CHABOT – LAS POSITAS COMMUNITY COLLEGE DISTRICT
Student Assistant Employment
Guidelines for New Hires
1. For Student Assistants Being Paid via Division Budget [non FWS]
Hiring Administrator must verify and check off that Student Assistant is enrolled in at least one (1)
class. Exemption: summer employment – a student must have successfully completed the
Spring semester ending just before the summer they are to be employed.)
2. For
Federal Work Study (FWS) Student Assistants
Federal Work Study (FWS) jobs are part of a student's financial aid award, and are paid from federal
financial aid funds. FWS students must maintain enrollment in at least six (6) units during any
period of employment in fall or spring semesters. Hiring Administrator must verify and check off that
FWS students are enrolled for the appropriate number of units before they are hired.
For Summer Employment: Hiring administrator is to verify with their respective college
Financial Aid Office on available funding and enrollment requirements.
3. Required Hiring Packet Forms
The following forms are to be submitted to your hiring administrator. For FWS paperwork: Hiring
Administrator is to process through the respective college Financial Aid Office.
All fully signed paperwork and the following are to be submitted to the Office of Human Resources.





Student Employment Requisition (Verification of Student Enrollment in Classes and copy of
Social Security Card)
Oath of Allegiance
Student Employee Confidentiality Agreement
 Student Personal Information Form
[Note: It is important to fill out completely, especially emergency contact.]
W-4 form
TB Certificate Information Form & TB/X-ray Medical Verification Results
TB/X-ray results must include the following information for the test to be considered complete:
Name of test; test results – which should include one or more of the following definitions:
“Negative”, “O”, “No Evidence of Current Tuberculosis Infection” or other relative definition;
name and address of hospital/clinic; date(s) of visit; doctor/nurse signature or initials; and, your
name.

Department of Homeland Security’s Employment Eligibility Verification (I-9) Form
and Required Documentation
If the Hiring Packet is incomplete, Human Resources will return it back to the hiring administrator,
which will delay Student Assistant’s start date. Once deemed complete, Human Resources will
notify hiring administrator when Student Assistant’s start date is.
HR|P:/FORMS/Student Assistants 2007-08/Rules and Regulations. Doc
Revised: 10 1 13; 4-9-14; 6-10-14
Hiring Packet Revised: 12-19-15
CHABOT – LAS POSITAS COMMUNITY COLLEGE DISTRICT
Student Assistant Employment
Guidelines for New Hires
4. Work Hours
The work hours for Student Assistants are not to exceed eight (8) hours per day and no more than
twenty (20) hours per week. Students may be employed by several on-campus offices concurrently;
however, they may not exceed the maximum number of hours (20) allowed per week.1
5. Employment
Enrolled students may be employed as provided in the Education Code and upon authorization of the
Chancellor as needed. Employment of either full-time or part-time students in any college work-study
program or in a work experience education program shall not result in the displacement of classified
personnel or impair existing contracts for services. Student positions are exempt from the classified
service.2
is the supervisor’s responsibility to inform the students that they are entitled to a fifteen (15) minute
paid break for every four (4) consecutive hours of work, at approximately the midway point. They
must take uninterrupted unpaid lunch for at least thirty (30) minutes when working six (6) or more
consecutive hours in one (1) day.
6. It
7. Student
Assistant positions are of a temporary nature. The maximum effective employment period
of a Student Assistant is from July 1 to June 30. Student Assistant services are automatically
terminated June 30 of each fiscal year. Student Assistants may be rehired effective on or after July 1
of the new fiscal year.3
8. International
students may be hired only if they have an F-1 visa. International students must have
approval from the Director of Admissions and Records (Chabot) or the Dean of Enrollment Services
(Las Positas).4
9. As
provided in the Education Code, all employees, prior to receiving official start work date, are
required to present a certificate from their examining physician giving evidence of freedom from active
tuberculosis. These provisions shall not apply to any employee who files an affidavit based on
adherence to the faith or teachings of any well-organized religious sect, denomination or organization as
provided in the Education Code.5
Personnel – General / Administrative Rules and Procedures / 4008 Student Assistants:http://www.clpccd.org/board/documents/4008ARP.pdf
Personnel – General / 4008 Student Assistants: http://www.clpccd.org/board/documents/4008Policy.pdf
Personnel – General / Administrative Rules and Procedures / 4008 Student Assistants: http://www.clpccd.org/board/documents/4008ARP.pdf
4
Personnel – General / Administrative Rules and Procedures / 4008 Student Assistants: http://www.clpccd.org/board/documents/4008ARP.pdf
5
Personnel –General / Employment / 4015 Freedom from Tuberculosis: http://www.clpccd.org/board/documents/4015Policy.pdf
1
2
3
HR|P:/FORMS/Student Assistants 2007-08/Rules and Regulations. Doc (updated 10 1 13; 4-9-14; 6-10-14)
CHABOT – LAS POSITAS COMMUNITY COLLEGE DISTRICT
For more information regarding student employment contact the following:
Chabot College
(510) 723-7105
Las Positas College
(925) 424-1632
Human Resources
(925) 485-5236
__________________________________________________________________________________________
___
Student Pay Schedule
Effective January 1, 2016, the State minimum wage increased to $10.00 per hour.
