Student-Hiring-Packet.Pdf

NEW EMPLOYMENT PACKET TRANSMITTAL FORM For Department Use Only

New Hire Last Name, First Name

Hiring Department Adloc #

Position Being Hired For:

Adjunct GA Student Non-Budgeted Hourly

Does this person work for another department at Tarleton? If yes, what department? YES NO

Does this person work for another A&M University/component? If yes, what University/component YES NO

Contact Person for the Department Contact Person's Phone Number First Name Last Name

Additional Comments / Notes

THIS FORM MUST ACCOMPANY ALL HIRING PACKETS SUBMITTED! EMPLOYEE SERVICES - BOX T-0510

The Texas A&M University System HR 181 (11/09) Check one: Employee Personal Data ___ TRS ___ ORP With few exceptions, you have the right to request, receive, review and correct information about yourself collected using this form.

Name: ______Last First Middle UIN or SSN: ______Birthdate: ______Month Day Year Citizenship: ______Visa type: ______Country If other than U.S. citizenship Male Highest 1–Less than high school 2–High school/GED 3–Associate degree Female Education 4–Baccalaureate degree 5–Master’s degree 6–Doctoral degree Level 7–Special professional (D.D.S., D.V.M., J.D., M.D., etc.) ______You are not obliged to respond to the asterisked items below (Veteran and Former Foster Child Status) and on Page 3; however, your response is important to meet federal and state reporting requirements. Any information you provide will remain confidential in accordance with applicable federal and state regulations. Your employment will not be adversely affected by any information you furnish. EEO Ethnicity/Race (See Page 2) *Veteran Status (See Page 2. Check all that apply.) 3-Hispanic or Latino? Yes If you selected ‘Yes,” you Veteran will be identified as Hispanic or Latino for federal and Armed Forces Service Medal Veteran and state reporting purposes, even if you select any of Other Protected Veteran the races below. Recently Separated Veteran (within last three years)-If yes, Select all that apply. indicate armed services separation date ______ 1–White 2–Black or African American Orphan of a Veteran 4–Asian 5–American Indian or Alaska Native Surviving Spouse of a Veteran 6–Native Hawaiian or Other Pacific Islander An option for disabled veterans is provided on Page 3. 8–Decline to provide information *Former Foster Child Status I am 25 years of age or younger If you selected more than one race (not including and was under the permanent managing conservatorship of the Hispanic or Latino), you will be identified as “Two or Texas Department of Family and Protective Services on the day More Races” for federal and state reporting purposes. preceding my 18th birthday. Yes No Residence address Mailing address Street: ______Street/P.O. Box: ______City: ______State: ____ ZIP: ______City: ______State: ____ ZIP: ______Phone: ( ) Phone: ( )

In event of emergency notify: Do you have relatives who are A&M System employees? Name: ______ Yes No Relationship: ______If yes, give name, title, relationship and organization: Address: ______City and state: ______Phone: ______State law gives you the right to choose whether The Texas A&M University System should allow public access to your home address, home telephone number, Social Security number, and whether you have family members. If you do not declare this personal information as confidential, it will be open to the public. If you are a “peace officer,” your home address and telephone number are automatically confidential. Mark one box in item 1 and one box in item 2. 1. Yes, I want my personal information to be confidential. No, I do not want my personal information to be confidential. 2. I am a certified peace officer. I am not a certified peace officer. Please read and sign Pages 2 and 3 of this form before returning it. Employer should complete the following for employee: PIN: ______Employee location code: ______ADLOC: ______Check distribution code: ______Campus or office address: ______Mail Stop: ______Office phone: ______1 HR 181 (11/09) The following definitions are provided for your information and assistance in completing the Employee Personal Data form: EEO Ethnicity/Race *Veteran Status Hispanic or Latino. A person of Cuban, Mexican, Puerto Rican, Veteran. The individual has served in the military for not less than South or Central American, or other Spanish culture or origin, 90 consecutive days during a national emergency declared in regardless of race. accordance with federal law and was honorably discharged from White. (Not Hispanic or Latino) A person having origins in any of military service, or was discharged for an established service- the original peoples of Europe, the Middle East, or North Africa. connected disability, and is competent. Black or African American. (Not Hispanic or Latino) A person Armed Forces Service Medal Veteran. The individual is a having origins in any of the Black racial groups of Africa. veteran who, while serving on active duty in the U.S. military, Asian. (Not Hispanic or Latino) A person having origins in any of ground, naval or air service, participated in a United States military the original peoples of the Far East, Southeast Asia, or the Indian operation for which an Armed Services Medal was awarded Subcontinent including, for example, Cambodia, China, India, Japan, pursuant to Executive Order 12985 (61 Fed. Reg. 1209). Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Other Protected Veteran. The individual has served on active Vietnam. duty in the U.S. military, ground, naval or air service during a war American Indian or Alaska Native. (Not Hispanic or Latino) A or in a campaign or expedition for which a campaign badge has person having origins in any of the original peoples of North and been authorized, under the laws administered by the department South America (including Central America) and who maintains tribal of defense. A list of campaigns and expeditions meeting this affiliation or community attachment. criteria is on Page 4. Native Hawaiian or Other Pacific Islander. (Not Hispanic or Recently Separated Veteran. The individual is any veteran during Latino) A person having origins in any of the original peoples of the three-year period beginning on the date of such veteran’s Hawaii, Guam, Samoa, or other Pacific Islands. discharge or release from active duty in the U.S. military, ground, naval or air service. Orphan of a Veteran. The individual is an orphan of a veteran killed on active duty who had served in the military for not less than 90 consecutive days during a national emergency in accordance with federal law, and is competent. Surviving Spouse of a Veteran. The individual is a surviving spouse (who has not remarried) of a veteran killed on active duty who had served in the military for not less than 90 consecutive days during a national emergency in accordance with federal law, and is competent.

Social Security Account Number: Notice to Employees Section 7(b) of the Privacy Act of 1974 (5 U.S.C. 552a) requires that any Federal, State, or local government agency which requests an individual to disclose his/her Social Security account number shall inform that individual whether that disclosure is mandatory or voluntary, by what statutory or other authority such number is solicited, and what uses will be made of it. Accordingly, employees, or applicants for employment, are advised that disclosure of an employee’s Social Security account number (SSAN) is required as a condition for employment within The Texas A&M University System and its members, in view of the practical administrative difficulties which would be encountered in maintaining adequate employee records without the continued use of the SSAN. The SSAN is used to verify the identity of the employee, and as an employee account number (identifier) throughout the period of employment in order to record necessary data accurately. As an identifier, the SSAN is used in such employee activities as: determining and recording salary entitlements, payments and deductions, determining, recording, and payment of social security contributions by both employees and employing agency; determining, recording, and payment of retirement contributions by both employee and employing agency; determining and recording employee annual and sick leave accumulation and use; recording entitlement and payment for official travel and per diem; determining and recording entitlement and payment for workers’ compensation; reporting earnings to the Texas Employment Commission, which serves as the basis for determining any future unemployment compensation insurance benefits; recording personal data in System group insurance files; determining and recording service for retirement and other benefits based on length and dates of employment and other service; and such other related requirement which may arise. Authority for requiring the disclosure of an employee’s SSAN is grounded on section 7(a)(2) of the Privacy Act, which provides that any Federal, State or local agency maintaining a system of records in existence and operating before January 1, 1975, may continue to require disclosure of an individual’s SSAN if such disclosure was required under statute or regulation adopted prior to such date to verify the identity of an individual. The Texas A&M University System and its members require the disclosure of the SSAN on necessary employee forms and documents used pursuant to statutes passed by the State of Texas and United States and regulations adopted by agencies of the State of Texas and United States, and by the Board of Regents of The Texas A&M University System.

I have read and understand this material and I certify that the information provided by me is true and correct to the best of my knowledge. This document is executed in good faith.

______Employee signature Date The Texas A&M University System is an equal employment opportunity and affirmative action employer. 2 The Texas A&M University System HR 181-Disability (11/09) Disabled Veteran Status (continued from the Employee Personal Data form) With few exceptions, you have the right to request, receive, review and correct information about yourself collected using this form. Because this form contains protected health information about you, it will not be placed in your personnel file.

Name: ______Last First Middle UIN or SSN: ______Birthdate: ______Month Day Year

Do you claim to be a Disabled Veteran*? Yes No

A disabled veteran is (1) a veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans’ Affairs or (2) an individual who was discharged or released from active duty because of a service-connected disability.

*You are not obliged to respond; however, your response is important to meet federal and state reporting requirements. Any information you provide will remain confidential in accordance with applicable federal and state regulations. Your employment will not be adversely affected by any information you furnish.

I have read and understand this material and I certify that the information provided by me is true and correct to the best of my knowledge. This document is executed in good faith.

______Employee signature Date

The Texas A&M University System is an equal employment opportunity and affirmative action employer. 3 HR 181 (11/09) OTHER PROTECTED VETERAN STATUS CRITERIA

CAMPAIGN/EXPEDITION DATES CAMPAIGN/EXPEDITION DATES START END START END

Armed Forces Expeditionary Medal (AFEM) Other Campaign and Service Medals Afghanistan (Enduring Freedom) 09/11/01 Present Army Occupation of Austria 05/09/45 07/27/55 Afghanistan (Iraqi Freedom) 03/19/03 Present Army Occupation of Berlin 05/09/45 10/02/90 Berlin 08/14/61 06/01/63 Army Occupation of Germany 05/09/45 05/05/55 Bosnia (Joint Endeavor, Joint Guard Army Occupation of Japan 09/03/45 04/27/52 & Joint Forge) 11/20/95 Present China Service Medal (Extended) 09/02/45 04/01/57 Cambodia 03/29/73 08/15/73 Korea Defense Service Medal 07/28/54 TBD* Cambodia Evacuation (Eagle Pull) 04/11/75 04/13/75 Korean Service 06/27/50 07/27/54 Congo 07/14/60 09/01/62 Kosovo Campaign Medal (KCM) Congo 11/23/64 11/27/64 Operation Allied Force 03/24/99 06/10/99 Cuba 10/24/62 06/01/63 Kosovo Campaign Medal (KCM) Dominican Republic 04/28/65 09/21/66 Operation Joint Guardian 06/11/99 TBD* El Salvador 01/01/81 02/01/92 Kosovo Campaign Medal (KCM) Global War on Terrorism 09/11/01 Present Operation Allied Harbor 04/04/99 09/01/99 Grenada (Urgent Fury) 10/23/83 11/21/83 Kosovo Campaign Medal (KCM) Haiti (Uphold Democracy) 09/16/94 03/31/95 Operation Sustain Hope/Shining Hope 04/04/99 07/10/99 Iraq (Northern Watch) 01/01/97 Present Kosovo Campaign Medal (KCM) Iraq (Desert Spring) 12/31/98 12/31/02 Operation Noble Anvil 03/24/99 07/20/99 Iraq (Enduring Freedom) 09/11/01 Present Kosovo Campaign Medal (KCM) Iraq (Iraqi Freedom) 03/19/03 Present Task Force Hawk 04/05/99 06/24/99 Korea 10/01/66 06/30/74 Kosovo Campaign Medal (KCM) Kosovo 03/24/99 Present Task Force Saber 03/31/99 07/08/99 Laos 04/19/61 10/07/62 Kosovo Campaign Medal (KCM) Lebanon 07/01/58 11/01/58 Task Force Falcon 06/11/99 TBD* Lebanon 06/01/83 12/01/87 Kosovo Campaign Medal (KCM) Libyan Area (Eldorado Canyon) 04/12/86 04/17/86 Task Force Hunter 04/01/99 11/01/99 Mayaguez Operation 05/15/75 05/15/75 Navy Occupation of Austria 05/08/45 10/25/54 Panama (Just Cause) 12/20/89 01/31/90 Navy Occupation of Trieste 05/08/45 10/25/54 Persian Gulf (Earnest Will) 07/24/87 08/01/90 Navy Units of the Sixth Fleet 05/09/45 10/25/55 Persian Gulf (Desert Thunder) 11/11/98 12/22/98 SW Asia Service Medal Persian Gulf (Desert Fox) 12/16/98 12/22/98 (Desert Shield/Storm) 08/02/90 11/30/95 Persian Gulf (Southern Watch) 12/01/95 Present Vietnam Service Medal (VSM) 07/04/65 03/28/73 Persian Gulf (Vigilant Sentinel) 12/01/95 02/01/97 Rwanda (Distant runner) 04/07/94 04/18/94 Persian Gulf Intercept Operation 12/01/95 Present Thailand 05/16/62 08/10/62 Quemoy and Matsu Islands 08/23/58 06/01/63 Somalia (Restore Hope & United Shield) 12/05/92 03/31/95 *TBD – To Be Determined Taiwan Straits 08/23/58 01/01/59 Thailand 05/16/62 08/10/62 Vietnam and Thailand 07/01/58 07/03/65 Vietnam Evacuation (Frequent Wind) 04/29/75 04/30/75

Navy Expeditionary Medal and Marine Corps Medal Cuba 01/03/61 10/23/62 Indian Ocean/Iran 11/21/79 10/20/81 Iranian/Yemen/Indian Ocean 12/08/78 06/06/79 Lebanon 08/20/82 05/31/83 Liberia (Sharp Edge) 08/05/90 02/21/91 Libyan Area 01/20/86 06/27/86 Panama 04/01/80 12/19/86 Panama 02/01/90 06/13/90 Persian Gulf 02/01/87 07/23/87 Rwanda (Distant Runner) 04/07/94 04/18/94 Thailand 05/16/62 08/10/62

4 Voluntary Self-Identification of Disability Form CC-305 OMB Control Number 1250-0005 Expires 1/31/2017 Page 1 of 2 Why are you being asked to complete this form?

Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities.i To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used against you in any way.

If you already work for us, your answer will not be used against you in any way. Because a person may become disabled at any time, we are required to ask all of our employees to update their information every five years. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier.

How do I know if I have a disability?

You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition.

Disabilities include, but are not limited to:

• Blindness • Autism • Bipolar disorder • Post-traumatic stress disorder (PTSD) • Deafness • Cerebral palsy • Major depression • Obsessive compulsive disorder • Cancer • HIV/AIDS • Multiple sclerosis (MS) • Impairments requiring the use of a wheelchair • Diabetes • Schizophrenia • Missing limbs or • Intellectual disability (previously called mental • Epilepsy • Muscular partially missing limbs retardation) dystrophy

Please check one of the boxes below:

☐ YES, I HAVE A DISABILITY (or previously had a disability) ☐ NO, I DON’T HAVE A DISABILITY ☐ I DON’T WISH TO ANSWER

______Your Name Today’s Date

Voluntary Self-Identification of Disability Form CC-305 OMB Control Number 1250-0005 Expires 1/31/2017 Page 2 of 2 Reasonable Accommodation Notice

Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment.

i Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal employment obligations of Federal contractors, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.

PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5 minutes to complete.

Tarleton State University

Statement of Previous State Employment

With few exceptions, you have the right to request, receive, review and correct information about yourself collected using this form.

Name Social Security Number

Department

All prior employment with Tarleton State University or and any other agency or institution of the State of Texas, including employment as a student worker, will be counted as state service. Employment with independent school districts and/or junior or community colleges is not state employment and will not be counted.

Please check one:

______I have not been employed by a State of Texas agency or institution at any time prior to employment at Tarleton State University.

______I have been employed by a State of Texas agency or institution prior to employment at Tarleton State University.

The state agencies at which I was employed are listed below:

Name of Agency Department Address From (MM/DD/YY) To (MM/DD/YY) Name Used During Employment

I hereby authorize the state agencies listed above to verify the above information.

Employee Signature ______Date ______

07/2009 ZW:\HR Forms\StmtOfPrevStateEmpl 07.2009.docx The exceptions do not apply to supplemental wages Nonwage income. If you have a large amount of Form W-4 (2015) greater than $1,000,000. nonwage income, such as interest or dividends, Basic instructions. If you are not exempt, complete consider making estimated tax payments using Form Purpose. Complete Form W-4 so that your employer the Personal Allowances Worksheet below. The 1040-ES, Estimated Tax for Individuals. Otherwise, you can withhold the correct federal income tax from your worksheets on page 2 further adjust your may owe additional tax. If you have pension or annuity pay. Consider completing a new Form W-4 each year withholding allowances based on itemized income, see Pub. 505 to find out if you should adjust and when your personal or financial situation changes. deductions, certain credits, adjustments to income, your withholding on Form W-4 or W-4P. Exemption from withholding. If you are exempt, or two-earners/multiple jobs situations. Two earners or multiple jobs. If you have a complete only lines 1, 2, 3, 4, and 7 and sign the form Complete all worksheets that apply. However, you working spouse or more than one job, figure the to validate it. Your exemption for 2015 expires may claim fewer (or zero) allowances. For regular total number of allowances you are entitled to claim February 16, 2016. See Pub. 505, Tax Withholding wages, withholding must be based on allowances on all jobs using worksheets from only one Form and Estimated Tax. you claimed and may not be a flat amount or W-4. Your withholding usually will be most accurate percentage of wages. when all allowances are claimed on the Form W-4 Note. If another person can claim you as a dependent for the highest paying job and zero allowances are on his or her tax return, you cannot claim exemption Head of household. Generally, you can claim head claimed on the others. See Pub. 505 for details. from withholding if your income exceeds $1,050 and of household filing status on your tax return only if includes more than $350 of unearned income (for you are unmarried and pay more than 50% of the Nonresident alien. If you are a nonresident alien, example, interest and dividends). costs of keeping up a home for yourself and your see Notice 1392, Supplemental Form W-4 dependent(s) or other qualifying individuals. See Instructions for Nonresident Aliens, before Exceptions. An employee may be able to claim completing this form. exemption from withholding even if the employee is a Pub. 501, Exemptions, Standard Deduction, and dependent, if the employee: Filing Information, for information. Check your withholding. After your Form W-4 takes effect, use Pub. 505 to see how the amount you are • Is age 65 or older, Tax credits. You can take projected tax credits into account in figuring your allowable number of withholding allowances. having withheld compares to your projected total tax for 2015. See Pub. 505, especially if your earnings • Is blind, or Credits for child or dependent care expenses and the child tax credit may be claimed using the Personal Allowances exceed $130,000 (Single) or $180,000 (Married). • Will claim adjustments to income; tax credits; or Worksheet below. See Pub. 505 for information on Future developments. Information about any future itemized deductions, on his or her tax return. converting your other credits into withholding allowances. 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 B Enter “1” if: { • You are married, have only one job, and your spouse does not work; or } . . . B • Your wages from a second job or your spouse’s wages (or the total of both) are $1,500 or less. C 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 D Enter number of dependents (other than your spouse or yourself) you will claim on your tax return ...... D E Enter “1” if you will file as head of household on your tax return (see conditions under Head of household above) . . E F 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.) G 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 $65,000 ($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. • If your total income will be between $65,000 and $84,000 ($100,000 and $119,000 if married), enter “1” for each eligible child ... G H 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 • If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions For accuracy, and Adjustments Worksheet on page 2. complete all • If you are single and have more than one job or are married and you and your spouse both work and the combined worksheets earnings from all jobs exceed $50,000 ($20,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2 to that apply. { 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. Employee's Withholding Allowance Certificate OMB No. 1545-0074 Form W-4 ▶ Department of the Treasury Whether you are entitled to claim a certain number of allowances or exemption from withholding is Internal Revenue Service subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS. 2015 1 Your first name and middle initial Last name 2 Your social security number

Home address (number and street or rural route) 3 Single Married 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 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. ▶ 5 Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2) 5 6 Additional amount, if any, you want withheld from each paycheck ...... 6 $ 7 I claim exemption from withholding for 2015, 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.) ▶ Date ▶ 8 Employer’s name and address (Employer: Complete lines 8 and 10 only if sending to the IRS.) 9 Office code (optional) 10 Employer identification number (EIN)

For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No. 10220Q Form W-4 (2015) Form W-4 (2015) Page 2 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 2015 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, 1951) of your income, and miscellaneous deductions. For 2015, you may have to reduce your itemized deductions if your income is over $309,900 and you are married filing jointly or are a qualifying widow(er); $284,050 if you are head of household; $258,250 if you are single and not head of household or a qualifying widow(er); or $154,950 if you are married filing separately. See Pub. 505 for details .... 1 $ $12,600 if married filing jointly or qualifying widow(er) 2 Enter: { $9,250 if head of household } ...... 2 $ $6,300 if single or married filing separately 3 Subtract line 2 from line 1. If zero or less, enter “-0-” ...... 3 $ 4 Enter an estimate of your 2015 adjustments to income and any additional standard deduction (see Pub. 505) 4 $ 5 Add lines 3 and 4 and enter the total. (Include any amount for credits from the Converting Credits to Withholding Allowances for 2015 Form W-4 worksheet in Pub. 505.) ...... 5 $ 6 Enter an estimate of your 2015 nonwage income (such as dividends or interest) ...... 6 $ 7 Subtract line 6 from line 5. If zero or less, enter “-0-” ...... 7 $ 8 Divide the amount on line 7 by $4,000 and enter the result here. Drop any fraction ...... 8 9 Enter the number from the Personal Allowances Worksheet, line H, page 1 ...... 9 10 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 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) 1 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” ...... 2 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 “-0-”) and on Form W-4, line 5, page 1. Do not use the rest of this worksheet ...... 3 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 Enter the number from line 2 of this worksheet ...... 4 5 Enter the number from line 1 of this worksheet ...... 5 6 Subtract line 5 from line 4 ...... 6 7 Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here . . . . 7 $ 8 Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed . . 8 $ 9 Divide line 8 by the number of pay periods remaining in 2015. 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 2015. Enter the result here and on Form W-4, line 6, page 1. This is the additional amount to be withheld from each paycheck 9 $ Table 1 Table 2 Married Filing Jointly All Others Married Filing Jointly All Others

If wages from LOWEST Enter on If wages from LOWEST Enter on If wages from HIGHEST Enter on If wages from HIGHEST Enter on paying job are— line 2 above paying job are— line 2 above paying job are— line 7 above paying job are— line 7 above $0 - $6,000 0 $0 - $8,000 0 $0 - $75,000 $600 $0 - $38,000 $600 6,001 - 13,000 1 8,001 - 17,000 1 75,001 - 135,000 1,000 38,001 - 83,000 1,000 13,001 - 24,000 2 17,001 - 26,000 2 135,001 - 205,000 1,120 83,001 - 180,000 1,120 24,001 - 26,000 3 26,001 - 34,000 3 205,001 - 360,000 1,320 180,001 - 395,000 1,320 26,001 - 34,000 4 34,001 - 44,000 4 360,001 - 405,000 1,400 395,001 and over 1,580 34,001 - 44,000 5 44,001 - 75,000 5 405,001 and over 1,580 44,001 - 50,000 6 75,001 - 85,000 6 50,001 - 65,000 7 85,001 - 110,000 7 65,001 - 75,000 8 110,001 - 125,000 8 75,001 - 80,000 9 125,001 - 140,000 9 80,001 - 100,000 10 140,001 and over 10 100,001 - 115,000 11 115,001 - 130,000 12 130,001 - 140,000 13 140,001 - 150,000 14 150,001 and over 15 Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this You are not required to provide the information requested on a form that is subject to the form to carry out the Internal Revenue laws of the United States. Internal Revenue Code Paperwork Reduction Act unless the form displays a valid OMB control number. Books or sections 3402(f)(2) and 6109 and their regulations require you to provide this information; your records relating to a form or its instructions must be retained as long as their contents may employer uses it to determine your federal income tax withholding. Failure to provide a become material in the administration of any Internal Revenue law. Generally, tax returns and properly completed form will result in your being treated as a single person who claims no return information are confidential, as required by Code section 6103. withholding allowances; providing fraudulent information may subject you to penalties. Routine The average time and expenses required to complete and file this form will vary depending uses of this information include giving it to the Department of Justice for civil and criminal on individual circumstances. For estimated averages, see the instructions for your income tax litigation; to cities, states, the District of Columbia, and U.S. commonwealths and possessions return. 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 If you have suggestions for making this form simpler, we would be happy to hear from you. countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal See the instructions for your income tax return. laws, or to federal law enforcement and intelligence agencies to combat terrorism. Instructions for Employment Eligibility Verification USCIS Form 1-9 Department ofHomeland Security OMB No. 1615-0047 U.S. Citizenship and Immigration Services Expires 03/31/2016

Read all instructions carefully before completing tbis form. Anti-Discrimination Notice. It is illegal to discriminate against any work-authorized individual in hiring, discharge, recruitment or referral for a fee, or in the employment eligibility verification (Form 1-9 and E-Verify) process based on that individual's citizenship status, immigration status or national origin. Employers CANNOT specify which document(s) they will accept from an employee. The refusal to hire an individual because the documentation presented has a future expiration date may also constitute illegal discrimination. For more information, call the Office ofSpecial Counsel for Immigration-Related Unfair Employment Practices (OSC) at 1-800-255-7688 (employees), 1-800-255-8155 (employers), or 1-800-237-2515 (TDD), or visit www.justice.gov/crtJaboutJosc.

IWhat Is the Purpose of This Form? Employers must complete Form 1-9 to document verification ofthe identity and employment authorization ofeach new employee (both citizen and noncitizen) hired after November 6, 1986, to work in the United States. In the Commonwealth ofthe Northern Mariana Islands (CNMI), employers must complete Form 1-9 to document verification ofthe identity and employment authorization ofeach new employee (both citizen and noncitizen) hired after November 27,2011. Employers should have used Form 1-9 CNMI between November 28,2009 and November 27,2011.

IGeneral Instructions Employers are responsible for completing and retaining Form 1-9. For the purpose ofcompleting this form, the term "employer" means aU employers, including those recruiters and referrers for a fee who are agricultural associations, agricultural employers, or farm labor contractors. Form 1-9 is made up ofthree sections. Employers may be fmed ifthe form is not complete. Employers are responsible for retaining completed forms. Do not mail completed forms to U.S. Citizenship and Immigration Services (USCIS) or Immigration and Customs Enforcement (ICE).

ISection 1. Employee Information and Attestation Newly hired employees must complete and sign Section 1 ofForm 1-9 no later than the first day ofemployment. Section 1 should never be completed before the employee has accepted a job offer. Provide the following information to complete Section 1: Name: Provide your full legal last name, first name, and middle initial. Your last name is your family name or surname. Ifyou have two last names or a hyphenated last name, include both names in the last name field. Your first name is your given name. Your middle initial is the first letter ofyour second given name, or the first letter ofyour middle name, ifany. Other names used: Provide all other names used, ifany (including maiden name). Ifyou have had no other legal names, write "N/A." Address: Provide the address where you currently live, including Street Number and Name, Apartment Number (if applicable), City, State, and Zip Code. Do not provide a post office box address (p.O. Box). Only border commuters from Canada or Mexico may use an international address in this field. Date of Birth: Provide your date ofbirth in the mm/ddlyyyy format. For example, January 23, 1950, should be written as 01/23/1950. U.S. Social Security Number: Provide your 9-digit Social Security number. Providing your Social Security number is voluntary. However, ifyour employer participates in E-Verify, you must provide your Social Security number. E-mail Address and Telephone Number (Optional): You may provide your e-mail address and telephone number. Department ofHomeland Security (DHS) may contact you ifDHS learns ofa potential mismatch between the information provided and the information in DHS ot Social Security Administration (SSA) records. You may write

"N/AIt ifyou choose not to provide this information.

