gov/dor. Mail
form to: Massachusetts Department of Revenue, PO Box 55141, Boston, MA 02205-5141 or fax to (617) 376-3262.
Date of Birth (mm/dd/yyyy)
CITY OF FITCHBURG
Department of Human Resources
Policy Name:
Harassment, Discrimination and
Sexual Harassment
Policy Number:
20180118
Date Issued:
January 8, 2020
Effective Date:
January 13, 2020
Amends
Rescinds
I. General
It is the goal of the City of Fitchburg to promote a workplace that is free from harassment of any type, including but not
limited to harassment of a discriminatory or sexual nature. The City of Fitchburg will not tolerate harassing conduct that
affects employment conditions, that interferes with an individual’s performance or that creates an intimidating, hostile or
offensive work environment.
Harassment of employees occurring in the workplace or in other work related settings, is unlawful and will not be tolerated
by the City of Fitchburg. Further, any retaliation against an individual who has made a complaint about harassment or
retaliation against individuals for cooperating with an investigation of a harassment complaint is similarly unlawful and will
not be tolerated. To achieve our goal of providing a workplace free from any type of harassment and retaliation, the City
of Fitchburg is committed to following the procedures set forth below in the event of allegations of inappropriate conduct.
Because the City of Fitchburg takes allegations of harassment seriously, we will respond promptly to complaints of
harassment. Where it is determined that such inappropriate conduct has occurred, the City of Fitchburg will act promptly
to eliminate the conduct and impose such corrective action as necessary, including disciplinary action where appropriate.
While this policy sets forth our goals of promoting a workplace that is free of harassment, the policy is not designed or
intended to limit the City of Fitchburg’s authority to discipline or take remedial action for workplace conduct which we deem
unacceptable, regardless of whether that conduct satisfies the definition of harassment.
II. Definitions
A. Harassment is defined as unwelcome conduct, whether verbal or physical, that is designed to threaten,
intimidate or coerce an individual in the workplace. Harassment based on unlawful discrimination occurs when
the conduct is based on a characteristic protected by law such as gender, race, color, national origin, ancestry,
religion, age, disability, genetics, military status, sexual orientation, gender identity or participation in
discrimination complaint related activities (retaliation).
Harassment includes, but is not limited to:
• Display or circulation of written materials or pictures that are degrading to a person or group as
described above;
• Verbal abuse, slurs, derogatory comments or insults about, directed at or made in the presence of an
individual or group as described above.
B. Sexual harassment is defined as unwelcome sexual advances, requests for sexual favors and other verbal or
physical conduct of a sexual nature when:
• Submission to such conduct is made explicitly or implicitly a term or condition of an individual’s
employment;
New
Amends and/or Rescinds Policy #/dated: January 18, 2018
✔
Page | 2
City of Fitchburg, MA
Harassment, Discrimination and Sexual Harassment
January 2020
Harassment, Discrimination and Sexual Harassment Policy, Definitions, Sexual Harassment, continued:
• Submission to or rejection of such conduct by an individual is used as the basis for employment decisions
affecting such individual; or
• Such conduct has the purpose or effect of unreasonably interfering with an individual’s work
performance or creating an intimidating, hostile or offensive work environment;
• Direct or implied requests by a supervisor for sexual favors in exchange for actual or promised job
benefits such as favorable performance reviews, salary increases, promotions, increased benefits or
continued employment constitutes sexual harassment.
While the legal definition of sexual harassment is broad, other sexually-oriented conduct, in addition to the aforementioned
examples, whether it is intended or not, that is unwelcome and has the effect of creating a work environment that is hostile,
offensive, intimidating or humiliating to male or female workers may also constitute sexual harassment.
A. Examples of Sexual Harassment
While it is not possible to list all those additional circumstances that may constitute sexual harassment, the following are
some examples of conduct which, if unwelcome, may constitute sexual harassment depending on the totality of the
circumstances, including the severity of the conduct and its pervasiveness:
• Unwelcome sexual advances – whether they involve physical touching or not;
• Sexual epithets, jokes, written or oral references to sexual conduct, gossip regarding one’s sex life;
comment on an individual’s body; comment about an individual’s sexual activity, deficiencies or prowess;
• Displaying sexually suggestive objects, pictures, cartoons;
• Unwelcome leering, whistling, brushing against the body, sexual gestures, suggestive or insulting
comments;
• Inquiries into one’s sexual experiences;
• Discussion of one’s sexual activities.
