Wherever Multiple Choices Are Provided, Please Circle the Selection

EMPLOYEE INFORMATION SHEET

Contract Development and Information Distribution

Wherever multiple choices are provided, please circle the selection.

Circle one: New employee Position Change

GENERAL INFORMATION (BIOGRAPHICAL)

SSN ______Employee ID ______Credential or Z ID# ______

First Name ______Middle Name ______Last Name ______

SSN Legal Name First ______Middle ______Last______Suffix_____

Address ______City ______State ____ Zip ______

Home Phone ______Email ______Gender: M F

Semester Hours: ______(Degree type) Educational Level: ______Certificate: ______

ECE Qualifications: ______Other Credentials: ______Report to EMIS ______

Total Years Experience: ______Authorized Years: ______District Years Experience ______

Race: A Asian Marital Status: 1 – Single Birth Date: ______

B – Black or African American (Non-Hispanic) 2 – Married

H – Hispanic 0 – Unstated Board Hire Date: ______

I – American Indian or Alaskan Native

M -Multiracial

N – Not Specified

P – Native Hawaiian or Other Pacific Islander

W – White, Non-Hispanic

Please Note: If employee holds more than one position, please fill out the remainder of this form for each job. If employee changes positions into a different EMIS position or assignment area please create a new job record for that position.

CONTRACT DEVELOPMENT (JOB SPECIFIC INFORMATION)

Position Title ______Position Type: Regular Supplemental Temporary

Type of Appointment: 1-Certified (STRS) or 2-Classified (SERS) EMIS Appointment Type: ______

Report Job to EMIS: Y N Grade level assigned (L/H) _____ /_____ Position Start Date ______

Contract Term: Beginning Date ______Ending Date ______Years 1 2 3 4 5 Cont

Building IRN:______Building/Department :______/______Assignment Area:______

Work Days in Contract ______Salary Schedule ______Step ______Degree ______

Annual salary ______Per Diem (daily rate) ______Hourly Rate ______Other ______

Sick: Y N Max:______Vacation: Y N Max______Personal: Y N

______

Hiring Authority signature/date Employee signature/date

PAYROLL – OFFICE USE ONLY

Building/Department _____/_____ Calendar start date ______Calendar stop date ______

First date paid:______

Retirement Code: STRS 450 Pay Group ______Calendar Type ______

SERS 400 FICA (blank) Work Days ______Extended Service Days ______

Pay account ______Maximum or % ______Amount ______BRDDIS Y or N

Equal Pays: Y or N Job Status 0 – Inactive 8 - Deceased Timesheets: Y N

1 – Active 9 - Terminated

Date reviewed by payroll ______Payroll initials ______

EMIS DETAILS

If EMIS reporting information is different than contract information provide EMIS contract amount, work days and hours per day

EMIS Contract Amt ______EMIS Hours Per Day ______EMIS Work Days ______EMIS FTE _____

Extended Service ______(ESC reportable Only) Certificate: ______EMIS SPEC ED FTE _____

Position Code ______EMIS Appt: 1-Certified 3-Internship 5-Veteran per ORC 3319.283

2-Classified 4-Six hour lay teacher

Position Type: R – Regular S – Supplemental T – Temporary

Position Status: C – Active/Continuing employee A – Contracted personnel - agency I – Contracted personnel - Individual

P – Leave of absence U - No longer employed by district in this position

HQPD: : ______Qualified Paraprofessional______

Assignment Area ______Funding Source ______Percentage ______

Funding Source ______Percentage ______

Funding choices: A – State Auxiliary Funds B – Other State Funds F – Federal Title VI-B (school age) G – Federal Title I Funds

I- State Poverty Based Assistance Funds J-Federal Head Start Program Funds L – Local Funds N – TANF /OWF O – Other Federal

P – Federal Preschool S-State Funds – Public Preschool Program T – Private/Tuition U – State Unit Funding X-Reading First Z – Preschool Unit F

Position Separation Reason ______Position Separation Date: ______

Separation Reasons: 1: Retirement 3: Employer initiated 5: Resigned – Took another education job in Ohio 6: Resigned – Took another education job out of state 7: Resigned – Other 8: Employee accepted a new position in the district 9: Deceased

Date reviewed by EMIS ______EMIS initials ______

North Coast Council 1/21/2015