EMPWYERS MUST RETAIN COMPLETED FORM 1-9 Fonn 1-9 Instructions 03/08/13 N DO NOT MAIL COMPLETED FORM 1-9 TO ICE OR USCIS Page 1 of9 All employees must attest in Section 1, under penalty ofpeIjury, to their citizenship or immigration status by checking one ofthe following four boxes provided on the form:

1. A citizen oftbe United States 2. A noncitizen national oftbe United States: Noncitizen nationals ofthe United States are persons born in American Samoa, certain former citizens ofthe former Trust Territory ofthe Pacific Islands, and certain children ofnoncitizen nationals born abroad. 3. A lawful permanent resident: A lawful permanent resident is any person who is not a U.S. citizen and who resides in the United States under legally recognized and lawfully recorded permanent residence as an immigrant. The term "lawful permanent resident" includes conditional residents. If you check this box, write either your Alien Registration Number (A-Number) or USCIS Number in the field next to your selection. At this time, the USCIS Number is the same as the A-Number without the"A" prefix. 4. An alien autborized to work: Ifyou are not a citizen or national ofthe United States or a lawful permanent resident, but are authorized to work in the United States, check this box. If you check this box: a. Record the date that your employment authorization expires, ifany. Aliens whose employment authorization does not expire, such as refugees, asylees, and certain citizens ofthe Federated States ofMicronesia, the Republic ofthe Marshall Islands, or Palau, may write "NIA" on this line. b. Next, enter your Alien Registration Number (A-Number)IUSCIS Number. At this time, the USCIS Number is the same as your A-Number without the "A" prefix. Ifyou have not received an A-NumberIUSCIS Number, record your Admission Number. You can find your Admission Number on Form 1-94, "Arrival-Departure Record," or as directed by USCIS or U.s. Customs and Border Protection (CBP). (1) If you obtained your admission number from CBP in connection with your arrival in the United States, then also record information about the foreign passport you used to enter the United States (number and country of issuance). (2) Ifyou obtained your admission number from USCIS within the United States, or you entered the United States without a foreign passport, you must write "N/A" in the Foreign Passport Number and Country ofissuance fields. Sign your name in the "Signature ofEmployee" block a..'ld l'e(lord the date you completed and signed Section 1. By signing and dating this form, you attest that the citizenship or immigration status you selected is correct and that you are aware that you may be imprisoned and/or fmed for making false statements or using false documentation when completing this form. To fully complete this form, you must present to your employer documentation that establishes your identity and employment authorization. Choose which documents to present from the Lists ofAcceptable Documents, found on the last page ofthis form. You must present this documentation no later than the third day after beginning employment, although you may present the required documentation before this date.

Preparer and/or Translator Certification The Preparer and/or Translator Certification must be completed ifthe employee requires assistance to complete Section 1 (e.g., the employee needs the instructions or responses translated, someone other than the employee fills out the information blocks, or someone with disabilities needs additional assistance). The employee must still sign Section 1.

Minors and Certain Employees witb Disabilities (Spetial Placement) Parents or legal guardians assisting minors (individuals under 18) and certain employees with disabilities should review the guidelines in the Handbook/or Employers: Instructions/or Completing Form 1-9 (M-274) on www.uscis.gov/ 1-9Central before completing Section 1. These individuals have special procedures for establishing identity ifthey cannot present an identity document for Form 1-9. The special procedures include (1) the parent or legal guardian filling out Section 1 and writing "minor under age 18" or "special placement," whichever applies, in the employee signature block; and (2) the employer writing "minor under age 18" or "special placement" under List B in Section 2.

Form J-9 Instructions 03/08/13 N Page 2 of9 Sedion 2. Employer or Authorized Representative Review and Verification Before completing Section 2, employers must ensure that Section 1 is completed properly and on time. Employers may not ask an individual to complete Section 1 before he or she has accepted a job offer. Employers or their authorized representative must complete Section 2 by examining evidence of identity and employment authorization within 3 business days ofthe employee's first day ofemployment. For example, ifan employee begins employment on Monday, the employer must complete Section 2 by Thursday ofthat week. However, ifan employer hires an individual for less than 3 business days, Section 2 must be completed no later than the first day ofemployment. An employer may complete Form 1-9 before the first day ofemployment ifthe employer has offered the individual a job and the individual has accepted. Employers cannot specify which document(s) employees may present from the Lists ofAcceptable Documents, found on the last page ofForm 1-9, to establish identity and employment authorization. Employees must present one selection from List A OR a combination ofone selection from List B and one selection from List C. List A contains documents that show both identity and employment authorization. Some List A documents are combination documents. The employee must present combination documents together to be considered a List A document. For example, a foreign passport and a Form 1-94 containing an endorsement ofthe alien's nonimmigrant status must be presented together to be considered a List A document. List B contains documents that show identity only, and List C contains documents that show employment authorization only. Ifan employee presents a List A document, he or she should not present a List B and List C document, and vice versa. Ifan employer participates in E-Verify, the List B document must include a photograph. In the field below the Section 2 introduction, employers must enter the last name, first name and middle initial, ifany, that the employee entered in Section 1. This will help to identify the pages ofthe form should they get separated. Employers or their authorized representative must: 1. Physically examine each original document the employee presents to determine ifit reasonably appears to be genuine and to relate to the person presenting it. The person who examines the documents must be the same person who signs Section 2. The examiner ofthe documents and the employee must both be physically present during the examination ofthe employee's documents. 2. Record the document title shown on the Lists ofAcceptable Documents, issuing authority; document number and expiration date (if any) from the original document(s) the employee presents. You may write "NIA" in any unused fields. Ifthe employee is a student or exchange visitor who presented a foreign passport with a Form 1-94, the employer should also enter in Section 2: a. The student's Form 1-20 or DS-2019 number (Student and Exchange Visitor Information System-SEVIS Number); and the program end date from Form 1-20 or DS·2019. 3. Under Certification, enter the employee's first day ofemployment. Temporary staffmg agencies may enter the first day the employee was placed in a job pool. Recruiters and recruiters for a fee do not enter the employee's first day of employment. 4. Provide the name and title ofthe person completing Section 2 in the Signature of Employer or Authorized Representative field. S. Sign and date the attestation on the date Section 2 is completed. 6. Record the employer's business name and address. 7. Return the employee's documentation.

Employers may, but are not required to, photocopy the document(s) presented. Ifphotocopies are made, they should be made for ALL new hires or reverifications. Photocopies must be retained and presented with Form 1-9 in case of an inspection by DHS or other federal government agency. Employers must always complete Section 2 even ifthey photocopy an employee's document(s). Making photocopies ofan employee's document(s) cannot take the place of completing Form 1-9. Employers are still responsible for completing and retaining Form 1-9.

Form 1-9 Instructions 03/08113 N Page 3 of9 Unexpired Documents Generally, only unexpired, original documentation is acceptable. The only exception is that an employee may present a certified copy ofa birth certificate. Additionally, in some instances, a document that appears to be expired may be acceptable ifthe expiration date shown on the face ofthe document has been extended, such as for individuals with temporary protected status. Refer to the Handbookfor Employers: Instructions for Completing Form 1-9 (M-274) or 1-9 Central (www.uscis.gov/I-9Central) for examples.

Receipts Ifan employee is unable to present a required document (or documents), the employee can present an acceptable receipt in lieu ofa document from the Lists ofAcceptable Documents on the last page ofthis form. Receipts showing that a person has applied for an initial grant ofemployment authorization, or for renewal ofemployment authorization, are not acceptable. Employers cannot accept receipts ifemployment will last less than 3 days. Receipts are acceptable when completing Form 1-9 for a new hire or when reverification is required. Employees must present receipts within 3 business days oftheir first day ofemployment, or in the case ofreverification, by the date that reverification is required, and must present valid replacement documents within the time frames described below. There are three types ofacceptable receipts: 1. A receipt showing that the employee has applied to replace a document that was lost, stolen or damaged. The employee must present the actual document within 90 days from the date ofhire.

2. The arrival portion ofForm 1-94/I-94A with a temporary 1-551 stamp and a photograph ofthe individual. The employee must present the actual Permanent Resident Card (Form 1-551) by the expiration date ofthe temporary 1-551 stamp, or, ifthere is no expiration date, within 1 year from the date ofissue. 3. The departure portion ofForm I-94/I-94A with a refugee admission stamp. The employee must present an unexpired Employment Authorization Document (Form 1-766) or a combination ofa List B document and an unrestricted Social Security card within 90 days.

When the employee provides an acceptable receipt, the employer should: 1. Record-the document title in Section 2 under the sections titled List A, List B, or List C, as applicable. 2. Write the word "receipt" and its document number in the "Document Number" field. Record the last day that the receipt is valid in the "Expiration Date" field.

By the end ofthe receipt validity period, the employer should: 1. Cross out the word "receipt" and any accompanying document number and expiration date. 2. Record the number and other required document information from the actual document presented. 3. Initial and date the change.

See the Handbookfor Employers: Instructionsfor Completing Fonn 1-9 (M-274) at www.uscis.2ov/I-9Central for more information on receipts.

ISection 3. Reverification and Rehires Employers or their authorized representatives should complete Section 3 when reverifying that an employee is authorized to work. When rehiring an employee within 3 years ofthe date Form 1-9 was originally completed, employers have the option to complete a new Form 1-9 or complete Section 3. When completing Section 3 in either a reverification or rehire situation, ifthe employee's name has changed, record the name change in Block A. For employees who provide an employment authorization expiration date in Section 1, employers must reverify employment authorization on or before the date provided.

Fonn 1-9 Instructions 03/08/13 N Page 4 of9 Some employees may write "N/A" in the space provided for the expiration date in Section 1 ifthey are aliens whose employment authorization does not expire (e.g., asylees, refugees, certain citizens ofthe Federated States ofMicronesia, the Republic ofthe Marshall Islands, or Palau). Reverification does not apply for such employees unless they chose to present evidence ofemployment authorization in Section 2 that contains an expiration date and requires reverification, such as Form 1-766, Employment Authorization Document. Reverification applies ifevidence ofemployment authorization (List A or List C document) presented in Section 2 expires. However, employers should not reverify: 1. U.S. citizens and noncitizen nationals; or 2. Lawful permanent residents who presented a Permanent Resident Card (Form 1-551) for Section 2. Reverification does not apply to List B documents. Ifboth Section 1 and Section 2 indicate expiration dates triggering the reverification requirement, the employer should reverify by the earlier date. For reverification, an employee must present unexpired documentation from either List A or List C showing he or she is still authorized to work. Employers CANNOT require the employee to present a particular document from List A or List C. The employee may choose which document to present.

To complete Section 3, employers should follow these instructions: 1. Complete Block A if an employee's name has changed at the time you complete Section 3. 2. Complete Block B with the date ofrehire ifyou rehire an employee within 3 years ofthe date this form was originally completed, and the employee is still authorized to be employed on the same basis as previously indicated on this form. Also complete the "Signature ofEmployer or Authorized Representative" block. 3. Complete Block C if: a. The employment authorization or employment authorization document ofa current employee is about to expire and requires reverification; or b. You rehire an employee within 3 years ofthe date this form was originally completed and his or her employment authorization or employment authorization document has expired. (Complete Block B for this employee as well.) To complete Block C: a. Examine either a List A or List C document the employee presents that shows that the employee is currently authorized to work in the United States; and b. Record the document title, document number, and expiration date (ifany). 4. After completing block A, B or C, complete the "Signature ofEmployer or Authorized Representative" block, including the date. For reverification purposes, employers may either complete Section 3 ofa new Form 1-9 or Section 3 ofthe previously completed Form 1-9. Any new pages ofForm 1~9 completed during reverification must be attached to the employee's original Form 1-9. If you choose to complete Section 3 ofa new Form 1-9, you may attachjustthe page containing Section 3, with the employee's name entered at the top ofthe page, to the employee's original Form 1-9. Ifthere is a more current version ofForm 1-9 at the time ofreverification, you must complete Section 3 ofthat version ofthe form.

IWhat Is the Filing Fee? There is no fee for completing Form 1-9. This form is not filed with USCIS or any government agency. Fonn 1-9 must be retained by the employer and made available for inspection by U.S. Government officials as specified in the "USCIS Privacy Ad Statement" below.

IUSCIS Forms and Information For more detailed information about completing Form 1-9, employers and employees should refer to the Handbook/or Employers: Instructions/or Completing Form 1-9 (M-274).

Fonn 1-9 Instructions 03/08/13 N Page 5 of9 You can also obtain information about Form 1-9 from the USCIS Web site at www.uscis.gov/I-9Central. bye-mailing USCIS at [email protected], or by calling 1-888-4644218. For TOO (hearing impaired), call 1-877-875--6028. To obtain USCIS forms or the Handbook/or Employers, you can download them from the USCIS Web site at www.uscis. gov/forms. You may order USCIS forms by calling our toll-free number at 1-806-876-3676. You may also obtain forms and information by contacting the USCIS National Customer Service Center at 1-800-375--5283. For TOD (hearing impaired), call 1-806-767-1833. Information about E-VeritY, a free and voluntary program that allows participating employers to electronically veritY the employment eligibility oftheir newly hired employees, can be obtained from the USCIS Web site at www.dhs.gov/E Verify, bye-mailing USCIS at [email protected] 1-888-464-4218. For TOO (hearing impaired), call 1-877-875-6028. Employees with questions about Form 1-9 and/or E-Verify can reach the USCIS employee hotline by calling 1-888-897-7781. For TOO (hearing impaired), call1-877-87S-6028.

IPhotocopying and Retaining Form 1-9 A blank Form 1-9 may be reproduced, provided all sides are copied. The instructions and Lists ofAcceptable Documents must be available to all employees completing this form. Employers must retain each employee's completed Form 1-9 for as long as the individual works for the employer. Employers are required to retain the pages ofthe form on which the employee and employer enter data. Ifcopies ofdocumentation presented by the employee are made, those copies must also be kept with the form. Once the individual's employment ends, the employer must retain this form for either 3 years after the date ofhire or 1 year after the date employment ended, whichever is later. Form 1-9 may be signed and retained electronically, in compliance with Department ofHomeland Security regulations at 8 CFR 274a.2.

IUSCIS Privacy Act Statement AUTHORITIES: The authority for collecting this information is the Immigration Reform and Control Act of 1986, Public Law 99-603 (8 USC 1324a). PURPOSE: This information is collected by employers to comply with the requirements ofthe Immigration Reform and Control Act of 1986. This law requires that employers veritY the identity and employment authorization of individuals they hire for employment to preclude the unlawful hiring, or recruiting or referring for a fee, ofaliens who are not authorized to work in the United States. DISCLOSURE: Submission ofthe information required in this form is voluntary. However, failure ofthe employer to ensure proper completion ofthis form for each employee may result in the imposition ofcivil or criminal penalties. In addition, employing individuals knowing that they are unauthorized to work in the United States may subject the employer to civil and/or criminal penalties. ROUTINE USES: This information will be used by employers as a record oftheir basis for determining eligibility of an employee to work in the United States. The employer will keep this form and make it available for inspection by authorized officials ofthe Department ofHomeland Security, Department ofLabor, and Office ofSpecial Counsel for Immigration-Related Unfair Employment Practices.

!Paperwork Reduction Act An agency may not conduct or sponsor an information collection and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. The public reporting burden for this collection of information is estimated at 35 minutes per response, including the time for reviewing instructions and completing and retaining the form. Send comments regarding this burden estimate or any other aspect ofthis collection ofinformation, including suggestions for reducing this burden, to: U.S. Citizenship and Immigration Services, Regulatory Coordination Division, Office ofPolicy and Strategy, 20 Massachusetts Avenue NW, Washington, DC 20529-2140; OMB No. 1615-0047. Do Dot mail your completed Form 1-9 to this address.

Fonn 1-9 Instructions 03/08/13 N Page 6 of9 Employment Eligibility Verification USCIS Form 1-9 Department ofBomeland Security OMB No. 1615-0047 U.S. Citizenship and Immigration Services Expires 03/3112016

~START HERE. React instructions carefully before completing this fonn. The Instructions must be available during completion of this tonn. ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) they will accept from an employee. The refusal to hire an individual because the documentation presented has a future expiration date may also constitute illegal discrimination. Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form 1-9 no later than the first day ofemployment, but not before accepting a job offer.)

Last Name (Family Name) First Name (Given Name) Middle Initial Other Names Used (if any)

Address (Street Number and Name) Apt. Number City or Town State Zip Code

Date of Birth (mm/ddlyyyy) IU.S. Social Security Number E-mail Address Telephone Number DO-I I I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form. I attest, under penalty of perjury, that I am (check one of the following): o A citizen of the United States o A noncitizen national of the United States (See instructions) o A lawful permanent resident (Alien Registration Number/USCIS Number): ------ o An alien authorized to work until (expiration date, if applicable, mmlddJyyyy) . Some aliens may write "N/A" in this field. (See instructions) For aliens authorized to work, provide your Alien Registration Number/USCIS Number OR Form 1-94 Admission Number: 1. Alien Registration Number/USCIS Number. _ 3·0 Barcode OR Do Not Write in This Space 2. Form 1-94 Admission Number: _

If you obtained your admission number from CBP in connection with your arrival in the United States, include the following: Foreign Passport Number: _

Country of Issuance: _

Some aliens may write "N/A" on the Foreign Passport Number and Country of Issuance fields. (See instructions)

ISignature of Employee: IDate (mmldcJlyyyy):

Preparer and/or Translator Certification (To be completed and signed if Section 1 is prepared by a person other than the employee.) I attest, under penalty of perjury, that I have assisted in the completion of this fonn and that to the best of my knowledge the information is true and corree:t

Signature of Preparer or Translator: IDate (mmiddlyyyy):

Last Name (Family Name) First Name (Given Name)

Address (Street Number and Name) ICity or Town IState IZip Code

Employer Completes Next Page

Fonn 1-9 03/08113 N Page 7 of9 ·Section 2. Employer or Authorized Representative Review and Verification (Employers or their authorized representative must complete and sign Section 2 within 3 business dayS ofthe employee's first day of e,?ploym~nt. You must physically examine one document from List A OR examine a combination ofone document from List B and on~ d~ment~rom List C as lIsted on the "Lists ofAcceptable Documents· on the next page of this form. For each document you reVIew, record the follOWing informatIon. document title, issuing authority, document number, and expiration date, ifany.)

Employee Last Name, First Name and Middle Initial from section 1:

List A OR LlstB AND Liste Identity and Employment Authorb:ation Identtly Employment Authorlzatton Document Title: Document Title: Document Title:

Issuing Authority: Issuing Authority: Issuing Authority:

Document Number: Document Number: Document Number:

Expiralion Date (if any)(mm/ddlyyyy): Expiration Date (ifany)(mm/ddlyyyy): Expiration Date (if any)(mm/ddlyyyy):

Document Title:

Issuing Authority:

Document Number:

Expiration Date (if any)(mm/ddlyyyy): 3-D Barcode Document Title: Do Not Write In This Space

Issuing Authority:

Document Number:

Expiration Date (if any)(mm/ddlyyyy):

Certification I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee. (2) the above-llsted document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the employee is authorized to wor1c in the United States. The employee'S first day of employment (mmiddlyyyy)' (See instructions for exemptions) Signature of Employer or Authorized Representative IDate (mmiddlyyyy) ITitle of Employer or Authorized Representative

Last Name (Family Name) First Name (Given Name) IEmployer's Business or Organization Name

Employer's Business or Organization Address (Street Number and Name) ICity or Town IState IZiPCode

Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.) A. New Name (if applicable) Last Name (Family Name) First Name (Given Name) Middle Inilial IB. Date of Rehire (ifapplicable) (mm/ddlyyyy):

C. If employee's previous grant of employment authorization has expired, provide the information for the document from List A or List C the employee presented that establishes current employment authorization in the space provided below. Document Title: IDocument Number: IExpiration Date (if any)(mm/ddlyyyy):

I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work In the United States, and if the employee presented document(s~ the document(s) I have examined appear to be genuine and to relate to the individual. ISignature of Employer or Authorized Representative: Date (mm/ddlyyyy): Print Name of Employer or Authorized Representative:

Fonn 1·9 03/08/13 N Page 8 of9 LISTS OF ACCEPTABLE DOCUMENTS All documents must be UNEXPIRED

Employees may present one selection from List A or a combination of one selection from List B and one selection from List C.

LIST A LIST B L1STe Documents that Establish Documents that Establish Documents that Establish Both Identity and Identity Employment Authorization Employment Authorization OR AND

1. U.S. Passport or U.S. Passport Card 1. Driver's license or 10 card issued by a 1. A Social Security Account Number State or outlying possession of the card, unless the card includes one of 2. Permanent Resident Card or Alien United States provided it contains a the following restrictions: Registration Receipt Card (Form 1-551) photograph or information such as (1) NOT VALID FOR EMPLOYMENT name, date of birth, gender, height, eye 3. Foreign passport that contains a color, and address (2) VALID FOR WORK ONLY WITH temporary 1-551 stamp or temporary INS AUTHORIZATiON 1-551 printed notation on a machine 2. 10 card issued by federal, state or local (3) VALID FOR WORK ONLY WITH readable immigrant visa government agencies or entities, DHS AUTHORIZATION provided it contains a photograph or 4. Employment Authorization Document information such as name, date of birth, 2. Certification of Birth Abroad issued that contains a photograph (Form gender, height, eye color, and address by the Department of State (Form 1-766) FS-545) 3. School 10 card with a photograph 5. For a nonimmigrant alien authorized 3. Certification of Report of Birth to work for a specific employer 4. Voter's registration card issued by the Department of State because of his or her status: (Form DS-1350) 5. U.S. Military card or draft record a. Foreign passport; and 4. Original or certified copy of birth b. Form 1-94 or Form 1-94A that has 6. Military dependenfs 10 card certificate issued by a State, the following: county, municipal authority, or 7. U.S. Coast Guard Merchant Mariner territory of the United States (1) The same name as the passport; Card bearing an official seal and 8. Native American tribal document (2) An endorsement of the alien's 5. Native American tribal document 9. Driver's license issued by a Canadian nonimmigrant status as long as 6. U.S. Citizen 10 Card (Form 1-197) that period of endorsement has government authority not yet expired and the 7. Identification Card for Use of proposed employment is not in For persons under age 18 who are Resident Citizen in the United conflict with any restrictions or unable to present a document States (Form 1-179) limitations identified on the form. listed above: 8. Employment authorization 6. Passport from the Federated States of document issued by the Micronesia (FSM) or the Republic of 10. School record or report card Department of Homeland Security the Marshall Islands (RMI) with Form 11. Clinic, doctor, or hospital record 1-94 or Form 1-94A indicating nonimmigrant admission under the 12. Day-care or nursery school record Compact of Free Association Between the United States and the FSM or RMI

Illustrations of many of these documents appear in Part 8 of the Handbook for Employers (M-274).

Refer to Section 2 of the instructions, tiUed "Employer or Authorized Representative Review and Verification," for more information about acceptable receipts.

Fonn 1-9 03/08/13 N Page 90f9

THE TEXAS A&M UNIVERSITY SYSTEM System Risk Management

NOTICE TO EMPLOYEES OF WORKERS' COMPENSATION INSURANCE

Notice is hereby given to all persons employed in the service of and on the payroll of the institutions and agencies under the direction and governance of the Board of Regents of The Texas A&M University System that Workers' Compensation Insurance coverage is provided in accordance with Chapter 502 of the Texas Labor Code.

I hereby acknowledge receipt of this notice that Workers' Compensation Insurance has been provided as above stated.

Date: ______Employee's Printed Name: ______Employee's Signature: ______UIN: ______System Member: Tarleton State University Department: ______

TAMUS Form - 8 This form may not be altered. Retain in Employee’s Personnel File

Rev 06/12

301 Tarrow Street, 5th Floor • College Station, Texas 77840-7896 979.458.6330 • 979.458.6247 fax • www.tamus.edu

Direct Deposit and Electronic W‐2 Authorization Form ______With few exceptions, you have the right to request, receive, review and correct information about yourself collected using this form. Direct Deposit instructions: Complete this form and return it, along with a voided check for either your checking account or a savings account deposit slip to: Payroll Services Box T‐0115 254‐968‐9608 Employee Identification (to be completed by employee). Name: Social Security Number:

Email Address: Department:

Action Requested: Indicate Account Type:

Initial Set Up Change Cancel Checking (Voided Check)* Savings (Deposit Slip)

*If you do not wish to present a voided check the following information must be completed by your financial institution representative: Name of Bank or Credit Union: Electronic Deposit Routing Number: Account Number: Name of Person completing information:

Electronic W‐2 Request You may now select to receive your official Form W‐2 using HRConnect. An email notice will be sent to you once the Form W‐2 is available through HRConnect. You will then be able to log into HRConnect and print your form at your convenience. Should you make this selection, you will have access to your Form W‐2 several days before the printed form would reach you in the mail. You will receive the information earlier, and eliminate the possibility of your W‐2 being lost in the mail or being intercepted by someone else. Because you will not receive a printed form in the mail, you will also be saving the A&M System significant time and money associated with generating and handling these forms. You may change this option during any time of the year except the period January 15‐31 (the period during which the Form W‐2 is generated).

Set Up Electronic W‐2: Yes No

Employee Authorization Pursuant to Section 403.016, Texas Government Code, I authorize Tarleton State University (TSU) to deposit by electronic transfer payments owed to me by the State of Texas and, if necessary, debit entries and adjustments for any amounts deposited electronically in error. Tarleton State University shall deposit the payments in the financial institution and account designated above. I recognize that if I fail to provide complete and accurate information on this authorization form, the processing of this form may be delayed so my payments may be erroneously transferred electronically. I consent to and agree to comply with the National Automated Clearing House Association Rules and Regulations and Tarleton State University’s rules about electronic transfers as they exist on the date of my signature on this form or as subsequently adopted, amended, or repealed. I understand that Tarleton State University has the authority to stop making electronic transfers to my account without advance notice. I also understand that my participation is limited to deposit of all net pay in one account in one financial institution and that I may have my paycheck deposited in any financial institution within the United States that uses the Federal Reserve System’s Automated Clearing House system. I further understand that it will be my responsibility to contact Tarleton State University’s Payroll Services Office prior to making changes in my account (closing account, changing banks, etc.).

