GROSSMONT-CUYAMACA COMMUNITY COLLEGE DISTRICT
PART-TIME (NON-FACULTY) HOURLY
HIRING CHECKLIST
All necessary paperwork must be completed BEFORE an employee begins work. Notification from HUMAN RESOURCES that the
employee is authorized to work is required. If you have questions, please contact HUMAN RESOURCES, x7644.
Applicants receive a hire packet from the department intending to employ them and consists of the following:
HIRE/REHIRE/CHANGE FORM - DEPARTMENT MUST OBTAIN APPROPRIATE HIRE FORM FROM
“FORMS DEPOT”
I-9 - EMPLOYMENT ELIGIBILITY VERIFICATION. HIRING SUPERVISOR/MANAGER MUST COMPLETE
SECTION #2 AND COPIES OF DOCUMENTS PRESENTED TO VERIFY THE I-9 MUST BE SUBMITTED
WITH THE I-9 AND HIRE PACKET.
SUPPLEMENTAL QUESTIONNAIRE FORM
EMPLOYEE INFORMATION FORM
TAX FORM(S) - W-4/FEDERAL, DE4/STATE
GCCCD COMPUTER SYSTEM SECURITY AND USE STATEMENT
OATH OF ALLEGIANCE
STATEMENT OF EMPLOYMENT NOT COVERED BY SOCIAL SECURITY
NOTICE OF EXCLUSION FROM CALPERS MEMBERSHIP (PERS-AESD-139)
PERS SELF-CERTIFICATION FORM (PERS-CASD-801)
VERIFICATION OF MEMBERSHIP IN RETIREMENT SYSTEM
DIRECT DEPOSIT INFORMATION
DIRECT DEPOSIT FORM (MANDATORY)
EMPLOYEE’S DESIGNATION OF BENEFICIARY
RECEIPT OF WORKER’S COMPENSATION INFORMATION
YORK INFORMATION
WELLCOMP MPN
PRE-DESIGNATION OF PERSONAL PHYSICIAN (OPTIONAL)
SAFETY TIPS/RIGHT TO KNOW ACKNOWLEDGEMENT
SAFETY TIP/RIGHT TO KNOW BOOKLET
FBC 3121 INFORMATION
3121 BENEFICIARY DESIGNATION FORM (EXCEPT FOR FT GCCCD WORK-STUDY AND FT GCCCD STUDENT
EMPLOYEES)
DISTRICT DRUG FREE-WORK PLACE POLICY
PAYROLL INFORMATION FOR HOURLY EMPLOYEES
FAQ HEALTH INSURANCE MARKETPLACE
MARKETPLACE NOTICE
NOTICE OF HEALTHY WORKPLACE HEALTHY FAMILY ACT OF 2014 PAID SICK LEAVE (AB1522)
LIVE SCAN (IF REQUIRED) (MUST BE SUBMITTED
USING DISTRICT
TB TEST (IF REQUIRED)
“REQUEST FOR LIVE SCAN SERVICE” FORM
Before signing the Hire/Rehire/Change form, the supervisor must review all information/forms to ensure that all is completed
accurately and legibly. It is the supervisor’s responsibility to review the Safety tips/Right to Know booklet for all new employees.
All completed hire forms are to be stapled together and routed through manager offices then forwarded to Human Resources.
1.
2.
Short-term Employment
a. Substitute employee
i. Classified Employee Absence
1. Replacing the temporary absence of a permanent classified employee on an approved leave of absence
2. Appointment may not exceed 175 days in an academic year. Work for any portion of a day constitutes a day.
3. Must pass a Live Scan background check and TB test
ii. Vacancy Replacement
1. Filling a vacancy of a permanent classified position
2. The district is actively engaged in the recruitment process (approved for recruitment and on the critical hire list)
3. Appointment period may not exceed 60 calendar days, subject to extension by mutual agreement between CSEA and
the District per the CSEA collective bargaining agreement.