Category
A
B
C
D
Rate of Pay
$ 10.00
$ 10.50
$ 11.00
$ 11.50
__________________________________________________________________________________________
____
Student Pay Categories
***NOTE: Hiring Administrator determines pay category based on job duties.
Student Salary Schedule Proposal for 1-1-16
Category A - Student Assistant
$10.00
No experience required. Under direct supervision, performs entry-level manual and clerical
tasks that require one-step demonstration and limited use of independent judgment and
creativity. Tasks are simple, routine and recurring.
Category B - Student Assistant
$10.50
Requires specialized training, broader range of expertise and greater responsibility.
Experience and/or education in an area related to the work assignment are required.
Under general supervision, performs tasks that require a moderate degree of experience
and independent judgment.
Category C - Student Assistant
$11.00
Requires minimum of one year's work experience which will demonstrate the skills, ability
and proficiency to work on complex assignments within the scope of student assignments,
under general and limited supervision.
Category D - Student Assistant
Requires a high degree of knowledge of work assignment or closely related area. Must
possess skills and demonstrate a high level of proficiency necessary to perform highly
complex tasks. Must be able to assume considerable responsibility and/or work under little
supervision. Performs tasks that require a high degree of independence, responsibility and
creativity within the scope of student assignments.
Placement in this category must be approved by the College President or appropriate
Vice President.
Human Resources: S:\personnl\FORMS\Student Assistants\New Hire Packet\Rules and Regulations - PAGE TWO - 11-23-15.docx
$11.50
CHABOT-LAS POSITAS COMMUNITY COLLEGE DISTRICT
Student Assistant Employment Requisition
For the 20
to 20
School Year
1. STUDENT APPLICANT INFORMATION (Type or print in ink, attach copy of Social Security card and student enrollment verification.)
Last Name:
First Name:
Middle Initial:
(Please write name exactly as found on Social Security Card or other official document.)
SSN or W#:
Birth Date:
Address:
Home Phone:
City:
Zip:
I am a Chabot  Las Positas College student currently enrolled/preregistered in
units for
semester, 20
.
I have read the attached "Guidelines for Student Employment.” I understand that my employment on campus is temporary and can be
immediately terminated.
Student Signature:
Date:
2. TO BE COMPLETED BY HIRING DIVISION
Employment is limited to eight (8) hours per day, twenty [20] hours per week (in all combined areas of the college).
To be employed by:
Building:
Room:
Division/Area
Student's direct supervisor:
Extension:
Name and Position
Position Hired: Federal Work Study Student
A
RANGE/STEP: CATEGORY:
B
Student Assistant Student Intern/Ambassador
C
D
Hours Per Week:
RATE OF PAY: $
(Please see information on next page for appropriate category and pay range.)
Funding Source(s):
FWS
Budget Account Number:
FUND
CalWorks
Division
Other:
(for FWS and HR use ONLY)
ORGN
ACCT
PROG
%
Position Code
Suffix
%
%
%
%
New hire: effective date:
Rehire: effective date:
Hiring Administrator has verified that student is enrolled in the appropriate number of units before hiring them as a
Student Assistant or in FWS.
