Springfield, MA 01103-1410 SPRINGFIELD PUBLIC SCHOOLS - S PRINGFIELD, MASSACHUSETTS Anti-Harassment Policy Acknowledgment Form The Springfield Public Schools ( SPS ) Anti-Harassment policy, covering all SPS community members, is intended to ensure a professional working and learning environment free from unlawful harassment. I understand that it is my responsibility to be familiar with and conform to the procedures contained in the policy. By signing this document, I acknowledge that I have received a copy of, read, and understand the SPS S Anti-Harassment Policy. Signature: Print Name: Date: This completed form is to be placed in each employee s official personnel file in the Department of Human Resources. The Springfield Promise: A Culture of Equity and Proficiency
Springfield, MA 01103-1410 Authorization to Release Information To Whom It May Concern: 1. I authorize all prior employers to provide the Springfield Public Schools any and all information and documentation that they request. Such information includes but is not limited to employment history, including dates of employment and salary information, including information requested on the Reference Form. 2. I authorize you, as a listed reference on my employment application, to respond to any written inquiry relative to my professional and/or personal characteristics. I hereby release you from all liability for any damage or inquiry resulting there from. 3. A copy of this Authorization to Release Information may be accepted as an original. 4. Your prompt reply to the Springfield Public Schools in this matter is appreciated. Please send your reply to the following address: Human Resources Department Springfield Public Schools Springfield, MA 01103 Applicant Signature Date
Springfield, MA 01103-1410 Bullying Prevention Policy Acknowledgment Form The Springfield Public Schools ( SPS ) Bullying Prevention Policy, covering all SPS community members, is intended to ensure a professional working and leaning environment free of bullying. I understand that it is my responsibility to be familiar with and conform to the procedures contained in the policy. By signing this document, I acknowledge that I have received a copy of, read, and understand the SPS S Bully Prevention Policy. Signature: Print Name: Date: This completed form is to be placed in each employee s official personnel file in the Department of Human Resources.
Springfield, MA 01103-1410 Drug-Free Workplace Act Acknowledgment Form I hereby acknowledge that I received from the Human Resources Department of the Springfield Pubic Schools a copy of the City of Springfield s Notice to Employees relative to certain information on the Drug-Free Workplace Act of 1998 and the City of Springfield s Employee Assistance Program. Signature: Print Name: Date: This completed form is to be placed in each employee s official personnel file in the Department of Human Resources.
Springfield, MA 01103-1410 PICTURE ID APPLICATION FORM Date: Employee Number: Employee Name: Last Name First Name MI Employee Position: Employee Job Location: Swiper (Paraprofessional, CAN, COT, Custodians, Lunch Supervisor, parent Facilitator, Temp Clerk, and Security Guards) Non-Swiper (Any other not listed above) ------------------------------------------------------------------------------------------------------ HR USE ONLY Card #: Access Level:
Springfield, MA 01103-1410 Employment/Assignment of Immediate Family Members Chapter 71 Section 67 reads in Paragraph No. 2 as follows: A school district shall neither (i) employ a member of the immediate family of a superintendent, central office administrator, or school committee member, not (ii) assign a member of the immediate family of the principal as an employ at the principal s school, unless written notice is given to the school committee of the proposal to employ or assign such person at least two weeks in advance of such person s employment or assignment. As used in this section, immediate family shall have the meaning assigned by subsection (e) of section one of chapter two hundred and sixty-eight A. Immediate family is defined in Chapter 268A Section One Subsection E as the employee and his spouse, and their parents, children, brothers and sisters. As a prospective employee, I make the following declaration: No member of my immediate family currently works for the Springfield Public Schools. The following members of my immediate family (see above definition) work for the Springfield Public Schools. 