Signature: Date:

SECURITY SENSITIVE POSITION VERIFICATION and BACKGROUND CHECK AUTHORIZATION

All Tarleton positions, including temporary and student positions, are deemed security sensitive and are subject to criminal record background checks in accordance with System Regulation 33.99.14. ………………………………………………………………………………………………

The following is to be completed by the EMPLOYEE:

I understand that a criminal history information background check will be conducted for positions that are designated as security sensitive. I understand that my employment or continued employment is conditional and contingent upon a satisfactory criminal history background check. I release all parties from any and all liability or claims for any damage whatsoever that may result from these actions.

Printed Name:______Signature:______

Department:______Date:______

BACKGROUND CHECK DISCLOSURE NOTICE AUTHORIZATION FORM

This form is used by the Human Resources Department as authorization to obtain criminal history information on the finalist candidate, as specified below. ------TO BE COMPLETED BY THE APPLICANT------

Last Name First Name Middle Name UIN (if available)

Other name(s) used in any and all other records of birth or records of residence

Street Address Apartment

City County State Zip

Date of Birth* Social Security Number* Gender* Race* *To be used solely for the purpose of conducting a background check.

In connection with my application for employment, my continued employment, or in connection with my desire to engage in volunteer activities, I have been advised and I hereby consent and authorize Tarleton State University and its agent, at any time during my application process and/or employment, to obtain a background check, consumer report and/or investigative consumer report that may include, but not be limited to, social security number verification, a criminal record check, employment and education verifications, verifications of personal reference and reputation; and driving record. Credit history will not be obtained. I do hereby consent and authorize Tarleton State University and its agent to use any information provided on this form during the application process or during my employment in obtaining a background check, consumer and/or investigative consumer report.

If a consumer or investigative consumer report is obtained on me, I have been informed that I have the right to review and challenge any negative information received that would adversely impact me or adversely affect a decision to offer employment. If a consumer reporting agency is utilized toThe secure follow aning investigative are my responses consumer to report,questions I understand about my that criminal I will history,be provided if any. the (name,Exclude address minor and traffic telephone offenses number punishable of the only consumer by fine. reporting IF agencyYOU ANSWER and the nature YES andTO ANYscope OFof the THE report FOLLOWING upon timely QUESTIONS, request. ATTACH DETAILS ON A SEPARATE SHEET OF PAPER TO INCLUDE THE STATE, COUNTY, DATE OF OFFENSE, AND DETAILS. I agree to release, indemnify and hold harmless Tarleton State University, any consumer reporting agency, any Federal, State, or local agency and any law enforcement agency used by Tarleton with regard to any information reported

I acknowledge that facsimile, copy or email of this document shall have the same validity, force and effect as the original.

The following are my responses to questions about my criminal history, if any. (Exclude minor traffic offenses punishable only by fine.) IF YOU ANSWER YES TO ANY OF THE FOLLOWING QUESTIONS, ATTACH DETAILS ON A SEPARATE SHEET OF PAPER TO INCLUDE THE STATE, COUNTY, DATE OF OFFENSE AND DETAILS.

1. Have you ever been convicted or plead guilty before a court for any federal, state or municipal criminal offense? YES NO (If yes, attach an extra page with the details including state, county, date of offense and details of the conviction.)

2. Have you ever received deferred adjudication or similar disposition for any federal, state or municipal offense? YES NO (If yes, attach an extra page with the details including state, county, date of offense and details of the disposition.)

3. Have you ever received pretrial diversion or similar disposition for any federal, state or municipal offense? YES NO (If yes, attach an extra page with the details including state, county, date of offense and details of the disposition.)

4. Have you ever received probation or community supervision for any federal, state or municipal offense? YES NO (If yes, attach an extra page with the details including state, county, date of offense and details of the disposition.)

5. Have you ever been convicted of any criminal offense in a country outside the jurisdiction of the United States? YES NO (If yes, attach an extra page with the details including state, county, date of offense and details of the conviction.)

6. As of the date of this consent form, do you have any pending charges against you? YES NO (If yes, attach an extra page with the details including state, county, date of offense and details.)

Background Check Authorization and Disclosure – January 2011

34.02 Drug and Alcohol Abuse

Approved February 27, 1995 (MO 44-95) Revised September 26, 1997 (MO 181-97) Revised September 24, 1999 (MO 225-99) Revised January 22, 2009 (MO 029-09) Next Scheduled Review: April 3, 2014

Policy Statement

The Texas A&M University System (system) strictly prohibits the unlawful manufacture, distribution, possession or use of illicit drugs or alcohol on system property, and/or while on official duty and/or as part of any system activities.

Reason for Policy

This policy is established to help members maintain a safe and healthy environment for all students and employees, to ensure compliance with applicable law and to require the adoption and implementation of a program to help prevent the use of illicit drugs and alcohol abuse by students and employees.

Procedures and Responsibilities

1. All members and member students and employees are expected to abide by state and federal laws pertaining to controlled substances, illicit drugs and the use of alcohol. Each member will adopt a plan consistent with this policy that will include implementation of an awareness and prevention program on the use of illicit drugs and the abuse of alcohol by students and employees.

2. Sanctions (consistent with local, state and federal law) will be imposed on students and employees for the violation of this policy. Sanctions may include disciplinary actions up to and including expulsion, termination of employment and referral for prosecution.

3. This policy is in addition to any alcohol or drug abuse policy or policies relating to participation in intercollegiate athletics.

4. The chancellor is authorized to implement regulations to ensure full compliance with applicable statutes and administrative rules or guidelines.

34.02 Drug and Alcohol Abuse Page 1 of 2

Related Statutes, Policies, or Requirements

20 U.S.C. § 1011i, Drug and Alcohol Abuse Prevention

41 U.S.C. Ch. 10 (§§ 701-707), Drug-Free Workplace Act of 1988

34 C.F.R. Pt. 86, Drug and Alcohol Abuse Prevention

System Regulation 34.02.01, Drug and Alcohol Abuse and Rehabilitation Programs

Contact Office

Office of General Counsel (979) 458-6120

System Human Resources Offices (979) 458-6169

34.02 Drug and Alcohol Abuse Page 2 of 2

SYSTEM REGULATIONS

34.02.01 Drug and Alcohol Abuse and Rehabilitation Programs July 14, 2000 Supplements System Policy 34.02

1. ADMINISTRATION

The provisions of this regulation are based on requirements of federal and state law. Administrators should exercise caution in all matters relating to this regulation, ensuring that procedures are carefully followed and that substantial evidence from reliable sources supports a decision to counsel or test a student or an employee for drug use. The System Office of General Counsel (OGC) must be informed by the appropriate administrator of possible violations of this regulation and advice of an OGC attorney must be secured before testing anyone due to reasonable suspicion of drug or alcohol use or abuse. Advice of the OGC is not needed for required testing as described in Section 6, and the general counsel may waive the requirement to seek OGC’s advice for reasonable suspicion testing when a System component shows documented evidence of training for administrators and supervisors in alcohol and drug awareness.

2. DEFINITIONS

As used in this regulation, the following definitions apply.

2.1 “Drugs or other controlled substances" means any substance, including alcohol, capable of altering an individual's mood, perception, pain level or judgment.

2.1.1 A "prescribed drug" is any substance prescribed for individual consumption by a licensed medical practitioner. It includes only drugs that have been legally obtained and are being used for the purpose for which they were prescribed or manufactured.

2.1.2 An "illicit drug" or chemical substance is: (a) any drug or chemical substance, the use, sale or possession of which is illegal under any state or federal law, or (b) one that is legally obtainable but has not been legally obtained. The term includes prescribed drugs not legally obtained and prescribed drugs not being used for prescribed purposes.

2.1.3 "Controlled substance" means a substance listed in schedules I through V of section 202 of the Controlled Substance Act (21 U.S.C.S. 812) or whose possession, sale or delivery results in criminal sanctions under the Texas Controlled Substances Act (Texas Health and Safety Code, Chapter 481). In general, controlled substances include all prescription drugs, as well as those substances for which there is no generally accepted

34.02.01: Drug and Alcohol Abuse and Rehabilitation Programs Page 1 of 7 medicinal use (e.g., heroin, LSD, marijuana, etc.), and substances that possess a chemical structure similar to that of a controlled substance (e.g., designer drugs). The term does not include alcohol.

2.2 "Alcohol" refers to any beverage containing more than one-half of one percent of alcohol by volume, which is capable of use for beverage purposes, either alone or when diluted.

2.3 "Alcohol abuse" means the excessive use of alcohol in a manner that interferes with: (1) physical or psychological functioning; (2) social adaptation; (3) educational performance; or (4) occupational functioning.

2.4 "Reasonable suspicion" shall be established by: (1) observation of the actions/behaviors of the individual; (2) supervisor or other reliable individual witnessing possession or use; or (3) any other legal measure used for alcohol or drug detection.

2.5 "Sanctions" may include completion of an appropriate rehabilitation or assistance program, suspension or expulsion from school, suspension or termination from employment, other disciplinary action, or referral to authorities for prosecution. If an employee has been convicted of a criminal drug statute, sanctions must be imposed within 30 days.

3. COMPONENT RULES

The chief executive officer of each System component shall establish a rule and procedures for the implementation of Policy 34.02 and this regulation. Such rules and procedures cannot be less stringent than the policy and regulation and shall be approved by the System General Counsel's office before being released. Requirements of the Department of Defense, the Department of Transportation, or other regulatory bodies and applicable state and federal laws must be included when applicable for the students or employees in the System component.

4. ALCOHOL AND DRUG-FREE AWARENESS AND PREVENTION PROGRAM

4.1 Each System component will provide an alcohol and drug-free awareness and prevention program for students and/or employees. Programs must conform with System policies and regulations as well as related federal and state laws.

4.2. As a part of its program, all System components must distribute annually to each employee and to each student, if applicable:

(1) standards of conduct that prohibit the unlawful manufacture, possession, use, and distribution of illicit drugs and alcohol by students and employees on the System's property or as part of any System activity;

34.02.01: Drug and Alcohol Abuse and Rehabilitation Programs Page 2 of 7

(2) a description of the applicable legal sanctions under local, state, or federal law for the unlawful manufacture, possession or distribution of illicit drugs or alcohol;

(3) a description of the health risks associated with the use of illicit drugs and the abuse of alcohol;

(4) a description of drug or alcohol counseling, treatment, rehabilitation or re-entry programs that are available to students or employees;

(5) a clear statement that the System component, consistent with local, state, or federal law, will impose sanctions against a student or employee who violates the standards of conduct. The statement must describe the possible sanctions as stated in Section 2.5; and

(6) a description of the institution's drug/alcohol abuse awareness, prevention and intervention program, if applicable, including alternative support, education and re-entry programs for students who are expelled as a result of violating standards required by these minimum requirements.

4.3 As required by federal law, each System component must conduct a biennial review of its drug and alcohol abuse awareness and prevention program. It will determine and put in report format: (1) the effectiveness of the program, and (2) the consistency of the enforcement of sanctions imposed pursuant to the program. It will also evaluate whether any changes are needed and will implement any such changes.

4.4 Each System component shall have available for review by the U.S. Secretary of Education, or designee, other applicable governmental agencies, and the general public, if requested, copies of all documents distributed to students and employees under the drug and alcohol abuse prevention program, and copies of the biennial review.

4.5 Academic institutions must certify the accessibility of a drug abuse prevention program for officers, employees and students of the institution, as required under 20 USC, Section 1094.

34.02.01: Drug and Alcohol Abuse and Rehabilitation Programs Page 3 of 7

5. STUDENT DRUG TESTING

Procedures related to students suspected of alcohol or drug abuse and testing of students shall be developed by the individual System universities and approved by the System General Counsel.

6. EMPLOYEE REQUIRED DRUG TESTING

6.1 Department of Defense

6.1.1 The Drug-Free Workplace Act of 1988 and Department of Defense (DOD) regulations mandate that government contractors establish a program for testing for the use of illicit drugs by an employee in a sensitive position under a DOD contract. System components that have such contracts must also be in compliance with the DOD regulations for maintaining a program for achieving a drug-free workplace.

6.1.2 "Employee in a sensitive position" means an employee who has been granted access to classified information or an employee in another position determined by appropriate administrative personnel to involve national security, health or safety concerns, or functions requiring a high degree of trust and confidence.

6.1.3 Testing of an employee in a DOD-funded sensitive position will be undertaken under the following circumstances: (1) there is reasonable suspicion that the employee's job performance has been affected by the use of illicit drugs, and (2) there is a reasonable belief that such impairment will affect national security, health or safety concerns, or functions requiring a high degree of trust and confidence.

6.2 Department of Transportation

Testing of employees required to have commercial driver’s licenses must comply with Federal Highway Administration and Department of Transportation regulations and will be done in the following situations: (1) pre-employment, (2) post-accident, (3) reasonable suspicion, (4) random, and (5) return-to-duty and follow-up.

7. REASONABLE SUSPICION OF EMPLOYEE DRUG OR ALCOHOL ABUSE

7.1 If a supervisor reasonably suspects that use of a controlled substance or alcohol has resulted in absenteeism, tardiness, or impairment of work performance or is the cause of workplace accidents, the supervisor shall immediately notify the appropriate department head or other designated administrator. Upon direction

34.02.01: Drug and Alcohol Abuse and Rehabilitation Programs Page 4 of 7 from the department head or designated administrator, the supervisor or other designated administrator shall discuss with the employee the suspected alcohol or drug-related problems. The employee should be advised of any available alcohol and drug counseling, rehabilitation, or employee assistance programs, and the terms of any applicable disciplinary sanctions. The employee may be required to participate in an assistance program and be subject to discipline (up to and including termination of employment) if he or she rejects participation in the program. All meetings between the employee and the supervisor or other administrator to address the suspected alcohol or drug-related problem and/or its resolution shall be documented in a memorandum to the record and filed in the employee's personnel file.

7.2 If discussion and/or participation in any available alcohol or drug counseling, rehabilitation, or employee assistance program fails to resolve the suspected alcohol or drug-related problems or if the employee fails to meet the terms of any applicable disciplinary sanctions, the employee may be subject to disciplinary action up to and including termination.

7.3 Any disciplinary action will be governed by System policies on discipline and dismissal and academic freedom, responsibility and tenure. A record of the action will be placed in the employee's personnel file.

7.4 Testing of employees other than those occupying DOD-funded sensitive positions or those required to have a commercial driver’s license may be undertaken only when there is reasonable suspicion that the employee is under the influence of alcohol or illicit drugs while on the job, the employee's job performance has been affected by the use of alcohol or illicit drugs, and such impairment presents a risk to the physical safety of the employee or another person. The decision to test an employee in these circumstances will be made by the appropriate chief executive officer or designee with the advice of the Office of General Counsel (advice of General Counsel may be waived as discussed in paragraph 1). The employee should be informed that a refusal to submit to a test, combined with a reasonable suspicion of usage, may be sufficient basis for termination.

8. TESTING PROCEDURES

The expense of the screening and any retest will be borne by the System component. The screening will be kept confidential, with the results being reported to the employee and the appropriate senior-level administrator as soon as they are available. Any written documentation will be kept in the employee’s confidential medical file.

34.02.01: Drug and Alcohol Abuse and Rehabilitation Programs Page 5 of 7

8.1 Drug Testing

8.1.1 Prior to the administration of a drug test, the appropriate administrator or supervisor must explain the drug testing procedures to the employee and arrange for component employee(s) to transport and accompany the employee to a hospital or clinic for the taking of a specimen for screening purposes. Except as provided in paragraph 8.1.3 below, if the System component has laboratory or medical facilities with personnel trained for such testing, those facilities may be used if there are adequate chain-of- custody procedures established for the samples and precautions are taken to guarantee the integrity of the testing against tampering or substitution.

8.1.2 Before the specimen is taken, the employee should be asked to sign a consent form agreeing to the taking of a specimen for testing purposes. The signed form will be required by the hospital or clinic. The employee may be asked to list any medications being taken. The employee will have a reasonable opportunity to rebut or explain a positive test result, including an independent retest of the sample.

8.1.3 Drug testing under the Federal Highway Administration and Department of Transportation regulations must be done by a laboratory that is certified by the Department of Health and Human Services (DHHS) pursuant to the DHHS “Mandatory Guidelines for Federal Workplace Drug Testing Programs.”

8.2 Alcohol Testing

Alcohol testing shall be done using an Evidential Breath Testing Device (EBT). Testing required by Department of Transportation regulations must be done using an EBT that has been approved by the National Highway Traffic Safety Administration.

9. DISCLOSURE

9.1 As a condition of employment, employees on government grants or contracts must abide by the required notification statement and must report any criminal drug statute conviction for a violation occurring in the workplace or on System business to their employer no later than five days after the conviction. The employer, in turn, must notify the contracting federal agency within 10 days after receiving notice from an employee or otherwise receiving actual notice of such conviction, and within 30 days must impose sanctions on the employee involved. Sanctions may take the form of personnel actions against the employee, up to and including termination, or requiring the employee to satisfactorily participate in an approved drug abuse assistance or rehabilitation program.

34.02.01: Drug and Alcohol Abuse and Rehabilitation Programs Page 6 of 7

9.2 Criminal drug statute means a criminal statute involving manufacture, distribution, dispensation, use, or possession of any controlled substance. Criminal drug statute conviction means a finding of guilt (including a plea of nolo contendere) or imposition of sentence by any judicial body charged with the responsibility to determine violations of the federal or state criminal drug statutes.

HISTORY: New Regulation

CONTACT OFFICE: The System Human Resources Office

RECOMMENDATION: ______Vice Chancellor for Business Services Date

RECOMMENDATION: ______Vice Chancellor for Academic and Student Affairs Date

RECOMMENDATION: ______Deputy Chancellor Date

LEGAL SUFFICIENCY ______General Counsel Date

APPROVAL ______Chancellor Date

34.02.01: Drug and Alcohol Abuse and Rehabilitation Programs Page 7 of 7 Rule 34.02.01.T1 Drug and Alcohol Abuse Prevention

Effective: June 5, 2002 Revised: September 18, 2012 Next Scheduled Review: September 18, 2014

Rule Statement

Tarleton State University desires to provide an educational and work environment free from drug and alcohol abuse. Drug and alcohol abuse affects all aspects of American life: it threatens the student’s educational development, the safety and security of the workplace and the confidence of the community.

Reason for Rule

Tarleton is committed to providing its employees and students a safe, healthy and efficient educational and work environment. This rule has been adopted to supplement existing system policies and regulations. Implementation of this rule is subject to restrictions contained in local, state, and federal laws.

Definitions

Alcohol: refers to any beverage containing more than one-half of one percent of alcohol by volume, which is capable of use for beverage purposes, either alone or when diluted.

Alcohol Abuse: Excessive use of alcohol in a manner that interferes with: physical or psychological functioning; social adaptation; educational performance; or occupational functioning.

Controlled Substance: A substance listed in schedules I through V of section 202 of the Controlled Substance Act (21 U.S.C.S. 812) or whose possession, sale or delivery results in criminal sanctions under the Texas Controlled Substances Act (Texas Health and Safety Code, Chapter 481). In general, controlled substances include all prescription drugs, as well as those substances for which there is no generally accepted medicinal use (e.g., heroin, LSD, Marijuana, etc.), and substances that possess a chemical structure similar to that of a controlled substance (e.g., designer drugs). The term does not include alcohol.

Rule 34.02.01.T1 Drug and Alcohol Abuse Prevention Page 1 of 5

Illicit Drug or Chemical Substance: Any drug or chemical substance, the use, sale or possession of which is illegal under any state or federal law, or one that is legally obtainable but has not been legally obtained. The term includes prescribed drugs not legally obtained and prescribed drugs not being used for prescribed purposes.

Impaired: Under the influence of an illicit drug or alcohol, such that the student or employee is unable to perform his or her assigned tasks or poses a danger to him- or herself or others.

Possess: To be contained either on a student’s or employee’s person, or in a student’s or employee’s motor vehicle, tools, briefcases, book bags, lockers or areas entrusted to the control of the student or employee.

Prescribed Drug: Any substance prescribed for individual consumption by a licensed medical practitioner. It includes only drugs that have been legally obtained and are being used for the purpose for which they were prescribed or manufactured.

Sanctions: Include completion of an appropriate rehabilitation or assistance program, suspension or expulsion from school, suspension or termination from employment, other disciplinary action, or referral to authorities for prosecution. If an employee has been convicted of a criminal drug statute, sanctions must be imposed within 30 days.

Workplace: Any office, building, classroom, or property (including parking lots) owned, leased, or operated by Tarleton, or any other site at which an employee is to perform work for the employer.

Procedures and Responsibilities

1. RISKS ASSOCIATED WITH ALCOHOL AND DRUG ABUSE

1.1. Educational and Work Environment Risks 1.1.1. Inhibiting educational development and a student’s capacity to learn 1.1.2. Interfering with safe and efficient performance of work 1.1.3. Increased absenteeism 1.1.4. Poor health, safety, and productivity 1.1.5. Decreased productivity and attention to safety 1.1.6. Deterioration of public confidence and trust

1.2. Health Risks

1.2.1. Alcohol abuse may lead to alcoholism, premature death through overdose and/or complications involving the brain, heart, liver and other body organs.

1.2.2. Illicit drugs may result in drug addiction, death by overdose, death from withdrawal, seizure, heart problems, infections (including HIV/AIDS), liver disease and brain dysfunction.

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1.2.3. Alcohol and drug use by a pregnant woman may cause additional health complications in her unborn child.

2. STANDARD OF CONDUCT

2.1. Unlawful manufacture, distribution, dispensation, possession or use of illicit drugs or alcohol by students or employee is prohibited at any time on any university property or at any university activity. No employee may report for work, work or be present in the workplace who is impaired by an illegal drug or by alcohol. No student may attend classes or any university activity who is impaired by illegal drugs or alcohol. Employees or students who are so impaired or who unlawfully possess, use, manufacture, dispense, or distribute illicit drugs or alcohol in the workplace, on any university property, or at any university activity are subject to the disciplinary procedures of the university, which may include dismissal, expulsion, and/or referral for prosecution.

2.2. All members of the university community shall abide by state and federal laws pertaining to controlled substances and illicit drugs.]

3. RESPONSIBILITY TO REPORT AND INVESTIGATE

3.1. Employees are responsible for reporting arrests, charges or criminal convictions in accordance with System Regulation 33.99.14, Criminal History Record Information – Employees and Applicants. The employee may be placed on a leave with pay while an investigation is completed. The Human Resources Department (HR) will initiate an investigation in accordance with System Regulation 33.99.14. Sanctions may include, but are not limited to, discipline, referral to a treatment program, or dismissal.

3.2. Employees shall report to their supervisors, or to HR, any use of a prescribed or over-the-counter medication that could adversely affect job performance. Any such medical information will be kept confidential and shared with appropriate personnel only on a need-to-know basis. For those employees adversely affected by the medication during the normal course of duty, the university will take appropriate action, such as placing the employee on leave, in accordance with leave regulations and, when applicable, the Americans with Disabilities Act.

3.3 Employees and students are responsible for reporting a reasonable suspicion of drug or alcohol abuse by employees or students to their immediate supervisor, HR, Office of Student Life Studies and Judicial Affairs, or to the University Police Department. A reasonable suspicion is a fair or usual belief or opinion a person might form based on a certain set of facts or circumstances. Individuals may have days when they exhibit behavior not normally associated with an educational or work environment nor characteristic of him or her. Unusual behavior during times of stress is not uncommon; however, when unusual behavior is displayed on a gradually increasing scale accompanied by general decline in work habits or classroom performance over a period of time, it may indicate that professional help is needed.

Rule 34.02.01.T1 Drug and Alcohol Abuse Prevention Page 3 of 5

3.3.1 Administrators or supervisors seeking advice on appropriate responses to possible violations of alcohol or drug rules by employees should consult with HR.

3.3.2 Students found in violation of drug and alcohol abuse rules and regulations will be subject to the disciplinary measures outlined in the Student Handbook, Student Athlete Handbook, and to all pertinent local, state and federal statutes.

3.3.2.1 Sanctions may include completion of an appropriate rehabilitation or assistance program, expulsion from school or referral to authorities for prosecution.

4. NOTIFICATION

4.1 Tarleton will provide notification of this rule to employees and students initially upon hire or first-time registration, and annually thereafter.

5. EDUCATION PROGRAM

5.1. A committee, appointed by the president, will develop and promote the university’s drug and alcohol prevention and education program. The committee will biennially review the education program in accordance with the Drug-free Schools and Communities Act to determine its effectiveness. The report generated by this review will be provided to the president and posted on the Tarleton website. The committee’s report will include recommendations for program changes as needed.

6. TREATMENT AND REFERRAL RESOURCES

6.1. An employee or student may be required to participate in and satisfactorily complete an approved rehabilitation or assistance program. Tarleton has identified the following sources available to employees and students. The Department of Human Resources, the Student Counseling Center, and the Office of the Assistant Dean of Students are available to assist employees and students in identifying services and assistance as well.

On Campus Resources:

Department of Human Resources 254-968-9128 Student Counseling Center: 254-968-9710 Office of the Assistant Dean of Students: 254-968-9080

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Related Statutes, Policies, or Requirements

Drug-Free Schools and Campuses Regulations (EDGAR) Part 86 System Policy 34.02 Drug and Alcohol Abuse System Regulation 34.02.01 Drug and Alcohol Abuse and Rehabilitation Programs Tarleton State University Student Handbook Tarleton State University Student Athlete Handbook

Contact Office

Human Resource Department 254.968.9128

University Compliance 254.968.9415

Rule 34.02.01.T1 Drug and Alcohol Abuse Prevention Page 5 of 5

Prevention of Alcohol Abuse and Illicit Drug Use Annual Awareness and Prevention Program Notice to Tarleton State University Employees

Alcohol abuse and illicit drug use disrupt the work and learning environment and create an unsafe and unhealthy workplace. To protect its employees and students and fully serve the citizens of Texas, The Texas A&M University System prohibits alcohol abuse and illicit drug use that could negatively impact its mission. This brochure, which is distributed annually, serves as an awareness and prevention tool for Tarleton employees by providing basic information about A&M System policy and regulations, legal sanctions and health risks related to alcohol abuse and illicit drug use. Information about counseling, treatment and rehabilitation programs is included.

As an employee of The Texas A&M University System, The abuse of illicit drugs can result in other health you must abide by state and federal laws on controlled problems such as drug addiction, death by overdose, substances, illicit drugs and use of alcohol. In addition, death from withdrawal, seizure, heart problems, infections you must comply with A&M System policy, which states: (including HIV/AIDS), liver disease and brain dysfunction. The Texas A&M University System (system) strictly Additional effects include occupational, social and family prohibits the unlawful manufacture, distribution, problems as well as a reduction inmotivation. Drug use by possession or use of illicit drugs on system property, a pregnant woman may cause additional health and/or while on official duty and/or as part of any complications in her unborn child. system activities. A&M System Sanctions Definitions The A&M System’s drug and alcohol abuse policy and Alcohol refers to any beverage that contains more than regulation are included in the System Orientation course one-half of one percent of alcohol by volume, which is reviewed by new employees as part of their orientation. capable of use for beverage purposes, either alone or The policy and regulation are posted online at when diluted. http://policies.tamus.edu/34-02.pdf and http://policies.tamus.edu/34-02-01.pdf. Alcohol abuse is the excessive use of alcohol in a manner that interferes with: If your work-related performance causes suspicion of use • physical or psychological functioning, of alcohol or a controlled substance, you may be tested • social adaptation, under the provisions of the A&M System regulation • educational performance, or related to testing and chemical screening. You also may • occupational functioning. be tested if necessary to comply with Department of Defense, Department of Transportation or other Controlled substances include all prescription drugs, as regulations that cover certain employees. Refusal to well as those substances for which there is no generally submit to a test may be the basis for employment accepted medicinal use (e.g., heroin, LSD and marijuana, termination. etc.), and that possess a chemical structure similar to that of a controlled substance (e.g., designer drugs). Off-duty use of alcohol, drugs or other controlled substances will not be tolerated if the use results in Illicit drugs are: absenteeism, tardiness or impairment of work • any drugs or chemical substances, the use, sale or performance or is the cause of workplace accidents. possession of which is illegal under any state or Should this occur, you may be referred to an assistance federal law, or program and subject to discipline, up to and including • ones that can be legally obtained but have not been employment termination. obtained legally. Any disciplinary action will be governed by A&M System policies and regulations on discipline and dismissal and The term includes prescribed drugs not legally obtained academic freedom, responsibility and tenure. A record of and prescribed drugs not being used for prescribed the action will be placed in your personnel file. Infractions purposes. of local, state or federal law will be reported to the appropriate law enforcement agency. Health Risks Alcohol abuse can lead to alcoholism, premature death Legal Sanctions through overdose, and complications involving the brain, Legal sanctions can include: heart, liver and many other body organs. Misdemeanor Jail Time and/or Fine Class A Up to one year; Up to $4,000 Class B Up to 180 days; Up to $2,000 September 2012 Page 1

Class C No confinement; Up to $500 penalties increase if controlled substances are delivered within 1,000 feet of any premises owned, rented or leased Felony Imprisonment and/or Fine by an institution of higher education. First Degree 5 to 99 years or life; Up to $10,000 Second Degree 2 to 20 years; Up to $10,000 Community Resources Third Degree 2 to 10 years; Up to $10,000 If you have an alcohol or other drug abuse problem, you State Felony 180 days to 2 years; Up to $10,000 may want to seek information or help from one of the following community resources. These sanctions may be imposed for many illegal actions including: STAR Council on Substance Abuse Purchasing or making available an alcoholic beverage to Education, Assessment and Referral Services a person younger than 21 239 S. Virginia Ave Class A Misdemeanor Stephenville, Texas 76401 (254) 965-5515 Selling an alcoholic beverage to a person younger than 21 Summer Sky, Incorporated Class A Misdemeanor Substance Abuse Treatment Facility 110 N McCart Ave Appearing in a public place while intoxicated to the Stephenville, Texas 76401 degree that you might endanger yourself or another (254) 968-2907 (24 hr. crisis line) person Alcoholics Anonymous Class C Misdemeanor Stephenville Group of Alcoholics Anonymous

611 S. Graham Possessing an open container of an alcoholic beverage Stephenville, Texas 76401 inside a motor vehicle on a public roadway (254) 965-4727 Class C Misdemeanor Email: [email protected]

Website: http://stephenvilleaa.webs.com/ Operating a motor vehicle, aircraft or watercraft in a public place while intoxicated Other Resources First Offense: Class B Misdemeanor with a minimum Other community services include therapists, counselors, confinement of 72 hours treatment centers and support groups. For assistance in Second Offense: Class A Misdemeanor identifying an appropriate service, contact the Department Subsequent Offenses: Third-Degree Felonies of Student Life, Alcohol and Drug Education Programs.

Causing serious bodily injury to another by accident or Community hospitals provide emergency care for drug or mistake while operating a motor vehicle, including motor alcohol medical problems. Most health plans cover aircraft or watercraft, in a public place while intoxicated treatment of alcohol abuse and other illicit drug use Third-Degree Felony problems. You should contact the Human Resources office or call your health plan member services number Causing the death of another by accident or mistake for information about plan coverage. while operating a motor vehicle, including motor aircraft or watercraft, in a public place while intoxicated The Texas Department of State Health Services’ Mental Second-Degree Felony Health and Substance Abuse Services agency, http://www.dshs.state.tx.us/mhsa, can provide information Possession, manufacture and/or delivery of a controlled on laws and services regarding drug and alcohol abuse. substance For More Information A violation of state and federal laws. Penalties vary Human Resources according to the type of substance, amount in Admin Annex I, Room 106, Box T-0510 possession, manufactured and/or delivered, and the Stephenville, Texas 76402 number and type of previous violations. In addition, (254) 968-9128

This brochure is a summary of System Policy 34.02, Drug and Alcohol Abuse and System Regulation 34.02.01, Drug and Alcohol Abuse and Rehabilitation Programs. It does not include the complete policy, regulation or detailed information on applicable local, state or federal law. In case of any discrepancy between this brochure and policy, regulation or law, the policy, regulation or law will govern. Detailed information on health risks is available from accredited health care providers and more information on community resources is available from the resources listed in this brochure.

September 2012 Page 2

HIV/AIDS and the Workplace HIV/STD FACTS HIV/STD FACTS You may be wondering what HIV and AIDS could have to do with your job and workplace. Well, it depends on the type of work you do. Some people, like health care workers, have to deal with HIV and AIDS every day. Most of us, though, don’t need to give much thought to HIV or AIDS when it comes to our jobs. And that makes a lot of sense, because HIV is not spread through the type of casual day-to-day contact that most of us have with other people in our jobs. On the other hand, it does make sense to be familiar with HIV and AIDS for our own personal health, as

well as with the situations that might come up at work that do involve HIV and AIDS. HIV/STD FACTS

What you should know about HIV, AIDS and the workplace:

• HIV is the virus that causes AIDS, a disease that destroys a person’s immune system. • There are only a few ways that a person can be infected with HIV - most of which don’t involve work related situations.

• It is easy to protect yourself from being infected with HIV, both in your personal life and in workplace HIV/STD FACTS settings.

Some general information about HIV/AIDS:

Acquired Immune Deficiency Syndrome (AIDS) is the final stage of an infection caused by the Human Immunodeficiency Virus (HIV). HIV attacks the body’s immune system, hurting the body’s ability to fight off diseases and other infections. HIV/STD FACTS There is no cure for HIV infection or AIDS. There are also no clear symptoms of HIV infection, although some people may have flu-like symptoms for a few days after they are infected with HIV. But, even if an infected person has no symptoms, feels, and looks healthy, he or she can still pass the virus to others.

HIV is spread from person to person in the following body fluids: • blood HIV/STD FACTS • semen • vaginal secretions • breast milk HIV is NOT spread through the environment; it is a very fragile blood-borne virus. HIV-infected persons do not

pose a threat to co-workers or clients during casual, day-to-day activities and contacts. HIV/STD FACTS

You CANNOT be infected with HIV through:

• handshakes • dishes, utensils, or food • hugs or casual touching • sneezing or coughing • close working conditions • air • telephones, office equipment, or furniture • water HIV/STD FACTS • sinks, toilets, or showers • insects

There are only a few ways for a person to come in contact with HIV:

• by having sex, either anal, oral, or vaginal, without the use of a condom;

• by sharing needles, syringes, and other instruments that break the skin, such as tattoo and/or ear/body piercing needles; HIV/STD FACTS • from an HIV-infected mother to her baby during pregnancy, birth, or breastfeeding; and • by coming in contact with HIV-infected blood either through an open wound or through a blood transfusion. Risks from transfusions, however, are now very low because of blood-screening, which started in 1985.

-OVER- HIV/AIDS and the Workplace HIV/STD FACTS HIV/STD FACTS

How HIV/AIDS affects you in your workplace:

As you can see from the information on the last page, most of the behaviors that pass HIV from one person to another do not occur in the workplace. The only way that most people in the average workplace could be exposed to HIV would be if they had an open wound and someone else’s infected blood entered their body through that broken skin. HIV/STD FACTS

How to avoid HIV infection in the workplace:

It is easy to avoid being exposed to HIV and other blood-borne diseases by using good personal hygiene and common sense at all times: • keep broken skin covered with a clean, dry bandage; • avoid direct contact with blood spills; HIV/STD FACTS • wear gloves to clean spills that contain visible blood; and • clean blood spills with an appropriate disinfectant or 1:10 solution of freshly mixed household bleach and water. After cleanup, wash hands thoroughly with soap and running water.

Ways to reduce your risk for HIV infection in your personal life: HIV/STD FACTS • Do not have sex (abstain) • Delay having sex until you are in a faithful relationship with one person who you know does not have HIV. • If you choose not to abstain from sex or to limit sex to one faithful, uninfected partner, then always use a latex condom every time you have sex (oral, anal, or vaginal). If used correctly and every time you have sex, latex condoms can provide protection against HIV and other sexually transmitted diseases (STDs).

• If you have a drug habit, do not share needles or syringes. If you can’t stop sharing needles/syringes, clean HIV/STD FACTS them with bleach and then rinse them with water between every use. Also, do not share any other type of needles, such as tattoo and ear/body piercing needles. • The best thing for your health is to stop using drugs. If you need help to stop using, call the National Drug Abuse Hotline at 1-800-662-4357.

If you work with someone who has HIV and/or AIDS: HIV/STD FACTS If you have a cold, fl u or other virus, remember that people with HIV or AIDS do not have a healthy immune system. They are more likely to become ill from a virus that a healthy person’s body could easily fight. Remember, too, that people with HIV or AIDS are just like anyone else living with a disease: they need caring, support, and understanding. HIV/STD FACTS HIV/STD FACTS HIV/STD FACTS

For HIV/STD testing locations in Texas, call: 2-1-1

For other HIV/STD questions, call: 1 (800) CDC-INFO (English/Español) 1 (888) 232-6348 (TTY) DSHS TB/HIV/STD Unit DSHS Stock E4-148 For more information, go to: www.dshs.state.tx.us/hivstd Revised 10/2007 NOTICE TO EMPLOYEES

The Texas Hazard Communication Act (revised 1993), codified as Chapter 502 of the Texas Health and Safety Code, requires public employers to provide employees with specific information on the hazards of chemicals to which employees may be exposed in the workplace. As required by law, your employer must provide you with certain information and training. A brief summary of the law follows.

HAZARDOUS CHEMICALS MATERIAL SAFETY DATA SHEETS

Hazardous chemicals are any products or Employees who may be exposed to hazardous materials that present any physical or health chemicals shall be informed of the exposure by hazards when used, unless they are exempted the employer and shall have ready access to the under the law. Some examples of more most current material safety data sheets commonly used hazardous chemicals are fuels, (MSDSs), which detail physical and health cleaning products, solvents, many types of oils, hazards and other pertinent information on compressed gases, many types of paints, those chemicals. pesticides, herbicides, refrigerants, laboratory chemicals, cement, welding rods, etc. LABELS

WORKPLACE CHEMICAL LIST Employees shall not be required to work with hazardous chemicals from unlabeled containers, Employers must develop a list of hazardous except portable containers for immediate use, chemicals used or stored in the workplace in the contents of which are known to the user. excess of 55 gallons or 500 pounds. This list shall be updated by the employer as necessary, EMPLOYEE RIGHTS but at least annually, and be made readily available for employees and their Employees have rights to: representatives on request. Χ access copies of MSDSs Χ information on their chemical exposures EMPLOYEE EDUCATION PROGRAM Χ receive training on chemical hazards Χ receive appropriate protective equipment Employers shall provide training to newly Χ file complaints, assist inspectors, or assigned employees before the employees work testify against their employer in a work area containing a hazardous chemical. Covered employees shall receive training from Employees may not be discharged or the employer on the hazards of the chemicals discriminated against in any manner for the and on measures they can take to protect exercise of any rights provided by this Act. A themselves from those hazards. This training waiver of employee rights is void; an employer’s shall be repeated as needed, but at least request for such a waiver is a violation of the whenever new hazards are introduced into the Act. Employees may file complaints with the workplace or new information is received on the Texas Department of State Health Services at chemicals which are already present. the telephone number provided below.