Hiring Administrator’s Signature:
Date:
3. TO BE COMPLETED BY FINANCIAL AID OFFICE (For Federal Work Study Students Only)
 Hired under Federal Work Study Awarded $
Total hours________
No. of units
Satisfactory Academic Progress
Approved by:
Date:
Financial Aid Officer
4. TO BE COMPLETED BY THE CalWORKS COORDINATOR (For CalWORKS Students Only)
Awarded $
Total hours
No. of units
Good Standing
Approved by:
 yes
 no
Date:
CalWORKS Coordinator
5. TO BE COMPLETED BY ADMINISTRATOR, ADMISSION & RECORDS (For International Students)
No. of units
Verification of approval to work:
Approved by:
Date:
Administrator of Admission & Records
6. HUMAN RESOURCES: Input by:
Human Resources:P:\FORMS\Student Assistants\Student Assist Requisition.doc
Date:
Revised: 11/27/07; 6/10/14
 yes
 no
CHABOT­LAS POSITAS COMMUNITY COLLEGE DISTRICT
Office of Human Resources
Oath of Allegiance
OATH OF ALLEGIANCE FOR PERSONS EMPLOYED BY A SCHOOL DISTRICT IN THE STATE OF CALIFORNIA (Required by Section 3 of Article XX Constitution of the State of California and by Chapter 8, Division 4, Title 1 of the Government Code) (State of California as County of Alameda) I, ___________________________________________, do solemnly swear (or affirm) that I will support and (type or print name) defend the Constitution of the United States and the Constitution of the State of California against all enemies, foreign and domestic, that I will bear true faith and allegiance to the Constitution of the United States and the Constitution of the State of California; that I take this obligation freely, without any mental reservation or purpose of evasion; and that I will well and faithfully discharge the duties upon which I am about to enter. Signature of Employee Title of position Taken, subscribed and sworn to before me This day of ,20 Signature of Administrator Title This oath must be signed by a Chabot­Las Positas Community College District administrator involved in the hiring and payroll process of faculty, classified and student assistance employees of the District REFERENCES: Governing Board Policy 2230 and Government Code Section 3104. Printed: 12/2/08 (updated 4/29/13) Document1 Page 1 of 1 CHABOT-LAS POSITAS COMMUNITY COLLEGE DISTRICT
Student Employee Confidentiality Agreement
Employees, including student workers, who may have access to student or employee
educational and personal records and information, must adhere to federal Family
Educational Rights and Privacy Act of 1974 regulations (FERPA), which govern the
confidentiality, use and release of these records. Student employees may not seek,
discuss, use or misappropriate any information other than that which is necessary to
fulfill their assigned duties.
Student employees must not divulge or otherwise release confidential records or
information in written or verbal form to anyone except the person of record (as positively
identified) without written consent of the person involved. Unauthorized release of
confidential information is a violation of laws regarding individual and family right to
privacy.
My signature denotes that I agree to consider all information that I become aware of in
the course of my employment as strictly confidential.
If I am in doubt about a request for information, I understand that it is my responsibility
to discuss the request with my supervisor prior to a decision to release the information.
FERPA Motto: “Keep any information obtained in the workplace at the workplace”.
I fully understand that if I divulge or misuse confidential information; I will be subject to
disciplinary action by Chabot/Las Positas Community College District and will be liable
to civil and criminal prosecution pursuant to the Family Rights and Privacy Act, and I
also understand that such actions on my part will result in termination of employment.
The Confidentiality Agreement must be read and signed by the student and supervisor.
_____________________________________________________
Student Employee’s Signature
_____/_____/_____
Date
_____________________________________________________
Supervisor’s Signature
_____/_____/_____
Date
Human Resources
P:\FORMS\Student Assistants 2007-08\New Hire Packet\Confidentiality Form.doc
CHABOT-LAS POSITAS COMMUNITY COLLEGE DISTRICT
Student Personal Information Form
Name: ____________________________________________________________________________________
(Last)
(First)
(Middle)
Permanent Address: _________________________________________________________________________
(Street & Number)
(City)
(State/Zip)
Mailing Address: ___________________________________________________________________________
(if different from Permanent Address)
(Street & Number)
(City)
(State/Zip)
Social Security Number: ___________-________-___________ Phone #: (______)_____________________
Date of Birth: ________________________________
Alternate Phone: (_______)____________________
Sex: _______ (Male) _______ (Female)
Email Address: _____________________________
Are you eligible to work in the US? ____Yes ____No (if you answer NO, please fill out the following)
____ A Lawful Permanent Resident: Alien #: _____________________________
____ An alien authorized to work until ____/____/____
Alien # or Admission #: __________________________________
Marital Status:
____ Single
____ Married
____ Divorced
____Other
If Married, name of Spouse: __________________________________________________________________
Other Names Used: _________________________________________________________________________
Person to Notify in Case of Emergency: _________________________________________________________
Relationship to Person: ______________________________________________________________________
Address: __________________________________________________________________________________
(Street & Number)
(City)
Phone #: (_______)_______________________
Human Resources
P:\FORMS\Student Assistants 2007-08\New Hire Packet\Student Personal Information Form.doc
(State/Zip)
Form W-4 (2016)
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. If you are exempt,
complete only lines 1, 2, 3, 4, and 7 and sign the form
to validate it. Your exemption for 2016 expires
February 15, 2017. See Pub. 505, Tax Withholding
and Estimated Tax.
