America Reads Program at Penn State

Letter of Agreement

I, ______(student name) am aware of the necessity of respecting the confidentiality of any information regarding any of the children I work with for theAmerica Readsprogram at Penn State. I will not share personal information about any child or the site with anyone other than the On-Site Supervisor and Campus Coordinator: I will not reveal the names of the children or the site during any Federal Work-Studytraining and discussions of work experiences.

I understand that I am to abide by the standards of conduct, mode of dress, attendance, and performance standards of the America Readsprogram at Penn State as well as those of the site in which I am working. I have discussed the policies and procedures with the On-Site Supervisor and acknowledge that I understand them and agree to abide by them.

I understand that I may work a maximum of 8 hours each day, and not work more than 20 hours in one week when classes are in session and not more than 40 hours in one week when classes are not in session. I understand that when I am close to earning the full amount of my award, I should contact Student Aid to find out if I am eligible for more funding. I understand that I MAY NOT BE PAID if I work more than 40 hours/week or 8 hours/day or if I earn more than my award amount without contacting Student Aid.

I understand that I may not transport in any vehicle (my own or the site's) any children I am working with or who are served by the placement site.

I realize that failure to comply with this agreement will result in the termination of my work-study assignment.

I understand I am bound to the confidentiality agreement even after I have discontinued my service.

Student's Signature ______Date ______

On-Site Supervisor’s Signature ______Date ______

America Reads Program at Penn State

Federal Work-Study Program Placement Form

Section 1: Student

1. ______2. ______

Student's Full Name (Print) Social Security Number

3. ______

Student’s Local Address (Street, City, and Zip Code)

4. ______5. ______

Student’s Local Telephone Number Student's County of Residence

6. ______7. ______

Current Academic level (undergraduate or graduate) Expected Date of Graduation

Student Forms Completed:_____Salary Deposit Request

_____W-4 (Employee's Withholding Allowance Certificate)

_____1-9, Section 1 (Employment Eligibility Verification Form)

_____Letter of Agreement

_____Placement Form, Section 1

Section 2: On-Site Supervisor

1. ______2. ______

Organization Name On-Site Supervisor's Name (Print)

3. ______

Organization Address (Street, City, State, and Zip Code)

4. ______5. ______

On-Site Supervisor's Telephone Number Payroll Period/Semester(s)

6. America Reads Reading Partner______

Job Title.

7. Job Description: ______

______

On-Site Supervisor Forms Completed:_____Letter of Agreement

_____Placement Form, Section 2

Responsibilities

As an America Reads reading partner, you will be expected to fulfill your job responsibilities professionally. This involves: 1) completing and submitting all paperwork on time; 2) participating in training and working to improve your skills; 3) abiding by all America Reads and site policies; and 4) maintaining professional standards.

1. Complete all necessary forms and paperwork:

  • Placement Form: Give original to Barb Holt and a copy to Dr. Hufnagel
  • Letter of Agreement: Give original to Dr. Hufnagel
  • 1-9, W-4, and Salary Deposit Request: Give to Barb Holt
  • Act 33 and Act 34 Clearance Forms: Keep originals and give copy to Dr. Hufnagel
  • A health appraisal: Give original to Dr. Hufnagel
  • Bi-weekly time sheets. All time sheets must be complete.

2. Participate in (and be paid for) all meetings and trainings, including:

  • Orientation meeting (individual or group)
  • Any specialized or general training requested by Penn State or your site

3. Abide by the policies of the America Reads program and the placement site:

  • Call the site in advance if you will be late; give 24 hours notice if you will be absent.
  • You will be dismissed from the program after 2 absences without prior notice.
  • Check local television or radio announcements for school cancellations during inclement weather.
  • Respect the confidentiality of the site and the children.
  • Dress appropriately according to the policies of the site.
  • Provide two weeks notice and a letter of resignation if at any time you choose to stop working at theplacement site.

4. Work with on-site supervisor to fulfill your job responsibilities professionally:

  • Arrive prepared for each session and apply the techniques and ideas learned in training and orientation.
  • Modify your job responsibilities or techniques as requested.

5.Work with your on-site supervisor to ensure that your bi-weekly time sheets are submitted on time.

America Reads Health Assessment Form

Name of Person Examined: ______

Did you conduct a physical examination? ______Yes ______No

(The physical examination should include a functional assessment of vision, hearing and a systems review looking for conditions that might affect performance or predispose this individual to occupational injury related to lifting, frequent hand washing, the stress of caring for groups of children, driving vehicles, food preparation, facility maintenance and exposure to the common infections of childhood.)

Did this individual have any communicable diseases?______Yes ______No

(If yes, attach separate sheets to describe the condition and the risk it might pose to this individual.)

Please list any information regarding this individual's medical condition that might threaten the health of children or prohibit the individual from providing adequate care to children.

In your assessment, is this individual suitable

to provide child care? ______Yes ______No

(If “No,”please explain your answer on a separate sheet.)

TESTING FOR TUBERCULOSIS BY THE INTRACUTANEOUS MANTOUX METHOD

Date Test Applied ______Date Test Read ______

Physician’s Interpretation of Tuberculin Test ResultsDate Interpretation Made:

Results: ______Positive ______Negative

(If skin test positive: Please attach a copy of the chest x -ray report.)

Does this individual need chemoprophylaxis? ______Yes ______No

Date ______Signature ______MD/DO/CRPN

Printed Name:______Phone Number ______

Address ______