4. Must pass a Live Scan background check and TB test
b. Short-Term Hourly Employees
i. Performing a service, upon the completion of which, the service required or similar services will not be extended or needed on a
continuing basis
ii. Appointment may not exceed 175 days of an academic year. Work for any portion of a day constitutes a day.
iii. Must pass a Live Scan background check and TB test
iv. Not eligible to work more than a cumulative total of 40 hours per week unless it is approved in advance and in writing by the
appropriate manager and VP/AVC
v. Cannot supplant classified work
Student Workers
a. Federal or State Funded College Work-Study or Work-Experience Programs
i. Must be part of a work-study or work experience program
ii. Must complete the federal/state Student Aid Application and it must be awarded to the student under federal/state methodology
iii. Must be enrolled in at least 6 units (part-time or full-time)
iv. Live Scan background checks and TB tests may be required by specific programs (e.g. Child Development Center)
v. Must work fewer than 40 hours during any workweek
vi. Must maintain satisfactory academic progress according to federal/state guidelines
b.
3.
4.
All Other Student Workers
i. Must be a student at GCCCD or other accredited College or University
ii. Must be full-time (12 units or as defined by academic program in which the student is enrolled)
1. Students working in the summer must have been full-time in the prior fall or spring semester or be a full-time student
during the summer semester (6 units or as defined by the academic program in which the student is enrolled).
iii. Must work fewer than 20 hours per week
iv. Must not be academically disqualified or on academic probation (refer to the college catalog)
v. Non-GCCCD students must pass a Live Scan background check and TB test. Live Scan background checks and TB tests may be
required by program needs (e.g. Child Development Center) for all student workers.
vi. May not work more than a cumulative maximum of 6 academic years within the District. Work for any portion of an academic
year constitutes one year. Summer school will count towards only one academic year and the cumulative maximum of 6
academic years applies.
vii. Students who fall below the full-time threshold (but maintain 6 units) or are academically disqualified or on academic probation
in the fall and spring semesters may complete work in the current semester only. If this occurs, student will not be employed the
following semester and not be eligible for future employment until they have reached full-time status and good academic
standing. These cases must be reviewed and approved by Human Resources.
Professional Expert
a. Work on a finite project that falls outside the skills and knowledge of existing positions within the classified service
b. Must have specialized knowledge or expertise
c. Recommendation of the appropriate Chancellor’s Cabinet level administrator is required.
Non Academic and Non Classified Employees (NANCE)
a. Unique positions that may be reoccurring from semester to semester, may be sporadic, and are dependent on student/program needs or
specific contractual obligations that may fluctuate
b. Must be directly correlated to classroom lecture and/or lab instruction only
c. Positions are: Tutors, Teaching Assistants, Models, Interpreters, and Life Guards
d. Employees in these positions may or may not be students
i. Above Work-Study and Work-Experience student requirements will apply. All Other Student Workers requirements do not
apply.
e. Non-GCCCD students must pass a Live Scan background check and TB test. Live Scan background checks and TB tests may be
required by specific programs (e.g. Child Development Center).
f. Not intended to supplant classified work
rev. 5/4/17
GROSSMONT-CUYAMACA COMMUNITY COLLEGE DISTRICT
HUMAN RESOURCES
SUPPLEMENTAL QUESTIONNAIRE FOR PART-TIME (NON-FACULTY) HOURLY EMPLOYEES
As a condition of employment, the information requested below must be provided (Reference Ed. Code Section
88022) for all potential (non-faculty) hourly employees with the District.
The existence of a criminal record does not constitute an automatic bar to employment, with the exception of certain
sex or drug offenses, specifically described by the California Education Code. In the cases of drug convictions,
further consideration is given to personal rehabilitation efforts as well as a certificate of rehabilitation and pardon.
Name:
Address:
Last
First
Mailing Address
Potential hire for:
City
Department
Social Security number
State
Zip
Supervisor
1. Have you ever been convicted of a felony or any crime related to drugs, alcohol abuse, or moral turpitude? Note,
expunged convictions must be reported.
Yes
No
If yes, explain in detail including the conviction date and Penal Code, Vehicle Code, Health and Safety Code or other code
provision of conviction:
Code violation section number:
Date of conviction:
Convicted of:
Place /city of occurrence:
Disposition /Outcome:
Code Violation Section Number:
Date of Conviction:
Convicted of:
Place /City of Occurrence:
Disposition /Outcome:
Code Violation Section Number:
Date of Conviction:
Convicted of:
Place /City of Occurrence:
Disposition /Outcome:
2. If your answer to question 1 is “Yes”, have you received a certificate of rehabilitation or pardon, or has the accusation or
information against you been dismissed pursuant to Penal Code Section 1203.4?
Yes
No
If your answer to question 2 is “Yes”, you must provide evidence that substantiates that you have been rehabilitated. (Proof of
rehabilitation can include but is not limited to: court documents, receipt of payment of fine, completion of required programs,
etc.)
Applicant’s Signature
Date
Grossmont-Cuyamaca Community College District
EMPLOYEE INFORMATION FORM
HUMAN RESOURCES
PLEASE REFER TO THE CODING INFORMATION ON REVERSE WHEN NECESSARY TO COMPLETE THIS FORM.
PLEASE TYPE OR PRINT CLEARLY IN BLACK INK.
1. DATE COMPLETED:
3.
2. SOCIAL SECURITY NUMBER
NAME
(As it appears on your Social Security Card) Last
First
4. LOCATION:
5.
BIRTH DATE:
(G = Grossmont, C = Cuyamaca, D = District)
6.
SALUTATION
Mr.
7.
MARITAL STATUS
Mrs.
Middle
M/D/Y
Ms.
Dr.
8. GENDER
(M = Male, F = Female)
(D = Divorced, M = Married, S = Single, U = Unknown, W = Widowed, P =Separated)
9. HOME ADDRESS
Number and Street
City
State
Zip
10. PHONE NUMBER
Cell Phone
Secondary Phone
email address:
11. PERMISSION TO RELEASE PHONE NUMBER
(B = Both Faculty & Student, F = Faculty, S = Student, N= None )
12. ETHNIC DATA:
A) ARE YOU HISPANIC OR LATINO? (CHECK ONE)
YES
B) WHAT IS YOUR RACE/ETHNICITY? (LIST ONE OR MORE)
ETHNIC GROUP
(See reverse for Coding Information)
13. DISABLED
(Y = Yes, N = No)
If yes: PRIMARY DISABILITY
NO
SECONDARY DISABILITY
(See reverse for Coding
Information.)
14. CITIZEN
(Y=Yes, N=No)
15. VETERAN
(Y=Yes, N=No)
ACTIVE
(Y=Yes, N=No)
RESERVE
(Y=Yes, N=No)
16. PRIMARY EMERGENCY INFORMATION:
Name: Last
Relationship
Phone: (day)
First
Middle I.
(evening)
SECONDARY EMERGENCY INFORMATION:
Name: Last
Relationship
Phone: (day)
First
(evening)
Middle I.
EMPLOYEE INFORMATION FORM (Continued)
NAME
17. EDUCATIONAL INFORMATION (Highest Level of Completion) (If additional space required, indicate in "Comments"
section.)
LHS (Less than High School)
HS (High School)
(Technical Trade)
AA
AS
a. Degree Type:
BA
BS
MA
MS
Ph.D.
Other (please specify)
Degree Awarded (Date: M/D/Y):
Institution:
Major:
Minor:
Description:
IF HIRED AS AN ACADEMIC EMPLOYEE AND IF EMPLOYED ELSEWHERE, PLEASE COMPLETE:
18. PLACE OF EMPLOYMENT
ADDRESS
Street
City
State
Zip
PHONE NUMBER
COMMENTS SECTION (to be used as needed):
Employee Signature
Date
RACE/ETHNICITY INFORMATION CODES:
(Indicate code in appropriate section--of front page.)
CODING INFORMATION
DISABILITY STATUS CODES:
(More than one may be entered--indicate code in
appropriate section--primary/secondary--of front page.)