1. Name Location Relationship Location 2. Name Location Relationship Location Springfield Public Schools Policy 1. It is the policy of the Springfield School Committee that no member of the immediate family or the Principal shall be assigned to the Principal s school. Should the Superintendent of Schools determine that a vacant position exists in a school that requires the hiring or assignment of an employee who possesses specialized skills for the position, he/she may approve in writing the hiring or assignment of a Principal s immediate family member to work in the same school as the Principal and shall notify the Springfield School Committee in accordance of M.G.L. Chapter 71, Section 67. 2. Two weeks written notice of the proposal to employ a member of the immediate family of a: (A) Central Office Administrator or (B) School Committee Member or (C) Superintendent or Assistant Superintendent of Schools must be given to the Springfield School Committee. 3. Current employees of the Springfield Public Schools who are a member of your immediate family, as defined above, may have to comply with M.G.L. Chapter 268A, Section 19. 4. Other restrictions involving employment of relatives are addressed in the Human Resource Policy and Procedure Manual. I hereby acknowledge and affirm that the information contained above is true to the best of my knowledge and belief. Employee/Prospective Employee Signature Date Executive Director of Human Resources (or Designee) Date
Springfield, MA 01103-1410 Please Print Clearly NAME: Last First Middle or Maiden DATE: Are you a former employee of the Springfield Public Schools: Yes No If yes, reason for termination of employment: Retirement Resignation Other (Please Specify): Due to commitments concerning affirmative action requirements pertaining to hiring practices, your voluntary cooperation in answering the following questions will be appreciated. Date of Birth: Gender: RACE/ETHNICITY Please select one of the following: Hispanic/Latino Not Hispanic/Latino Please select one at least one of the following: White Black/African American Asian American Indian or Alaska Native Native Hawaiian or Other Pacific Islander Please list your degrees from highest to lowest: EDUCATION Degree Major Institution Signature:
CONDITIONS OF THIS MEDICAL HISTORY HEALTH STATEMENT AND PRE-EMPLOYMENT PHYSICAL EXAMINATION I certify that the above answers are mine and true and complete to the best of my knowledge. I authorize the release of information and evaluation results to the City of Springfield since employment has been offered to me by the City of Springfield. This document is considered CONFIDENTIAL under M.G.L. Ch. 4 sec. 7 clause 26, it is not a PUBLIC RECORD, however, this document may be subject to court subpoena. WARNING: ANY FALSIFICATION OF INFORMATION BY THE NEWLY HIRED EMPLOYEE IN THE MEDICAL HISTORY OR EVALUATION FORMS IS GROUNDS FOR SAID EMPLOYEE S SUSPENSION OR DISCHARGE BY THE APPOINTING AUTHORITY. I understand that this Pre-Employment Medical evaluation is NOT considered a complete medical examination, but is done to determine my eligibility to perform the essential functions of the job for which I was hired. I understand that this limited medical evaluation is NOT intended to replace routine medical care. NOTE: You will be required to present a valid picture identification at the time of your Medical evaluation. Also, if you wear glasses, be sure to bring them with you. If you wear contacts, please bring your case and solution along with your glasses. Applicant Signature Date Witness Signature Date
Pre-Employment Physical Medical History Section Name: Last, First, M.I. Date of Birth: Male: Female: Please check all that apply: New Hire: Full Time: Rehire: Part Time: Please indicate if you have had any of the following issues in the past or present by checking the appropriate box. Please explain all yes answers in the space provided below. Please include pertinent dates when/where available. Yes No Yes No Eczema or dermatitis Cancer Skin rashes or infections Tumor/Cyst Skin conditions or hives Does your skin react to: Back or neck problems Chemicals or solvents Back or neck pain Gloves More than 2 episodes of back or neck pain Soap or detergents Associated leg pain Bleaches Back pain due to a fall Do you use glasses Out of work more than 5 weeks due to back pain For reading Disc Problems For distance vision Shoulder or Arm problems Do you use contact lenses Leg or Knee problems Are you color blind Swollen Joints Any other visual problems Arthritis or Gout Any work with lasers Bursitis or Tendonitis Trouble walking or standing Difficulty hearing Trouble sitting Ear Disease Have you had surgery on the following: Ear Trouble Back or neck Shoulder Chest pain Arm, Wrist or Hand High Blood pressure Knee, leg, ankle or foot Shortness of breath Do you have weakness of: Swelling of ankles Arm, Wrist or Hand Heart murmur Knee, leg, ankle or foot Palpitations Stroke Previous jobs involving highly repetitive motion Jobs using vibrating tools Lung trouble Do you exercise regularly? Pneumonia Sinus trouble Arm or leg numbness Hay Fever Dizziness or fainting Allergies Ulcers Chronic Cough Abdominal surgery Asthma, bronchitis Ruptured Hernia Tuberculosis Other intestinal problems Coughing up blood History of Smoking: Excessive weight loss # Packs per day Anemia/Blood disease # Years Phlebitis/blood clots Night sweats Rheumatism/Arthritis Diabetes Varicose veins Thyroid Kidney trouble Liver trouble/hepatitis Gall bladder trouble Cirrhosis Difficulty working due to stress, anxiety, or depression Jaundice