Sexual harassment can occur in a variety of circumstances, including but not limited to:
• The harasser can be the victim’s supervisor, a supervisor in another department, division or area, an
agent of the employer, co-worker or a someone who is not an employee of the employer, such as a
client or customer;
• The victim does not have to be the person harassed but can be anyone affected by the offensive
conduct;
• Unlawful harassment may occur without economic injury to, or discharge of, the victim.
The foregoing list is only meant to be illustrative and is not exhaustive. Further, all employees should take note that, as
stated above, retaliation against an individual who has complained about sexual harassment and retaliation against
individuals for cooperating with an investigation of a sexual harassment complaint is unlawful and will not be tolerated by
the City of Fitchburg.
III. Complaint Procedure
If an employee believes that s/he has been subjected to harassment, sexual harassment, discrimination, retaliation or
similarly abusive verbal or physical conduct which interferes with work performance or creates an intimidating, hostile or
offensive work environment, the employee has the right and is encouraged to file a complaint. The complaint may be made
in writing or verbally and should be filed with a City of Fitchburg Sexual Harassment Officer promptly following any incident
of alleged harassment.
Page | 3
City of Fitchburg, MA
Harassment, Discrimination and Sexual Harassment
January 2020
A. City of Fitchburg Sexual Harassment Officers
Susan A. Davis Mary de Alderete
Director, Human Resources City Clerk
166 Boulder Drive, Ste. 108 166 Boulder Drive, Ste. 108
Fitchburg, MA 01420 Fitchburg, MA 01420
978.829.1808 978.829.1821
sdavis@fitchburgma.gov mdealderete@fitchburgma.gov
If an employee cannot file a complaint comfortably because the alleged harasser is involved with the complaint procedure,
the initial complaint should be made to the Mayor of the City of Fitchburg.
B. State and Federal Remedies
In addition to the above, if an employee believes that s/he has been subjected to unlawful harassment or discrimination or
retaliation, the employee may file a formal complaint with either or both of the government agencies set forth below.
Utilizing the City’s complaint process neither prohibits an employee from filing a complaint with these agencies nor does
the employee’s decision not to utilize the City’s complaint process prohibit the employee from filing a complaint with either
of the agencies listed below. Any claims filed with these agencies must be done within a set period of time (EEOC – 30
days; MCAD – 300 days).
C. Sexual Harassment Complaint Investigation
When a complaint is received, the allegation will be promptly and thoroughly investigated in a fair and expeditious manner.
The investigation will be conducted in such a way as to maintain confidentiality to the extent practicable under the
circumstances. The investigation will normally include a private interview with the person filing the complaint and with any
witnesses. The City will also interview the person alleged to have committed sexual harassment. When the investigation is
completed, the City will, to the extent appropriate, inform both the person filing the complaint and the person alleged to
have committed the conduct of the results of said investigation. If the investigation determines that sexual harassment
has occurred, the City will act promptly to eliminate and remedy the offending conduct. Where it is appropriate, disciplinary
action will be imposed, which may include termination of the offending employee.
D. Disciplinary Action
If it is determined that inappropriate conduct has occurred, the City will take immediate action to stop the offending conduct
and, where appropriate, impose disciplinary action against the offending employee. Contingent upon the severity of the
inappropriate conduct, such action may include counseling, formal reprimand, verbal or written warning, suspension or
other formal sanctions up to and including termination of employment.
United States Equal Employment Opportunity Commission (EEOC)
John F. Kennedy Federal Building
475 Government Center
Boston, MA 02203
Phone: 800.669.4000
Fax: 617.565.3196
Massachusetts Commission Against Discrimination (MCAD)
Boston Headquarters Worcester Office
One Ashburton Place, Suite 601 484 Main Street, Room 320
Boston, MA 02108 Worcester, MA 01608
Phone: 617.994.6000 Phone: 508.453.9630
City of Fitchburg
Office of Human Resources
City Hall
166 Boulder Drive
Fitchburg, MA 01420
Phone: 978.829.1808
Fax: 978.829.1966
Susan A. Davis
Director
CITY OF FITCHBURG ALCOHOL AND DRUG POLICY
I. GENERAL
This section applies to all employees of the City of Fitchburg whether or not they are also subject to the
requirements of the
Omnibus Transportation Employee Testing Act of 1991.
The City of Fitchburg has a strong commitment to its employees to provide a safe work place and to
establish programs promoting high standards of employee health. Consistent with the spirit and intent
of this commitment, the City of Fitchburg has established this policy regarding drug and alcohol use or
abuse. Quite simply, our goal will continue to be one of establishing and maintaining a work environment
that is free from the effects of alcohol and drug use.
