Employee Forms

Absence/Leave Forms

Absentee Form

Floating Holiday Form

Personal Day Request Form

Uncompensated Leave Application

Vacation Day Request Form

 

Work Related Injuries

PICS Amerihealth WC Provider Panel

Work Related Injury Form

 

Payroll Forms

Direct Deposit Form

W4

For a name and/or address change, please complete the following forms and return to Aimee Pepper, Payroll Specialist in the Canton Office. If you have questions, please contact Aimee at apepper@iu17.org or 570-673-6001 ext 2003.

Earned Income Tax Form

Change of Name/Address

 

Timesheets

Support Staff Timesheet – 200 Day Calendar

Support Staff Timesheet

Support Staff Timesheet with Sub Line

Part-time Hourly Timesheet

 

Printer Toner/Ink

Replacement Cartridge Request Form

 

Mileage /Travel / Supply Reimbursement Vouchers

Travel Voucher 2017 protected (effective January 1)

Travel Voucher 2017 2 page protected (effective January 1)

 

Travel Voucher 2016 – January 2016

Travel Voucher 2016 2 pages – January 2016

 

Supply Voucher

 

Purchasing Forms

PSS – Personal Care Supplies

Dice – Personal Care Supplies

XPEDX

Requisition Form 2016-2017 (Excel)

 

 

Continuing Education Forms

Tuition Request Form

Conference Request Form

Inservice Attendance Form

 

Mandated Reporter Information

Reporting Process Guidelines

CY-47

 

Student Services

Student Learning Objective (SLO) template

Field Trip Request Form

Visual Release Form

Notice of Recommended Educational Placement

Procedural Safeguards

Re-evaluation Permission Form

Release of Student Information

School Age IEP

BrainSTEPS Referral Form

 

Contracted Services

Request for Board Approval

BLaST Service Request Contract (Excel)

BLaST Service Request Contract (pdf)

 

CBA

CBA for 2016 to 2019 (pdf)

 

Handbooks

Handbook Office Support

Paraprofessional Handbook

 

Policies

Acceptable Use Policy

Dress Code

Confidentiality Agreement

 

Clearances

Act 34 – State Police Background Check – This clearance may be obtained by completing the above form and mailing per the instructions on the form or by completing the online process at https://epatch.state.pa.us/Home.jsp.

Act 114 – FBI (Fingerprinting) Check – This clearance may only be obtained by registering with Cogent at http://www.pa.cogentid.com/index.htm. Select Pa Dept of Education and follow the onscreen instructions.

Act 151 – Child Abuse Clearance – This cleanance may only be obtained by completing the above form and mailing per the instructions on the form or may also be completed at Child Abuse History Clearance Online:  https://www.compass.state.pa.us/CWIS

PDE-6004 – This form must be completed by all new hires and is also used for current employees to report an arrest or conviction of offenses enumerated under 24 P.S. § 1-111 (e) and 24 P.S. § 1-111 (f.1) within 72 hours of the arrest or conviction.

More information on the above background checks can be found at: http://www.portal.state.pa.us/portal/server.pt/community/background_checks_%28act_114%29/7493

 

Benefits

Health/Medical Insurance

BCNEPA Newsletter June 2015

Web Portal Access Form

Employee Enrollment Form

Change Request Form – NSHEB-6005 (1-14)

Services Requiring Coverage – PPO 2015 BCNEPA

NEB Admin Guide – 4/8/15

Employee Assistance Program – 1/2015

Travel Assistance Program

Highmark AllClear ID Protection

 

Traditional – Summary of Coverage and Benefits

Workers’ Compensation Program: Designated Health Care Providers

PPO E – Summary of Coverage and Benefits

PPO G – Summary of Coverage and Benefits

Traditional – Outline of Services

PPO E – Outline of Services

PPO G – Outline of Services

Summary of Coverage and Benefits Glossary

Henry Dunn Contact Information

Preventative Schedule

Preventative Schedule Addendum – Women’s Health

Prescription Home Delivery

Tier Zero Prescriptions

Urgent Care Centers Information

2012 Women’s Health and Cancer Rights Act Notice

2013 Medicare Part D Creditable Coverage Notice

2014 HIPAA Notice of Privacy Practice

BCNEPA July 2014 Benefit Changes

 

Dental Insurance

Outline of Dental Coverage

 

125 Flexible Spending Account (FSA)

Vendor (CBiZ) Contact Information

FSA Agreement for Direct Deposit

FSA Debit Card Detail

FSA Debit Card FAQs

FSA Reimburseable OTC Medicines

FSA Reimbursement Form

 

403(b)

403(b) Plan Summary

403(b) Salary Reduction Agreement

403(b) Disclosure Form

403(b) Information