Have you ever worked with: Yes No Radiation Asbestos Fiberglass Formaldehyde Lead Pesticides Exhaust Temperature extremes Infectious agents Other Harmful materials: Fumes-Dust Metals Chemicals Solvents Have you ever used a respirator? Please explain what other agents: Explanation(s) of yes answers: Please answer all of the following questions. Any yes answers may be explained in the section below. Are you currently under a doctor's care for any condition? Have you ever had an illness, injury or disease for which you received Workers Comp? Have you ever been limited or restricted at work as a result of your health? Have you missed more than 5 consecutive days of work due to an illness or injury in the past 5 years? Have you ever had to change work assignments or jobs due to a work related injury? When was your last doctor's appointment? Explanation(s) of yes answers: Please lists all medications that you take on a regular basis: List any known allergies: Yes No Reviewed by: Physician Signature Date
City of Springfield EMPLOYEE REGISTRATION Pre-Employment Physical Name: Date of Birth: Please Circle One: Gender: M F Employment: Full-time Part-time Race: Black White Hispanic American Indian Asian Other Telephone: Alternate: Address: City: State: Zip Code: Marital Status: Religion (optional): Language(s): Hiring Department: Classification: Emergency Contact: Relationship: Address: Home Phone: Work Phone: (For Demographics Only)
Springfield, MA 01103-1410 Social Media Guidelines Acknowledgment Form The Springfield Public Schools ( SPS ) social media guidelines, covering all SPS community members, is intended to communicate and align the expectations for the practice and use of social media. I understand that it is my responsibility to be familiar with and conform to the procedures contained in the guidelines. By signing this document, I acknowledge that I have received a copy of, read, and understand the SPS s Social Media Guidelines. Signature: Print Name: Date: This completed form is to be placed in each employee s official personnel file in the Department of Human Resources. The Springfield Promise: A Culture of Equity and Proficiency
Springfield, MA 01103 TECHNOLOGY DEPARTMENT Domain / Email Account Registration Form RETURN COMPLETED FORM TO: THE DATA CENTER AT DUGGAN MIDDLE SCHOOL The information on this form will remain confidential and the sharing of passwords by employees is strictly forbidden. All information on this form is to be printed clearly and full legal names MUST be used! Last Name First Name Middle Initial Employee ID Position Location Reason for submission: New Account *Password Change *Name Change o *Current user name needed for change Username will be assigned based on full legal last name and some part of the first name Ex: Mary A. Smith-Jones Username: smith-jonesm or smith-jonesma or etc. Email: username@sps.springfield.ma.us Requested Password (See Rules Below) PASSWORD must be a minimum length of 6 characters and include at least 1 character from 3 of these 4 groups: 1) UPPER CASE 2) lower case 3) Numeric 4) Special Characters (i.e. $, #,!, %) (Note: Please do not use any part of your username or a simple phrase that can be read over your shoulder.) Ex: Xjedf6 or kejrt3! or UD537$ THIS FORM WILL BE RETURNED TO THE EMPLOYEE BY THE TECHNOLOGY DEPARTMENT AFTER PROCESSING. IF ADDITIONAL ASSISTANCE IS NEEDED, THEN PLEASE CALL 750-2175 FOR ASSISTANCE! PLEASE REMEMBER TO DESTROY THIS FORM UPON RECEIPT. ------------------------------------------------------------------------------------------------------------------------------------ For Technology Department Use Only USERNAME assigned PASSWORD assigned Notes:
Springfield, MA 01103-1410 403(b) Salary Reduction Contribution Eligibility Notification I have been notified that I am eligible to participate in the Springfield Public Schools 403(b) Salary Reduction Program. I have received a copy of the Summary Plan Description and Salary Reduction Agreement. Should I choose to participate I will complete the Salary Reduction Agreement form and return it to the Springfield Public Schools Payroll Department. Name: Date of Hire: Signature: Date: