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


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



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 2016 – January 2016

Travel Voucher 2016 2 pages – January 2016


Travel Voucher 2015 – January 2015

Travel Voucher 2015 2 pages – January 2015


Supply Voucher


Purchasing Forms

PSS – Personal Care Supplies

Dice – Personal Care Supplies


Requisition Form 2015-2016 (Excel)



Continuing Education Forms

Tuition Request Form

Conference Request Form

Inservice Attendance Form


Mandated Reporter Information

Reporting Process Guidelines



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)



Support Staff Handbook

Paraprofessional Handbook



Acceptable Use Policy

Dress Code

Confidentiality Agreement



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



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


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) Plan Summary

403(b) Salary Reduction Agreement

403(b) Disclosure Form

403(b) Information