AC
AI
AJ
AK
Chinese
Asian Indian
Japanese
Korean
AL
AM
AV
AX
B
F
HM
HR
HS
XH
N
PG
PH
PS
PX
W
Laotian
Cambodian
Vietnamese
Other Asian
Black Non-Hispanic
Filipino
Mexican, Mexican-American, Chicano
Central American
South American
Other Hispanic
American Indian/Alaskan Native
Guamanian
Hawaiian
Samoan
Other Pacific Islander
White Non-Hispanic
M
V
O
H
S
E
Physical Disability (Mobility)
Physical Disability (Visual)
Physical Disability (Other Health)
Communications Disability (Hearing)
Communications Disability (Speech)
Mental Disability (Emotional)
GROSSMONT-CUYAMACA COMMUNITY COLLEGE DISTRICT
COMPUTER SYSTEM SECURITY AND USE STATEMENT
I understand that the Grossmont-Cuyamaca Community College District (GCCCD) network represents an
essential asset of the district and that misuse of networking resources may result in the loss of privileges.
Users may be held accountable for their conduct under any applicable District/campus policy, procedure,
or collective bargaining agreement. Under California state law anyone who maliciously accesses, alters,
deletes, damages, or destroys any computer system, network, computer program or data is guilty of a
felony. Complaints alleging misuse of network resources will be directed to those responsible for taking
appropriate disciplinary action.
I understand that the GCCCD computing systems are provided for the use of Grossmont/Cuyamaca
Community College District students, faculty, and staff in support of the educational programs of the
colleges, and are to be used for such activities only. Commercial uses are specifically prohibited.
I agree to use the network in a legal and ethical manner which respects the rights, privacy, and needs of
others, which honors copyright and license agreements, and which does not interfere with the operation,
integrity, or security of the network. I understand that all communications are to reflect the mutual respect
and civility expected in an academic community.
I understand that I am responsible for all activity under my user name, and understand that abuse of the
network privilege will result in the immediate suspension of network access. I understand that I may not
transfer or confer these privileges to another individual, unless I provide explicit written permission to
another person access to my e-mail accounts. The authorized user is responsible for the proper use of
the system, including any password protection.
I am aware that network traffic may be subject to search under court order. I understand that network
traffic, and E-mail and voice mail in particular, may be considered a public record of the GrossmontCuyamaca Community College District. Such records are subject to examination by District officials in the
necessary conduct of District business and release by request under provisions of California Government
Code Section 6250 et.seq. System administrators may monitor network traffic or access user files as
required to protect the integrity of the network. I am aware that all users have the right to be free from
any conduct connected with the use of GCCCD computing systems which discriminates against any
person on the basis of race, color, national origin, sex, sexual orientation, or disability or creates a hostile
educational environment.
Nothing in this statement supersedes the right of a network service provider to impose more restrictive
terms.
I have read the above GCCCD Computer System Security and Use Statement and agree to comply with
all policies and procedures set forth by the Grossmont District.
Identification Number
Print Name
Identification Number
Signature
Date
Date
For a complete statement clarifying District Computing operating guidelines and procedures, see District
Administrative Procedure 3720, Computer and Network Use.
12/2008
Grossmont-Cuyamaca Community College District
Oath of Allegiance and Citizenship Affidavit for persons employed by a school district of the State
of California
(Oath of Allegiance is required by Sections 3100-3109 of the Government Code)
State of California
County of San Diego
I,
do solemnly swear (or affirm) that I
Print name
will support and defend the Constitution of the United States and the Constitution of the State of
California against all enemies, foreign and domestic; that I will bear true faith and allegiance to the
Constitution of the United States and the Constitution of the State of California; that I will take this
obligation freely, without any mental reservation or purpose of evasion, and that I will well and
faithfully discharge the duties upon which I am about to enter.
Are you a U.S. Citizen:
Yes
No
If you are not a U.S. Citizen, can you provide documentation of your temporary or permanent legal
right to work in the United States?
Yes
No
Employee signature:
Social Security number:
Date:
-
-
Social Security Administration
Statement Concerning Your Employment in a Job
Not Covered by Social Security
Employee Name
Employer Name
Employee ID#
GCCCD
Employer ID# 95-6006652
Your earnings from this job are not covered under Social Security. When you retire, or if you become disabled,
you may receive a pension based on earnings from this job. If you do, and you are also entitled to a benefit
from Social Security based on either your own work or the work of your husband or wife, or former husband or
wife, your pension may affect the amount of the Social Security benefit you receive. Your Medicare benefits,
however, will not be affected. Under the Social Security law, there are two ways your Social Security benefit
amount may be affected.