Employees of the City of Fitchburg are visible and active members of the communities where they live
and work. They are inescapably identified with the City and are expected to represent it in a responsible
and creditable fashion. The vast majority of our employees reflect credit upon themselves and the City
of Fitchburg which they represent.
While the City of Fitchburg has no intention of intruding into the private lives of its employees, the City
does expect employees to report for work in condition to perform their duties. The City recognizes that
employee off-the-job as well as on-the-job involvement with drugs and alcohol can have an impact on
the work place and on our ability to accomplish our goal of an alcohol and drug-free environment.
The following is the City of Fitchburg's policy:
1. The illegal use, sale or possession of narcotics, drugs, or controlled substances while on the job or
on City property is an offense warranting discharge. Any illegal substances will be turned over to the
appropriate law enforcement agency.
2. Employees who are under the influence of alcohol or narcotics, drugs or controlled substances, either
on the job or when reporting for work, or who possess or consume alcohol during work hours, have
the potential for interfering with their own, as well as their co-workers' safe and efficient job
performance. Consistent with existing City of Fitchburg practices, such conditions will be proper
cause for administrative action up to and including termination of employment.
CITY OF FITCHBURG ALCOHOL AND DRUG POLICY
September 2016
2
City of Fitchburg policy, continued:
3. Off-the-job illegal drug activity which could adversely affect an employee's job performance or which
could jeopardize the safety of other employees, the public, or City property or equipment is proper
cause for administrative or disciplinary action up to and including termination of employment as
additionally provided for in the Omnibus Transportation Act of 1991. In deciding what action to take,
management will take into consideration the nature of the charges, the employee's present job
assignment, the employee's record with the City and other factors relative to the impact of the
employee's arrest upon the conduct of City business.
4. Some of the drugs which are illegal under federal, state or local laws include, among others,
marijuana, heroin, hashish, cocaine, opioids, hallucinogens and/or depressants not prescribed for
current personal treatment by a licensed physician.
5. Employees are expected to follow any directions of their health care provider concerning prescription
medications, and must immediately notify their supervisor if any prescription drug is likely to have an
impact on job performance. In addition, notification must be given at the time of any testing or
screening as to any drugs or medicine being taken.
Any employee, while on City property or during that employee's work shift, including without limitation
all breaks and meal periods, who consumes or uses, or is found to have in his or her personal possession,
in his or her locker or desk or other repository, alcohol or drugs, which are not medically authorized, or
is found to have used or to be using such alcohol or drugs, will be suspended immediately pending
further investigation. If use or possession is substantiated, disciplinary action, up to and including
discharge, will be imposed.
Any employee who voluntarily requests assistance in dealing with a personal drug addition or alcohol
problem may participate in the Employee Assistance Program (EAP) without jeopardizing his or her
continued employment with the City of Fitchburg. If an employee chooses to notify the City or request
assistance from the City regarding an alcohol or drug problem, that notice or request will not jeopardize
his or her continuing employment, provided the employee stops any and all involvement with the
substance being abused, and maintains adequate job performance. While the EAP is a valuable source
in dealing with personal problems, participation in the program will not prevent disciplinary action for a
violation of this policy.
This statement is to clarify the City's operational stance and to provide for prompt effective reaction to
any alcohol or drug related situation which has or could have any impact on operations. It does not alter
in any way the policy of assisting employees in securing proper treatment or extending the coverage of
the health benefits plan as indicated for problem drinking, alcoholism, or other drug dependencies.
II. OMNIBUS TRANSPORTATION EMPLOYEE TESTING ACT OF 1991:
TESTING FOR DRUGS AND ALCOHOL
It is the policy of the City of Fitchburg to comply fully with the Rules issued by the U.S. Department of
Transportation under the 1991 Omnibus Transportation Employee Testing Act dealing with limitations on
alcohol and drug use by transportation workers, drug and alcohol testing of such workers and the
reporting/record-keeping requirements relative to such testing. The Rules found at 49 C.F.R. s382.100
et seq. apply to all interstate and intrastate truck and motor coach operators, including but not limited
to, school bus drives and all City employees with commercial driver’s licenses. (CDL’s)
CITY OF FITCHBURG ALCOHOL AND DRUG POLICY
September 2016
3
The following conduct is strictly prohibited:
1. Reporting for duty or remaining on duty requiring the performance of safety-sensitive
functions with a breath/blood alcohol content of 0.04 percent (or higher)
2. Use of alcohol within the four (4) hours prior to performing a safety-sensitive
function, such as driving
3. Use of alcohol on the job:
4. Use of alcohol during the eight (8) hours following an accident or until tested
5. Possession of any medication or food containing alcohol while driving a vehicle
6. Refusal to take a required test
7. Use of controlled substances on or off duty unless a doctor has prescribed the
controlled substance and the doctor has informed the employee that the substance
does not adversely affect the employee's ability to operate a vehicle safely
III. PROCEDURES-Alcohol and Drug Testing Pursuant to 49 C.F.R. s382.100 et seq.
A. Types of Required Tests
1. Pre-Placement Testing for Controlled Substances and Alcohol
All applicants for employment in covered positions, or candidates for transfer or promotion
to such positions, as well as those covered employees returning from layoff, are subject
to screening for use of alcohol or controlled substances.