Note: If another person can claim you as a dependent
on his or her tax return, you cannot claim exemption
from withholding if your income exceeds $1,050 and
includes more than $350 of unearned income (for
example, interest and dividends).
Exceptions. An employee may be able to claim
exemption from withholding even if the employee is a
dependent, if the employee:
• Is age 65 or older,
• Is blind, or
• Will claim adjustments to income; tax credits; or
itemized deductions, on his or her tax return.
The exceptions do not apply to supplemental wages
greater than $1,000,000.
Basic instructions. If you are not exempt, complete
the Personal Allowances Worksheet below. The
worksheets on page 2 further adjust your
withholding allowances based on itemized
deductions, certain credits, adjustments to income,
or two-earners/multiple jobs situations.
Complete all worksheets that apply. However, you
may claim fewer (or zero) allowances. For regular
wages, withholding must be based on allowances
you claimed and may not be a flat amount or
percentage of wages.
Head of household. Generally, you can claim head
of household filing status on your tax return only if
you are unmarried and pay more than 50% of the
costs of keeping up a home for yourself and your
dependent(s) or other qualifying individuals. See
Pub. 501, Exemptions, Standard Deduction, and
Filing Information, for information.
Tax credits. You can take projected tax credits into account
in figuring your allowable number of withholding allowances.
Credits for child or dependent care expenses and the child
tax credit may be claimed using the Personal Allowances
Worksheet below. See Pub. 505 for information on
converting your other credits into withholding allowances.
Nonwage income. If you have a large amount of
nonwage income, such as interest or dividends,
consider making estimated tax payments using Form
1040-ES, Estimated Tax for Individuals. Otherwise, you
may owe additional tax. If you have pension or annuity
income, see Pub. 505 to find out if you should adjust
your withholding on Form W-4 or W-4P.
Two earners or multiple jobs. If you have a
working spouse or more than one job, figure the
total number of allowances you are entitled to claim
on all jobs using worksheets from only one Form
W-4. Your withholding usually will be most accurate
when all allowances are claimed on the Form W-4
for the highest paying job and zero allowances are
claimed on the others. See Pub. 505 for details.
Nonresident alien. If you are a nonresident alien,
see Notice 1392, Supplemental Form W-4
Instructions for Nonresident Aliens, before
completing this form.
Check your withholding. After your Form W-4 takes
effect, use Pub. 505 to see how the amount you are
having withheld compares to your projected total tax
for 2016. See Pub. 505, especially if your earnings
exceed $130,000 (Single) or $180,000 (Married).
Future developments. Information about any future
developments affecting Form W-4 (such as legislation
enacted after we release it) will be posted at www.irs.gov/w4.
Personal Allowances Worksheet (Keep for your records.)
A
Enter “1” for yourself if no one else can claim you as a dependent .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
A
}
• You are single and have only one job; or
• You are married, have only one job, and your spouse does not work; or
. . .
B
Enter “1” if:
• Your wages from a second job or your spouse’s wages (or the total of both) are $1,500 or less.
Enter “1” for your spouse. But, you may choose to enter “-0-” if you are married and have either a working spouse or more
than one job. (Entering “-0-” may help you avoid having too little tax withheld.) . . . . . . . . . . . . . .
C
Enter number of dependents (other than your spouse or yourself) you will claim on your tax return . . . . . . . .
D
Enter “1” if you will file as head of household on your tax return (see conditions under Head of household above)
. .
E
Enter “1” if you have at least $2,000 of child or dependent care expenses for which you plan to claim a credit
. . .
F
(Note: Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for details.)
Child Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information.
• If your total income will be less than $70,000 ($100,000 if married), enter “2” for each eligible child; then less “1” if you
have two to four eligible children or less “2” if you have five or more eligible children.
G
• If your total income will be between $70,000 and $84,000 ($100,000 and $119,000 if married), enter “1” for each eligible child . .
Add lines A through G and enter total here. (Note: This may be different from the number of exemptions you claim on your tax return.) ▶ H
{
B
C
D
E
F
G
H
For accuracy,
complete all
worksheets
that apply.
{
• If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions
and Adjustments Worksheet on page 2.
• If you are single and have more than one job or are married and you and your spouse both work and the combined
earnings from all jobs exceed $50,000 ($20,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2
to avoid having too little tax withheld.
• If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W-4 below.
Separate here and give Form W-4 to your employer. Keep the top part for your records.
Form
W-4
Department of the Treasury
Internal Revenue Service
1
Employee's Withholding Allowance Certificate
OMB No. 1545-0074
▶ Whether you are 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.
Your first name and middle initial
Last name
Home address (number and street or rural route)
2
3
Single
Married
2016
Your social security number
Married, but withhold at higher Single rate.