Windfall Elimination Provision
Under the Windfall Elimination Provision, your Social Security retirement or disability benefit is figured using a
modified formula when you are also entitled to a pension from a job where you did not pay Social Security tax.
As a result, you will receive a lower Social Security benefit than if you were not entitled to a pension from this
job. For example, if you are age 62 in 2013, the maximum monthly reduction in your Social Security benefit as
a result of this provision is $395.50. This amount is updated annually. This provision reduces, but does not
totally eliminate, your Social Security benefit. For additional information, please refer to Social Security
Publication, “Windfall Elimination Provision.”
Government Pension Offset Provision
Under the Government Pension Offset Provision, any Social Security spouse or widow(er) benefit to which you
become entitled will be offset if you also receive a Federal, State or local government pension based on work
where you did not pay Social Security tax. The offset reduces the amount of your Social Security spouse or
widow(er) benefit by two-thirds of the amount of your pension.
For example, if you get a monthly pension of $600 based on earnings that are not covered under Social
Security, two-thirds of that amount, $400, is used to offset your Social Security spouse or widow(er) benefit. If
you are eligible for a $500 widow(er) benefit, you will receive $100 per month from Social Security ($500 $400=$100). Even if your pension is high enough to totally offset your spouse or widow(er) Social Security
benefit, you are still eligible for Medicare at age 65. For additional information, please refer to Social Security
Publication, “Government Pension Offset.”
For More Information
Social Security publications and additional information, including information about exceptions to each
provision, are available at www.socialsecurity.gov. You may also call toll free 1-800-772-1213, or for the deaf
or hard of hearing call the TTY number 1-800-325-0778, or contact your local Social Security office.
I certify that I have received Form SSA-1945 that contains information about the possible effects of the
Windfall Elimination Provision and the Government Pension Offset Provision on my potential future
Social Security Benefits.
Signature of Employee
Form SSA-1945 (01-2013)
Destroy Prior Editions
Date
NOTICE OF EXCLUSION FROM CalPERS MEMBERSHIP
1.
SOCIAL SECURITY NUMBER
2.
CURRENT NAME
3.
NAME OF PUBLIC AGENCY
Your employer has contracted with the California Public Employees’ Retirement
System (CalPERS) to provide an employee benefit package which includes service
retirement, death, and disability benefits.
(LAST)
(FIRST)
(MIDDLE)
DEPARTMENT OR SCHOOL DISTRICT
5.
JOB OR POSITION TITLE
IF TEMPORARY, ENTER NEAREST NUMBER
OF WHOLE MONTHS THE APPOINTMENT IS
EXPECTED TO LAST.
8.
APPOINTMENT DATE
MM
DD
YYYY
4.
GCCCD
6.
TERM OF APPOINTMENT
PERMANENT
9.
7.
TEMPORARY
MONTHS
TIME BASE
FULL-TIME
INDETERMINATE
PART-TIME
IF PART TIME, ENTER THE FRACTION OF FULL TIME:
In your present position with this agency, you are excluded from CalPERS membership because:
1. Your full-time seasonal or limited term appointment is limited to 6 months or less.
2. Your part-time appointment is limited to less than an average of 20 hours per week for less than
one year.
3. Your appointment is an on-call, intermittent, emergency, substitute, or other irregular basis which
excludes you from membership until you have worked 1,000 hours (or 125 days if paid on per
diem basis) this fiscal year.
4. Your position is excluded by law or by contract agreement which excludes:
Enter contract exclusion (for Public Agencies only).
5. You are an independent contractor.
6. You are employed to render professional legal service to a city.
Exceptions: Persons holding the office of city attorney, deputy city attorney, or assistant city attorney.
7. You are employed as a student aide by a school district in a position established for students
only and you are attending school in the same district (for County Schools only).
