<p> EMPLOYEE INFORMATION SHEET Contract Development and Information Distribution</p><p>Wherever multiple choices are provided, please circle the selection. Circle one: New employee Position Change</p><p>GENERAL INFORMATION (BIOGRAPHICAL)</p><p>SSN ______Employee ID ______Credential or Z ID# ______- __</p><p>First Name ______Middle Name ______Last Name ______</p><p>SSN Legal Name First ______Middle ______Last______Suffix_____</p><p>Address ______City ______State ____ Zip ______</p><p>Home Phone ______Email ______Gender: M F</p><p>Semester Hours: ______(Degree type) Educational Level: ______Certificate: ______</p><p>ECE Qualifications: ______Other Credentials: ______Report to EMIS ______</p><p>Total Years Experience: ______Authorized Years: ______District Years Experience ______</p><p>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</p><p>Master Teacher: BC – National Board Certified FA – Full Application Process NO- Not a MT MT Designation YR ______</p><p>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)</p><p>Position Title ______Position Type: Regular Supplemental Temporary</p><p>Type of Appointment: 1-Certified (STRS) or 2-Classified (SERS) EMIS Appointment Type: ______</p><p>Report Job to EMIS: Y N Grade level assigned (L/H) _____ /_____ Position Start Date ______</p><p>Contract Term:Beginning Date ______Ending Date ______Years 1 2 3 4 5 Cont</p><p>Building IRN:______Building/Department :______/______Assignment Area:______</p><p>Work Days in Contract ______Salary Schedule ______Step ______Degree ______</p><p>Annual salary ______Per Diem (daily rate) ______Hourly Rate ______Other ______EMPLOYEE INFORMATION SHEET Contract Development and Information Distribution</p><p>Sick: Y N Max ______Vacation: Y N Max ______Personal: Y N Max ______</p><p>______Hiring Authority signature/date Employee signature/date</p><p>PAYROLL – OFFICE USE ONLY</p><p>Building/Department :______/______Calendar start date ______Calendar stop date ______</p><p>First date paid:______</p><p>Retirement Code: STRS 450 Pay Group ______Calendar Type ______SERS 400 FICA (blank) Work Days ______Extended Service Days ______</p><p>Pay account ______Maximum or % ______Amount ______BRDDIS Y or N</p><p>Pay account ______Maximum or % ______Amount ______BRDDIS Y or N</p><p>Pay account ______Maximum or % ______Amount ______BRDDIS Y or N</p><p>Equal Pays: Y or N Job Status 0 – Inactive 8 - Deceased Timesheets: Y N 1 – Active 9 - Terminated</p><p>Date Reviewed By Payroll ______Payroll Initials ______</p><p>EMIS DETAILS </p><p>If EMIS reporting information is different than contract information provide EMIS contract amount, work days and hours per day</p><p>EMIS Contract Amt ______EMIS Hours Per Day ______EMIS Work Days ______EMIS FTE _____</p><p>Extended Service ______(ESC reportable Only) Certificate: ______</p><p>Position Code ______EMIS Appt: 1-Certified 3-Internship 5-Veteran per ORC 3319.283 2-Classified 4-Six hour lay teacher</p><p>Position Type: R – Regular S – Supplemental T – Temporary </p><p>Position Status: C - Continuing/Active A – Agency Contracted I – Individual Contracted P – Leave of Absence U - No Longer Employed</p><p>HQPD: : ______Qualified Paraprofessional______Special Education FTE: ______</p><p>Assignment Area ______Funding Source ______Percentage ______Funding Source ______Percentage ______Funding Source ______Percentage ______</p><p>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</p><p>Position Separation Reason ______Position Separation Date: ______</p><p>Date Reviewed By EMIS ______EMIS Initials ______</p>