Wherever Multiple Choices Are Provided, Please Circle the Selection

EMPLOYEE INFORMATION SHEET Contract Development and Information Distribution

Wherever multiple choices are provided, please circle the selection. Circle one: New employee Position Change

GENERAL INFORMATION (BIOGRAPHICAL)

SSN ______Employee ID ______Credential or Z ID# ______- __

First Name ______Middle Name ______Last Name ______

SSN Legal Name First ______Middle ______Last______Suffix_____

Address ______City ______State ____ Zip ______

Home Phone ______Email ______Gender: M F

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

ECE Qualifications: ______Other Credentials: ______Report to EMIS ______

Total Years Experience: ______Authorized Years: ______District Years Experience ______

Race: A-Asian Marital Status: 1 – Single Birth Date: ______H – Hispanic 2 – Married W – White, Non-Hispanic 0 – Unstated Board Hire Date: ______B – Black, Non Hispanic I – American Indian/Alaskan Native M – Multiracial N – Not Specified P – Native Hawaiian or Other Pacific Islander

Master Teacher: BC – National Board Certified FA – Full Application Process NO- Not a MT MT Designation YR ______

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

Position Title ______Position Type: Regular Supplemental Temporary

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

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

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

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

Work Days in Contract ______Salary Schedule ______Step ______Degree ______

Annual salary ______Per Diem (daily rate) ______Hourly Rate ______Other ______EMPLOYEE INFORMATION SHEET Contract Development and Information Distribution

Sick: Y N Max ______Vacation: Y N Max ______Personal: Y N Max ______

______Hiring Authority signature/date Employee signature/date

PAYROLL – OFFICE USE ONLY

Building/Department :______/______Calendar start date ______Calendar stop date ______

First date paid:______

Retirement Code: STRS 450 Pay Group ______Calendar Type ______SERS 400 FICA (blank) Work Days ______Extended Service Days ______

Pay account ______Maximum or % ______Amount ______BRDDIS Y or N

Equal Pays: Y or N Job Status 0 – Inactive 8 - Deceased Timesheets: Y N 1 – Active 9 - Terminated

Date Reviewed By Payroll ______Payroll Initials ______

EMIS DETAILS

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

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

Extended Service ______(ESC reportable Only) Certificate: ______

Position Code ______EMIS Appt: 1-Certified 3-Internship 5-Veteran per ORC 3319.283 2-Classified 4-Six hour lay teacher

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

Position Status: C - Continuing/Active A – Agency Contracted I – Individual Contracted P – Leave of Absence U - No Longer Employed

HQPD: : ______Qualified Paraprofessional______Special Education FTE: ______

Assignment Area ______Funding Source ______Percentage ______Funding Source ______Percentage ______Funding Source ______Percentage ______

Funding choices: A – State Auxiliary Funds B – Other State Funds F – Federal Title VI-B G – Title H – Head Start Program EMPLOYEE INFORMATION SHEET Contract Development and Information Distribution I- State DPIA Funds J-Federal ELI L – Local Funds N – TANF O – Other Federal P – Federal Preschool S-State ECE T – Private/Tuition U – State Unit Funding X-Reading First Z – Preschool Unit F

Position Separation Reason ______Position Separation Date: ______

Date Reviewed By EMIS ______EMIS Initials ______