NOTE: If you are a member of CalPERS by previous employment (either you have funds on
deposit or service credit), exclusions 1, 2, and 3 do not apply to you and you should be a member
in your present position. Be sure to notify your employer to complete a (PERS-1) Member Action
Request Form or appoint via ACES to report your employment to CalPERS.
If you believe that your employment does qualify you for CalPERS membership, ask your employer
for an explanation. If you still have doubts, you may appeal directly to CalPERS by sending a letter
to the Actuarial & Employer Services Branch, Membership Analysis & Design Unit, P.O. Box 942709,
Sacramento, CA 94229-2709, stating the reasons why you feel you should be a member.
SIGNATURE OF CERTIFYING OFFICER
TITLE
SIGNATURE OF EMPLOYEE
DATE
DATE
NOTE: Benefits provided by CalPERS are described in the “CalPERS Benefits” information booklet
available from your employer.
PERS-AESD-139 (3/08)
California Public Employees’ Retirement System
www.calpers.ca.gov
California Public Employees’ Retirement System
P.O. Box 942709 Sacramento, CA 94229-2709
888 CalPERS (or 888-225-7377)
TTY: (877) 249-7442 | Fax: (916) 795-4166
www.calpers.ca.gov
RECIPROCAL SELF-CERTIFICATION FORM
Complete the following information and return this form to your Personnel Office within 10 business days:
Employee
Name
(Last)
(First)
(Middle)
Social Security Number or CalPERS ID Number:
Check the applicable statement:
_____ I have not been a member of CalPERS or of a qualifying Public Retirement System in California.
_____ I was a member of CalPERS or a qualifying Public Retirement System in California and terminated my
membership by withdrawing my funds.
_____ I am retired from CalPERS.
_____ I am retired from another Public Retirement System in California.
_____ I am an active member of CalPERS. I have funds on deposit with CalPERS.
_____ I am an active member of another Public Retirement System in California. (Complete the box below).
Name of Most Recent Reciprocal System:
Membership Date:
Separation Date:
Name of Prior Reciprocal System:
Membership Date:
Separation Date:
Name of Prior Reciprocal System:
Membership Date:
Separation Date:
I understand that by accepting employment in a specific retirement system, I am subject to the applicable laws and regulations
of that system. I also understand that completing this form does not constitute a request to establish reciprocity. I must
complete and return the form Confirmation of Intent to Establish Reciprocity When Changing Retirement Systems to CalPERS.
I hereby certify that the foregoing information is true and correct and any information found to be incorrect may require
corrections to my account in the California Public Employees’ Retirement System including, but not limited to, my date of
membership. CalPERS may make any necessary corrections to my account to ensure I am properly enrolled and eligible to
receive the correct retirement benefits.
_________________________________________
Employee Signature
_________________
Date
TO BE COMPLETED BY EMPLOYER ONLY:
Name of CalPERS Agency:
Designee of Employer: (Print Name)
CalPERS Business Partner ID:
(Title)
Designee’s Signature:
Employees’ CalPERS Original Hire Date:
Employees’ CalPERS Membership Eligibility
Date:
(Date)
The employer must retain this form in the employee’s file for auditing purposes.
PERS-CASD-801 (6/16)
Page 3 of 4
California Public Employees’ Retirement System
P.O. Box 942709 Sacramento, CA 94229-2709
888 CalPERS (or 888-225-7377)
TTY: (877) 249-7442 | Fax: (916) 795-4166
www.calpers.ca.gov
Employer Account Management Division
Dear Member,
You are being provided with the background, explanation, and instructions for the Reciprocal
Self-Certification Form (PERS-CASD 801).
With the implementation of The Public Employees’ Pension Reform Act of 2013 (PEPRA) on
January 1, 2013, CalPERS requires that employers determine the applicable retirement benefit formula
for new employees. The Reciprocal Self-Certification form allows you to provide essential information
to your employer and will be used by your employer to enroll you into CalPERS membership. This
information will assist in identifying your retirement benefit level 1.
Reciprocity among public retirement systems is to allow members to separate from one public employer
and enter into employment with another public employer within a specific time limit without losing
valuable retirement and related benefit rights.
