Absence/Leave Forms
Uncompensated Leave Application
Work Related Injuries
PICS Amerihealth WC Provider Panel
Payroll Forms
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.
Timesheets
Support Staff Timesheet – 200 Day Calendar
Support Staff Timesheet with Sub Line
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
Purchasing Forms
Requisition Form 2015-2016Â (Excel)
Continuing Education Forms
Mandated Reporter Information
Student Services
Student Learning Objective (SLO) template
Notice of Recommended Educational Placement
Release of Student Information
Contracted Services
BLaST Service Request Contract (Excel)
BLaST Service Request Contract (pdf)
Handbooks
Policies
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:Â http://www.portal.state.pa.us/portal/server.pt/community/background_checks_%28act_114%29/7493
Benefits
Health/Medical Insurance
Change Request Form – NSHEB-6005 (1-14)
Services Requiring Coverage – PPO 2015 BCNEPA
Employee Assistance Program – 1/2015
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
Summary of Coverage and Benefits Glossary
Henry Dunn Contact Information
Preventative Schedule Addendum – Women’s Health
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
125 Flexible Spending Account (FSA)
Vendor (CBiZ) Contact Information
FSA Agreement for Direct Deposit
FSA Reimburseable OTC Medicines
403(b)
403(b) Salary Reduction Agreement