EMPLOYERS MAY BE SUBJECT TO ADMINISTRATIVE

PENALTIES AND CIVIL OR CRIMINAL FINES RANGING FROM $50

TO $100,000 FOR EACH VIOLATION OF THIS ACT

Further information may be obtained from:

Texas Department of State Health Services Division for Regulatory Services Enforcement Unit (512) 834-6665 Texas Department of 1100 West 49th Street State Health Services Austin, Texas 78756 Fax: (512) 834-6606 Approved 5/05 AVISO A LOS TRABAJADORES

La Ley sobre Comunicaciones de Peligro en Texas (revisión de 1993), codificada bajo el Capítulo 502 del Código de Salud y Seguridad de Texas, exige que los patrones o empleadores del sector público ofrezcan a los trabajadores con información específica sobre los peligros de aquellos productos químicos a los que trabajadores pueden estar expuestos en su lugar de trabajo. De acuerdo con la ley, el patrón debe ofrecer la información y entrenamiento correspondiente. A continuación tenemos un breve resumen de la ley. PRODUCTOS QUÍMICOS PELIGROSOS HOJAS DE DATOS SOBRE LA SEGURIDAD

Los productos químicos peligrosos pueden ser DEL MATERIAL cualquiera de los productos o materiales que presentan algún peligro físico o de salud cuando se Los trabajadores que pueden estar expuestos a está usando, a menos de que sea uno de los productos químicos peligrosos deberán ser exentos por la ley. Algunos ejemplos de los informados por el patrón sobre esa exposición y productos químicos peligrosos usados más deberán tener libre acceso a las hojas de datos más comúnmente son los combustibles como la gasolina, recientes sobre la seguridad de los materiales productos de limpieza y muchos tipos de pinturas, vigentes (MSDSs), en donde se explican los peligros pesticidas, herbicidas, congelantes, productos físicos y de salud y dan información adicional sobre químicos de laboratorio, cemento, varillas de estos productos químicos. soldadura, etc. ETIQUETAS LISTA DE PRODUCTOS QUÍMICOS EN LOS Los trabajadores no deberán trabajar con productos CENTROS DE TRABAJO químicos peligrosos con recipientes sin etiquetas, a excepción de los recipientes portátiles para su uso Los patrones deben desarrollar en el lugar de inmediato, cuyos contenidos son conocidos por el trabajo una lista de productos químicos peligrosos usuario. usados o almacenados de tamaño mayor de 55 galones o de 500 libras de peso. Esta lista deberá DERECHOS DE LOS TRABAJADORES ser renovada por el patrón, cuando sea necesario, pero cuando menos una vez al año, y debe ponerse Los trabajadores tienen los siguientes derechos: al alcance de los trabajadores y sus representantes cuando lo soliciten. • tener acceso a las copias de MSDSs. • recibir información sobre su exposición PROGRAMA DE EDUCACIÓN PARA EL a productos químicos peligrosos. TRABAJADOR • recibir entrenamiento sobre los productos químicos peligrosos. Los patrones deberán proveer entrenamiento a los • recibir equipo de protección apropiado. trabajadores nuevos asignados antes de que los • levantar quejas, ayudar a los inspectores, o trabajadores trabajen en una área que contiene un atestiguar contra su patrón. producto o material peligroso. Los trabajadores cubiertos deberán recibir entrenamiento por parte No se pueden despedir o discriminar contra los del patrón sobre el peligro de los productos trabajadores en ninguna forma por hacer ejercicio químicos y sobre las medidas que pueden tomar de cualquiera de estos derechos proporcionados por para protegerse a sí mismos de esos peligros. Este esta Ley. La renuncia de un trabajador a sus entrenamiento deberá ser repetido tantas veces derechos es nula; el patrón que solicita tal renuncia como sean necesario, pero por lo menos cuando un comete una violación de esta Ley. Los trabajadores nuevo producto peligroso es introducido en el lugar pueden llamar al número de información que de trabajo o se reciba nueva información sobre los aparece más adelante, para levantar quejas ante el productos químicos que ya están presentes. Departamento Estatal de Servicios de Salud.

LOS PATRONES PUEDEN RECIBIR PENALIZACIONES ADMINISTRATIVAS Y MULTAS CRIMINALES O CIVILES QUE VARÍAN DE $50 HASTA $100,000 POR CADA VIOLACIÓN A ESTA LEY. Para poder recibir más información por favor llame al:

Texas Department of State Health Services Division for Regulatory Services Texas Department Enforcement Unit of State Health 1100 West 49th Street Services Austin, Texas 78756 (512) 834-6665 Approved 5/05 Fax: (512) 834-6606 The Texas A&M University System Overview of Voluntary Supplemental Retirement Savings Programs The 403(b) Tax-Deferred Account Program and the 457(b) Texa$aver Deferred Compensation Plan

Regardless of the mandatory retirement program you participate in (TRS or ORP), you can choose to save additional money for retirement on a tax-deferred basis through the Tax-Deferred Account (TDA) Program and/or Texa$aver Deferred Compensation Plan (DCP). All Texas A&M University System employees are eligible to participate in one or both of these voluntary supplemental pre-tax savings programs at any time.

The TDA and DCP programs allow you to save money for retirement and postpone paying federal income tax on your savings and investment earnings until you begin receiving the money. This will generally be after retirement, when your income may be less and your tax bracket is likely to be lower. While employed, you may make financial hardship withdrawals, though the plans’ definitions of a hardship differ. Upon termination of employment or retirement, you can rollover your TDA and DCP accounts to another retirement plan (including an IRA) if you meet the requirements for a rollover distribution.

You decide how much you want to save, from a $25 minimum monthly contribution for the TDA and a $20 minimum monthly contribution for the DCP to the maximum allowed by federal law. Contributions are processed through convenient payroll deduction. You can change the amount you save once each month. You may also choose to defer part or all of a lump sum payment of annual leave upon termination of employment or retirement. However, you must enroll in the DCP or TDA prior to your final day of employment in order to defer your annual leave lump sum payment. Under the TDA Program, you must choose an investment vendor from the A&M System list of active vendors. Under the DCP, you choose investment options from those companies authorized by the State of Texas. You are responsible for choosing investment vendors and investment options and for any gains or losses on your account. There are no employer matching contributions under either plan.

TAX-DEFERRED ACCOUNT PROGRAM

Enrollment

The Tax-Deferred Account Program is subject to Internal Revenue Code section 403(b), which allows you to defer a portion of your current pre-tax or post-tax (Roth) income until retirement.

When you enroll in a TDA, you agree to have a specific amount or percentage of gross pay deducted from each paycheck and sent to the vendor you choose from the A&M System list of active vendors, available on the System Benefits Administration web site at tamus.edu/benefits/retirement/orptda.html. You may enroll in a TDA at any time and invest with up to two active vendors simultaneously. To enroll, you complete a TDA Salary Reduction Agreement (SRA) and turn it in to your Human Resources or Payroll Office, along with a copy of your completed vendor application. The TDA form is available from your Human Resources Office or online at tamus.edu/benefits/publications/index.html#retirement.

Your TDA contribution will be deducted from your pay during or after the effective month you state on the SRA form, depending on when your Human Resources or Payroll office receives your form. For example, if you are paid monthly and turn in a SRA form stating an effective month of January before the payroll runs in January, the first deduction will be made from the paycheck you receive at the beginning of February. If you are paid biweekly and turn in a SRA form stating an effective month of January on or before the payroll first runs in January, the first TDA deduction will be made from your paycheck that covers the first pay period that begins on or after January 1. The initial deduction for biweekly employees will depend on the payroll schedule during the month in which the TDA enrollment is effective.

Prepared by System Benefits Administration November 2009 IMPORTANT: If your TDA deduction amount is greater than your net pay for any pay period, no TDA deduction will be taken.

Distribution Options

Because the purpose of a TDA is to provide retirement income, you may begin receiving distributions from your account without penalty any time after you reach age 59½. You must pay federal income tax on your TDA savings when you receive payments unless you have a Roth TDA. Because Roth TDA contributions are made after taxes, your distributions upon retirement are tax-free. Federal law requires that you begin receiving payments by age 70½, unless you are still employed. You choose how your benefit will be paid from the payment options offered by your investment vendor(s). Your beneficiary will receive your account balance if you die before payment begins or will receive any survivor benefits you choose if you die after you begin receiving payments.

Under the TDA Program, if you withdraw money before age 59½, you generally must pay a 10% penalty tax in the year in which the money is withdrawn unless you withdraw because you become disabled and unable to work, you die, you leave A&M System employment after age 55, or elect an annuity payout upon termination or retirement at any age.

While you are employed with the A&M System, you may withdraw money from your TDA account only for one of the above reasons unless you have a financial hardship as defined by federal law. This includes major unreimbursed medical expenses, college costs for immediate family members, purchase of your primary residence or payments to prevent eviction from or foreclosure on your primary residence. If you receive a financial hardship withdrawal, federal law requires that contributions to the plan be suspended for six months. Some investment vendors allow you to take a loan from your TDA account, some do not. Contact your TDA vendor to determine loan availability.

If you leave A&M System employment before retirement, you may leave your account invested, but you may make no further contributions. You may also choose to withdraw your funds and pay any taxes due (including the penalty tax in most cases) or roll your account balance into a similar plan at a new employer or an individual retirement account.

Additional Resources

• System Regulation 31.02.10 Tax-Deferred Account Program (tamus.edu/offices/policy/31- 02-10.pdf)

For additional information, review the following documents on the System Benefits Administration web site (tamus.edu/benefits/retirement/):

Selecting a TDA Vendor TDA Vendors List TDA Fee Summary TDA Annuity Product Summary Maximum Contribution Limits TDA and Texa$aver DCP Comparison TDA and Texa$aver DCP TDAs: An Investment in Your Future

Prepared by System Benefits Administration November 2009 TEXA$AVER DEFERRED COMPENSATION PLAN

Enrollment

The Texa$aver Deferred Compensation Plan is subject to Internal Revenue Code section 457(b), which allows you to defer a portion of your current pre-tax income until retirement. The DCP is managed by the Employees Retirement System of Texas, and Great West is the third-party administrator who can answer any questions you have about the program. To enroll in the Texa$aver Deferred Compensation Plan, visit the web site at www.texasaver.com, click on “457 Plan” for information about the plan and how to enroll. Next, download enrollment form, enroll online or call at (800) 634-5091 to visit with a customer service representative who will assist you in enrolling in the Texa$aver Program. You must identify yourself as an A&M System employee and be prepared to provide the representative with the following information: name, Social Security number, address, date of birth, date of hire, phone number, agency name, deferral amount and investment elections.

Deferral instructions received by Great West by 3 p.m. Central Time (CT) on the last business day of the month will be effective the following month.

In the following example, the initial DCP deferral for an employee paid monthly is deducted in a new tax year, although the effective enrollment date is December 1 of the previous year. The initial deduction for biweekly employees will depend on the payroll schedule during the month in which the DCP enrollment is effective.

Enrollment period: Before 3 p.m. CT on last business day of November Effective date: December 1 Initial deduction: January 1 pay voucher (December earnings but included in new tax year)

IMPORTANT: If your DCP deduction amount is greater than your net pay for any pay period, no DCP deduction will be taken.

Distribution Options

Although the purpose of a DCP is to provide retirement income, you may begin receiving distributions from your account when you leave state employment. You must pay federal income tax on your DCP savings when you receive payments. Federal law requires that you begin receiving payments by age 70½, unless you are still employed. You choose how your benefit will be paid from the payment options. Your beneficiary will receive your account balance if you die before payment begins or will receive any survivor benefits you choose if you die after you begin receiving payments.

While you are employed with the A&M System, two types of withdrawals are available through the DCP: financial hardship and de minimus. The financial hardship withdrawals can be taken from your account to help cover the costs of an unforeseeable emergency. The amount withdrawn cannot exceed the amount needed to satisfy the emergency. If you receive a financial hardship withdrawal, your contributions to the DCP will be suspended for six months. De minimis withdrawals can be taken from your account if you have a balance of $5,000 or less and you have not made contributions for two years or longer. Hardship withdrawals are not subject to a penalty tax. However, the financial hardship and de minimus withdrawals will be taxed as regular income in the year in which the money is received.

You may borrow funds from your Texa$aver Deferred Compensation Plan (DCP) account for a general loan (12-60 months) or a residential loan (61-180 months). Great West will process your request for loans and answer questions. Unlike hardship withdrawals, contributions are not suspended for six months

Prepared by System Benefits Administration November 2009 when you borrow funds from your DCP. Amounts borrowed through the DCP loan program are not taxable unless you fail to repay the loan. Contact Great West at (800) 634-5091 if you have questions regarding the loan process.

If you leave A&M System employment before retirement, you may leave your account invested, but you may make no further contributions. Or, you may withdraw your funds and pay regular income taxes (with no penalty tax) or roll your account balance into a similar plan at a new employer or an individual retirement account.

Additional Resources

• System Regulation 31.02.11 Deferred Compensation Program (tamus.edu/offices/policy/31- 02-11.pdf)

For additional information, review the following documents on the System Benefits Administration web site (http://tamus.edu/benefits/retirement/):

Maximum Contribution Limits for TDA and Texa$aver DCP Comparison TDA and Texa$aver DCP

Additional information about the Texa$aver Program is available online at texasaver.com click on “457 Plan.” Links are provided for various features of the Texa$aver DCP.

Participation in the 403(b) Tax-Deferred Account Program or 457(b) Texa$aver Deferred Compensation Plan entails certain responsibilities for the participant, including selection and monitoring of the vendor and individual investments. The Texas A&M University System has no fiduciary responsibilities for the financial stability of the vendor or the market value of individual investments chosen by the participant. Each employee bears the risk of the performance of the product(s) of his/her choosing under these voluntary retirement programs, and The Texas A&M University System is not liable for any tax consequences occurring under these retirement programs.

The contents of this document are intended for informational purposes only and should not be construed as tax or legal advice, which can be rendered only when related to specific fact situations. In all cases, you should consult your attorney or tax adviser if you have questions about your individual situation.

Prepared by System Benefits Administration November 2009