Note: If married, but legally separated, or spouse is a nonresident alien, check the “Single” box.
City or town, state, and ZIP code
5
6
7
4 If your last name differs from that shown on your social security card,
check here. You must call 1-800-772-1213 for a replacement card. ▶
Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2)
5
Additional amount, if any, you want withheld from each paycheck . . . . . . . . . . . . . .
6 $
I claim exemption from withholding for 2016, 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 . . . . . . . . . . . . . . . ▶ 7
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.)
8
Date
▶
Employer’s name and address (Employer: Complete lines 8 and 10 only if sending to the IRS.)
For Privacy Act and Paperwork Reduction Act Notice, see page 2.
9 Office code (optional)
Cat. No. 10220Q
10
▶
Employer identification number (EIN)
Form W-4 (2016)
Page 2
Form W-4 (2016)
Deductions and Adjustments Worksheet
Note: Use this worksheet only if you plan to itemize deductions or claim certain credits or adjustments to income.
1
Enter an estimate of your 2016 itemized deductions. These include qualifying home mortgage interest, charitable contributions, state
and local taxes, medical expenses in excess of 10% (7.5% if either you or your spouse was born before January 2, 1952) of your
income, and miscellaneous deductions. For 2016, you may have to reduce your itemized deductions if your income is over $311,300
and you are married filing jointly or are a qualifying widow(er); $285,350 if you are head of household; $259,400 if you are single and
not head of household or a qualifying widow(er); or $155,650 if you are married filing separately. See Pub. 505 for details . . .
2
3
4
5
6
7
8
9
10
}
$12,600 if married filing jointly or qualifying widow(er)
$9,300 if head of household
. . . . . . . . . . .
Enter:
$6,300 if single or married filing separately
Subtract line 2 from line 1. If zero or less, enter “-0-” . . . . . . . . . . . . . . . .
Enter an estimate of your 2016 adjustments to income and any additional standard deduction (see Pub. 505)
Add lines 3 and 4 and enter the total. (Include any amount for credits from the Converting Credits to
Withholding Allowances for 2016 Form W-4 worksheet in Pub. 505.) . . . . . . . . . . . .
{
Enter an estimate of your 2016 nonwage income (such as dividends or interest) . . . . . . . .
Subtract line 6 from line 5. If zero or less, enter “-0-” . . . . . . . . . . . . . . . .
Divide the amount on line 7 by $4,050 and enter the result here. Drop any fraction . . . . . . .
Enter the number from the Personal Allowances Worksheet, line H, page 1 . . . . . . . . .
Add lines 8 and 9 and enter the total here. If you plan to use the Two-Earners/Multiple Jobs Worksheet,
also enter this total on line 1 below. Otherwise, stop here and enter this total on Form W-4, line 5, page 1
1
$
2
$
3
4
$
$
5
6
7
8
9
$
$
$
10
Two-Earners/Multiple Jobs Worksheet (See Two earners or multiple jobs on page 1.)
Note: Use this worksheet only if the instructions under line H on page 1 direct you here.
1
Enter the number from line H, page 1 (or from line 10 above if you used the Deductions and Adjustments Worksheet)
2
Find the number in Table 1 below that applies to the LOWEST paying job and enter it here. However, if
you are married filing jointly and wages from the highest paying job are $65,000 or less, do not enter more
than “3” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
If line 1 is more than or equal to line 2, subtract line 2 from line 1. Enter the result here (if zero, enter
3
“-0-”) and on Form W-4, line 5, page 1. Do not use the rest of this worksheet . . . . . . . . .
Note: If line 1 is less than line 2, enter “-0-” on Form W-4, line 5, page 1. Complete lines 4 through 9 below to
figure the additional withholding amount necessary to avoid a year-end tax bill.
4
5
6
7
8
9
Enter the number from line 2 of this worksheet . . . . . . . . . .
4
Enter the number from line 1 of this worksheet . . . . . . . . . .
5
Subtract line 5 from line 4 . . . . . . . . . . . . . . . . . . . . . . . . .
Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here . . . .
Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed . .
Divide line 8 by the number of pay periods remaining in 2016. For example, divide by 25 if you are paid every two
weeks and you complete this form on a date in January when there are 25 pay periods remaining in 2016. Enter
the result here and on Form W-4, line 6, page 1. This is the additional amount to be withheld from each paycheck
Table 1
Married Filing Jointly
If wages from LOWEST
paying job are—
$0 - $6,000
6,001 - 14,000
14,001 - 25,000
25,001 - 27,000
27,001 - 35,000
35,001 - 44,000
44,001 - 55,000
55,001 - 65,000
65,001 - 75,000
75,001 - 80,000
80,001 - 100,000
100,001 - 115,000
115,001 - 130,000
130,001 - 140,000
140,001 - 150,000
150,001 and over
Enter on
line 2 above
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
1
2
3
6
7
8
$
$
9
$
Table 2
All Others
If wages from LOWEST
paying job are—
$0 - $9,000
9,001 - 17,000
17,001 - 26,000
26,001 - 34,000
34,001 - 44,000
44,001 - 75,000
75,001 - 85,000
85,001 - 110,000
110,001 - 125,000
125,001 - 140,000
140,001 and over
Married Filing Jointly
Enter on
line 2 above
0
1
2
3
4
5
6
7
8
9
10
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 who claims no
withholding allowances; 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.
If wages from HIGHEST
paying job are—
$0 - $75,000
75,001 - 135,000
135,001 - 205,000
205,001 - 360,000
360,001 - 405,000
405,001 and over
Enter on
line 7 above
$610
1,010
1,130
1,340
1,420
1,600
All Others
If wages from HIGHEST
paying job are—
$0 - $38,000
38,001 - 85,000
85,001 - 185,000
185,001 - 400,000
400,001 and over
Enter on
line 7 above
$610
1,010
1,130
1,340
1,600
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.
CHABOT - LAS POSITAS COMMUNITY COLLEGE DISTRICT
Tuberculosis (TB) Certificate Information
SECTION 1: PERSONAL INFORMATION
Name: _____________________________________________________________________________________________
(Last)
(First)
(Middle)
SSN/W#: ___________________________________
Position Title: ________________________________________
Division/Office: ______________________________
Employee Signature: ___________________________________
SECTION 2: TB CERTIFICATE
Have you submitted a clear/negative TB test or X-ray (no later than 4 years old) to the Office of Human Resources for
work prior to this job?
□ Yes (If you answered yes, please turn in this form to the Office of Human Resources)
□ No (If you answered no, please proceed to SECTION 3)
SECTION 3: INSTRUCTIONS
1) Schedule an appointment with your personal physician or health care center. (List of available locations are listed on the next page
for your convenience)
2) Take this form with you when you go in for your TB test.
3) Your test will require two visits: The first visit will be for taking your TB test and the second visit will be for a follow-up
to have the test viewed for results. (You will have to wait 48 to 72 hours before returning for the second visit to review the results.
Remember to schedule your initial visit only if you know you will be able to meet the second visit time requirement, otherwise you may be charged to
re-test)
4) Once you have completed your examination successfully, your physician will give you a copy of the TB / X-ray
certificate. Please check to see if the following information is listed on your certificate:
- Hospital / Health Clinic Name
- Date of TB examination or X-ray and final date of results
- Results of the test is marked as either negative or positive
(NOTE: if positive, a chest X-ray will be required for continuation of employment with the District. An X-ray may be scheduled at most
hospitals and clinics)
5) Submit this TB form along with a copy of your TB / X-ray certificate to the Office of Human Resources after
you have received a clear TB test from the physician.
6) Expense for the initial examination, including X-rays, if needed, is the responsibility of the employee with the exception
of student assistants. Only TB examinations are covered for student assistants, not X-rays examinations. Expenses for
renewal tests are paid by the District. Please see board policy: http://www.clpccd.org/board/documents/4015Policy.pdf
7) Once your TB test has expired, after 4 years, a renewal letter will be sent out to notify you that an updated TB test is
required for your personnel file. The letter will state a 3-month due date by which you must submit your test to the Office
of Human Resources, 7600 Dublin Boulevard, 3rd Floor, Dublin CA 94568. (A current TB certificate must be on file with Human
Resources at all times in order to continue active employment with Chabot-Las Positas Community College District).
CALIFORNIA EDUCATION CODE:
Education Code Section 87408.6 provides that each person employed by a school district shall undergo an examination at least once every
four years to determine that he/she is free of active tuberculosis. This examination shall consist of an approved intradermal tuberculin test
which, if positive, shall be followed by an x-ray of the lungs. After such examination, each employee shall file with the school district of
employment a certificate showing the employee was examined and found free from active tuberculosis. The certificate signed by the
examining physician and surgeon or a notice from a public health agency or unit of the Tuberculosis Association which indicates freedom
from active tuberculosis will constitute evidence of compliance with this section.
Human Resources
Revised: 2/1/11; 4/24/13; 2/3/14
P:\TB\Form - Instructions - Locations 2014
2 3 14.doc
TB TESTING LOCATIONS
HEALTH CENTERS:
Please be aware that the following are recommended centers; however, we are unable to guarantee available
appointments. Expense for the initial examination, including X-Rays, if needed, is the responsibility of the employee
with the exception of student assistants. Only TB examinations are covered for student assistants,
not X-rays examinations. Expenses for renewal tests are paid by the District (re CLPCCD Board Policy 4015).