All applicants who test positive for either drugs or alcohol will not be offered
employment with the City of Fitchburg.
2. Post-Accident
All covered employees shall be tested after accidents where there has been a citation for
a moving traffic violation, or there is a fatality even if the driver is not cited for a moving
traffic violation. Tests for alcohol use shall be conducted within 2 hours, but in no case
more than 8 hours of the accident, while tests for controlled substances shall be conducted
within 32 hours of the accident. Employees must refrain from all alcohol and controlled
substance use until the test is complete. Employees are obligated to cooperate in such
testing or will be deemed to have refused. It is the employee's responsibility to make
him/her available for testing. Generally, the employee will be accompanied to/from the
testing site by a City of Fitchburg employee/supervisor.
3. Reasonable Suspicion
An employee shall be tested when a trained supervisor or manager observes behavior,
speech, appearance or odor that leads to a reasonable suspicion that the employee has
violated Number 1-7 of Section II of the guidelines or has been or is using controlled
substances without a doctor's prescription. In the case of alcohol use, the observation
shall be made during, preceding or after the workday. No such limitations are placed on
observations for impermissible use of controlled substances. Tests for alcohol use shall
be conducted within two (2) hours, but in no case more than eight (8) hours, after the
CITY OF FITCHBURG ALCOHOL AND DRUG POLICY
September 2016
4
Required Tests, Reasonable Suspicion continued:
observation is made. If a test cannot be administered, the driver must be removed from
performing safety- sensitive duties for at least 24 hours.
4. Random
Employees shall be tested for the use of alcohol and controlled substances on a random,
unannounced basis just before, during or after performance of safety-sensitive functions
for alcohol or at any time for controlled substances. Each year, the number of random
alcohol tests conducted by the City must equal at least 25% of all covered employees.
Random drug tests conducted by the City must equal at least 50% of all covered
employees.
5. Return to Duty and Follow-Up
An employee who has violated the prohibited alcohol or drug standards shall be tested for
alcohol and/or drug use prior to his/her return to performing safety sensitive duties.
Follow-up tests are unannounced and at least six (6) tests must be conducted in the first
12 months after an employee returns to duty. The City of Fitchburg agrees to bear the
expense of the six (6) follow-up tests. Follow-up testing may be extended for up to 60
months following the return to duty.
B. Conducting Tests
1. Alcohol
DOT rules require breath testing using evidential breath testing (EBT) devices. Two breath
tests are required to determine if a person has a prohibited alcohol concentration. A
screening test is conducted first. Any results less than 0.02 alcohol concentration is
considered a "negative" test. If the alcohol concentration is 0.02 or greater, a
confirmation test must be conducted. Refusal of an employee to complete and sign the
breath alcohol testing form shall be deemed to be a refusal to test. In addition, blood
alcohol testing can be used in reasonable suspicion and post-accident testing where an
evidentiary breath testing device is not available or where an employee is not capable of
producing adequate breath.
2. Drugs
Drug testing is conducted by analyzing a driver's urine specimen is subdivided into two
bottles labeled as primary and split. Both bottles are sent to the laboratory. Initially, only
the primary specimen is opened and used for the urinalysis. The split specimen remains
sealed at the laboratory. If the analysis of the primary specimen confirms the presence
of illegal controlled substances, the driver has 72 hours to request that the split specimen
be sent, at the driver's expense, to another DHHS certified laboratory for analysis. The
driver will be reimbursed should the split specimen come back negative.
Testing is conducted using a two-stage process. First, a screening test is performed. If
the test is positive for one or more drugs, a confirmation test is performed for each
identified drug. Sophisticated testing requirements ensure that over-the-counter
medications or preparations are not reported as positive results.