CHABOT COLLEGE HEALTH CENTER
LOCATED AT:
25555 Hesperian Boulevard
Building 100, Room 204
Hayward, CA 94545
(510) 723-7625
www.chabotcollege.edu/healthcenter
Charge for TB testing is $25.00 for new hires
Chest X-Rays are referred out as needed
IMMUNIZATION:
Please call for an appointment or business hours, as the schedule
below changes according to seasons or holidays as needed:
Monday and Wednesday: 11:00 a.m. – 7:00 p.m.
Tuesday and Thursday: 9:00 a.m. – 5:00 p.m.
Friday: 9:00 a.m. – 1:00 p.m.
Closed for lunch: 1:00 p.m. – 2:00 p.m.
No TB testing on Thursday
LAS POSITAS COLLEGE HEALTH CENTER
LOCATED AT:
3000 Campus Hill Drive
Livermore, CA 94551
(925) 424-1830
www.laspositascollege.edu/healthcenter
Charge for TB testing is $25.00 for new hires
Chest X-Rays are referred out as needed
IMMUNIZATION:
Please call for an appointment or business hours, as the schedule
below changes according to seasons or holidays as needed:
Monday, Tuesday, Thursday: 9:00 a.m. – 5:00 p.m.
Wednesday: 11:00 a.m. – 7:00p.m.
Friday: Closed
This site remains OPEN during lunchtime.
TB Testing performed on Mondays & Tuesdays only
Please Note:
We no longer have an account set up with Pleasanton Urgent Care, nor are we continuing to refer our employees to
them for TB tests and x-rays. If you still choose to use this clinic on your own, Pleasanton Urgent Care has undergone
new management and is now called Redwood Medical Center and Urgent Care.
For questions contact Denise Marriott in the Human Resources Department at dmarriott@clpccd.org or by calling
(925) 485-5236.
NOTE: SUBJECT TO CHANGE
P:/TB/Locations updated list 12 8 15
Date
June 25, 2013
TO:
All New and Potential Hires
CLPCCD Hiring Supervisors and Managers
SUBJECT: Department of Homeland Security’s I-9 Form
The Department of Homeland Security has changed their procedures and form(s),
effective March 2013. All Potential Hires are required to fill out and complete the
attached form as well as provide the required documentation to the CLPCCD
Hiring Supervisor or Manager.
If Human Resources does not receive the I-9 Form within the hiring packet or it is
not complete, this will cause a delay in hiring process and start work date. Any
questions can be directed to Human Resources at 925.485.5236.
Attachment
pamphlet
If a work injury occurs
California law guarantees certain benefits to
employees who are injured or become ill
because of their jobs.
Any job related injury or illness is covered.
Types of injuries include, but may not be limited
to, strains, sprains, cuts, cumulative or repetitive
traumas, fractures, illnesses and aggravations.
Some injuries from voluntary, off duty,
recreational, social or athletic activity may not be
covered. Check with your supervisor or Keenan
& Associates if you have any questions.
All work related injuries must be reported to
your supervisor immediately. Don’t delay.
There are time limits. If you wait too long, you
may lose your right to benefits. Your employer
is required to provide you a claim form within
one working day after learning about your
injury.
It is a misdemeanor for an employer to
discriminate against workers who are injured on
the job or who testify in another employee’s
case. Any such employee may be entitled to
compensation, reinstatement and
reimbursement for lost wages and benefits.
chiropractic, 24 physical therapy and 24
occupational therapy visits. However this limit
does not apply for post surgical treatments.
Costs are paid directly by Keenan & Associates,
through your employers workers’ compensation
program, so you should never see a bill.
If emergency treatment is required go to the
nearest emergency room or contact 911.
Keenan & Associates will arrange medical
treatment, often by a specialist for the particular
injury. Preferred Provider Networks may be
utilized for physicians as well as medical care
centers.
If you have health care coverage you are eligible
to treatment with your personal physician or
medical group should you become injured on
the job. If you are eligible, before you are
injured, you must notify your employer in
writing and provide your employer written
documentation from your personal physician or
medical group that they agree to be
predesignated. Your personal physician must be
your regular primary care physician who
previously directed your medical treatment, who
retains your medical history and records. You
may only predesignate your primary care
physician if they are a family practitioner,
general practitioner, board certified or board
eligible internist, obstetrician-gynecologist, or
pediatrician. Your personal physician may be a
multispecialty medical group composed of
licensed doctors or osteopathy providing
Workers’ compensation benefits include
medical services predominantly for nonoccupational illness and injuries.
Medical Care – All medical treatment, without
a deductible or dollar limit. For dates of injury
on or after 1/1/04 there is a limit of 24
Your employer may be using a Medical Provider
Network (MPN), which is a selected group of
health care providers to provide treatment to
April 2014
workers injured on the job. If you have
predesignated a personal physician prior to your
work injury, then you may receive treatment
from your predesignated doctor. If you have not
predesignated and your employer is using and
MPN, you are free to choose an appropriate
provider from the MPN list after the first
medical visit directed by your employer or
Keenan & Associates. If you are treating with a
non-MPN doctor for an existing injury, you may
be required to change to a doctor within the
MPN. For more information, see the MPN
contact information on reverse side.
If your employer does not participate in a
Medical Provider Network (MPN) you may be
able to change your treating physician to your
personal chiropractor or acupuncturist.
Generally your employer, or Keenan, has the
right to select your treating physician within the
first 30 days after your employer knows of your
injury or illness. After your employer, or
Keenan, initiates treatment you may, upon
request, have your treatment transferred to your
personal chiropractor or acupuncturist. To be
eligible you must notify your employer in
writing prior to being injured. However, a
chiropractor cannot be your treating physician
after receiving 24 chiropractic office visit.
Your employer will provide you with a form to
use an optional method to predesignate your
personal physician.
Contact Keenan & Associates if you plan to
change physicians at any time.
Payment for Lost Wages - If you’re
temporarily disabled by a job injury or illness,
you’ll receive tax-free income until your doctor
says you are able to return to work. Payments
are two-thirds of your average weekly pay, up to
a maximum set by state law. Payments aren’t
made for the first three days unless you are
hospitalized in an inpatient basis or unable to
work more than 14 days.
If the injury or illness results in permanent
disability, additional payments will be made after
recovery. If the injury results in death, benefits
will be paid to surviving, eligible dependents.
Rehabilitation – For dates of injury on or
after 1/1/04 - you may be entitled to a
Supplemental Job Displacement Voucher,
which entitles you to a voucher for educational
training.
How to obtain additional information
Contact your employer representative or
Keenan & Associates if you have questions
about workers’ compensation benefits. You
may also contact an Information and Assistance
Officer at the State Division of Workers’
Compensation. You can consult an attorney.
Most attorneys offer one free consultation. If
you decide to hire an attorney, his or her fee will
be taken out of some of your benefits. For
names of workers’ compensation attorneys, call
the State Bar of California at 415-538-2120.
Department of Workers’ Compensation
Anaheim
Bakersfield
Eureka
Fresno
Goleta
Long Beach
Los Angeles
Marina Del Rey
Oakland
Oxnard
Pomona
Redding
Riverside
Sacramento
Salinas
San Bernardino
San Diego
San Francisco
714-414-1804
661-395-2514
707-441-5723
559-445-5355
805-968-4158
562-590-5001
213-576-7389
310-482-3858
510-622-2861
805-485-3528
909-623-8568
530-225-2047
951-782-4347
916-928-3158
831-443-3058
909-383-4522
619-767-2082
415-703-5020
San Jose
San Luis Obispo
Santa Ana
408-277-1292
805-596-4159
714-558-4597
Santa Rosa
Stockton
Van Nuys
707-576-2452
209-948-7980
818-901-5367
Keenan & Associates adjusting locations
Information and Assistance Offices
Torrance
800-654-8102
You can get free information from a state
Division of Workers’ Compensation
Information & Assistance Officer. The phone
numbers are listed below. Hear recorded
information by calling toll-free 800-736-7401 or
visit www.dwc.ca.gov.
Eureka
707-268-1616
Pleasanton
925-225-0611
April 2014
Rancho Cordova
800-343-0694
Redwood City
650-306-0616
Riverside
800-654-8347
San Jose
800-334-6554
Anyone who knowingly files
or assists in the filing of a
false workers’ compensation
claim may be fined up to
$150,000 and sent to prison
for up to five years.
[Insurance Code Section 1871.4]
Office of Human Resources
DATE:
January 30, 2014
TO:
All Student Assistant New Hires
FROM:
Human Resources
SUBJECT: Student Assistant Time Sheets
Please verify with your hiring administrator or designee the appropriate
student assistant time sheet as well as when the monthly time sheet
deadline is.
Time sheets are posted on the Business Services Forms website:
www.clpccd.org/business/CLPCCD-InternalFormsandProcedures.php.
For security reasons, we ask that students utilize the W number rather
than SSN when filling time sheet out.