All drug tests are reviewed and interpreted by a physician designated as a Medical Review
Officer (MRO) before they are reported to the employer. If the laboratory reports a
positive result to the MRO, the MRO will contact the driver and conduct an interview to
CITY OF FITCHBURG ALCOHOL AND DRUG POLICY
September 2016
5
Conducting Tests, Drugs, continued:
determine if there is an alternative medical explanation for the drugs found in the urine
specimen. For all the drugs listed above, except PCP, there are some limited, legitimate
medical uses that may explain a positive test result. If MRO determines that the drug use
is legitimate, the test will be reported to the City as a negative result.
3. Refusal to Participate/Tampering
Any refusal to participate in any of the types of alcohol and or drug tests authorized in
this policy will be treated as indicative of a positive result.
If there is any evidence that an employee engaged in sample tampering, such conduct
shall be treated as a refusal to participate in testing for purposes of imposing discipline.
C. Consequences of Alcohol/Drug Misuse
1. Drivers who have any alcohol concentration (defined as 0.02 to 0.039) when tested just
before, during or just after performing safety and sensitive functions must be removed
from performing such duties for 24 hours, and will be sent home with pay or assigned
suitable non safety sensitive work if available.
2. Drivers who engage in prohibited alcohol (at a level of 0.04 or greater) or drug conduct
(that is, who test positive for alcohol or drug use) must be immediately removed from
safety sensitive functions must be evaluated by a substance abuse professional and must
undergo a treatment program as defined by the professional.
3. Drivers who wish to continue employment with the City of Fitchburg must be evaluated
within five (5) days by a substance abuse professional and comply with any treatment
recommendations to assist them with an alcohol or drug problem. Employees will be
placed on non-occupational sick leave or leave without pay status during the treatment
period, whichever is appropriate.
4. Drivers who have been evaluated by a substance abuse professional, who comply with
any recommended treatment, who have taken a return to duty test with a result less than
0.02 and/or a urine drug test which is negative who are then subject to unannounced
follow-up tests, may return to work.
5. Drivers who have returned to work under these conditions and who subsequently test
positive for alcohol or drugs in accordance with this policy may be subject to discipline,up
to and including termination. Any action may be subject to the grievance and arbitration
procedure.
D. Information/Training
1. All current and new employees will receive written information about the testing
requirements and how and where they may receive assistance for alcohol or drug misuse.
All employees must receive a copy of the policy and sign the Confirmation of Receipt (See
page 7).
CITY OF FITCHBURG ALCOHOL AND DRUG POLICY
September 2016
6
Information/Training continued:
2. All supervisory and management personnel in the Department of Public Works must attend
at least two hours of training on alcohol and drug misuse symptoms and indicators used
in making determinations for reasonable suspicion testing.
E. Record Keeping
1. The City is required to keep detailed records of its alcohol and drug misuse prevention
program.
2. Driver alcohol and drug testing records are confidential. Test results and other confidential
information may only be released to the employer, the substance abuse professional, the
MRO, and any arbitrator of a grievance filed in accordance with this policy. Any other
release of this information may only be made with the driver's consent.
F. Pre-employment References
1. The City must obtain and review the following information from each employer that the
prospective driver worked for, in a safety sensitive position, during the previous two years;
information about a test in which the employee's blood alcohol was 0.04 or greater;
information about a positive drug test; and information about any refusal to participate in
the alcohol and drug testing program.
2. The prospective employee must provide the former employer with a written release
allowing the release of this information or he/she may not be hired.
3. If the previous employer indicates that a positive result was received, or that the employee
refused to participate when selected for an alcohol or drug test, the applicant may not be
appointed unless he/she has consulted with a substance abuse professional, received
recommended treatment, and tested negative in a return to duty test.
4. The City of Fitchburg must provide the same information to subsequent employers of
current city employees when provided with a written release.
G. Questions
Questions about this policy should be referred to the employee’s Division Supervisor, the
Commissioner of Public Works and /or the Director of Human Resources.
January 2019
City of Fitchburg, Massachusetts
EMPLOYEE ACKNOWLEDGMENT OF RECEIPT OF POLICIES
THE UNDERSIGNED HEREBY ACKNOWLEDGES RECEIPT AND REVIEW
OF THE FOLLOWING POLICIES AND AGREES TO ABIDE BY THESE
POLICIES CONTAINED HEREIN.
________ ALCOHOL AND DRUG POLICY
________ HARASSMENT, DISCRIMINATION AND SEXUAL
HARASSMENT POLICY
__________________________________
EMPLOYEE NAME (PRINT)
__________________________________ _____________
EMPLOYEE SIGNATURE DATE
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Pollworker-Application P:Human ResourcesSteffaniNew Hire PacketsRequired DocsEmployee Data Form TO BE COMPLETE BY NEW HIRE 11.15.2019

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Completed 12 July 2020

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