Within 10 business days of employment you must complete, sign, date, and submit to your employer
the Reciprocal Self-Certification form. When completing the form, reference the attached list of
qualifying Public Retirement Systems in California. If applicable, list your previous membership date(s) in
the qualifying Public Retirement System and your permanent separation date(s); OR indicate that you
are not a current or past member of a qualifying Public Retirement System.
The completion of the Reciprocal Self-Certification Form does not establish reciprocity and is not a
request to establish reciprocity. In order to request that reciprocity be established, visit the CalPERS
website, www.calpers.ca.gov and download the publication When You Change Retirement Systems. It
is the responsibility of the employee to complete and send the form, Confirmation of Intent to Establish
Reciprocity When Changing Retirement Systems to CalPERS.
Sincerely,
Membership Management Section
Enclosures: List of Qualifying Public Retirement Systems in California, Reciprocal Self-Certification form
1
A new member is defined in the Public Employees’ Retirement Law (PERL) under Government Code section 7522, the Public
Employees’ Pension Reform Act of 2013 (PEPRA), as any of the following:
•A new hire who is brought into CalPERS membership for the first time on or after January 1, 2013, who has no prior
membership in any California Public Retirement System.
•A new hire who is brought into CalPERS membership for the first time on or after January 1, 2013, who has a break in service
of greater than six months with another California Public Retirement System that is subject to Reciprocity.
•A member who first established CalPERS membership prior to January 1, 2013, who is rehired by a different CalPERS employer
after a break in service of greater than six months.
PERS-CASD-801 (6/16)
Page 1 of 4
List of Qualifying Public Retirement Systems in California
Name of County/Agency/System:
Alameda County^
City and County of San Francisco*
City of Concord*
City of Costa Mesa*
City of Fresno
City of Los Angeles
City of Oakland
City of Pasadena
City of Sacramento*
City of San Clemente*
City of San Diego
City of San Jose
Contra Costa County^
Contra Costa Water District
County of San Luis Obispo
East Bay Municipal Utility District
East Bay Regional Park District
Fresno County^
Imperial County^
Judges’ Retirement System
Kern County^
Legislators’ Retirement System
Los Angeles County Metropolitan
Transportation Authority
Qualification(s):
Safety Employees only
Miscellaneous and Safety Retirement systems
Non-Safety only
Non-Safety only
Fire and Police Only
Non-Safety only
Safety Employees only
Non-Contract Employees’ Retirement Income Plan, formerly
Southern California Rapid Transit District
Los Angeles County^
Marin County^
Mendocino County^
Merced County^
Orange County^
Sacramento County^
San Bernardino County^
San Diego County^
San Joaquin County^
San Mateo County^
Santa Barbara County^
Sonoma County^
Stanislaus County^
State Teachers’ Retirement System
Tulare County^
University of California Retirement System
Ventura County^
*=Also CalPERS-covered agency
PERS-CASD-801 (6/16)
^=1937 Act Counties
Page 2 of 4
Privacy Notice
The privacy of personal information is of the utmost importance to CalPERS.
The following information is provided to you in compliance with the Information
Practices Act of 1977 and the Federal Privacy Act of 1974.
Information Purpose
The information requested is collected pursuant
to the Government Code (sections 20000 et seq.)
and will be used for administration of Board
duties under the Retirement Law, the Social
Security Act, and the Public Employees’ Medical
and Hospital Care Act, as the case may be.
Submission of the requested information is
mandatory. Failure to comply may result in
CalPERS being unable to perform its functions
regarding your status.
Please do not include information that is
not requested.
Social Security Numbers
Social Security numbers are collected on a
mandatory and voluntary basis. If this is CalPERS’
first request for disclosure of your Social Security
number, then disclosure is mandatory. If your
Social Security number has already been provided,
disclosure is voluntary. Due to the use of Social
Security numbers by other agencies for
identification purposes, we may be unable to
verify eligibility for benefits without the number.
Social Security numbers are used for the
following purposes:
1. Enrollee identification
2. Payroll deduction/state contributions
3. Billing of contracting agencies for employee/
employer contributions
4. Reports to CalPERS and other state agencies
5. Coordination of benefits among carriers
6. Resolving member appeals, complaints,
or grievances with health plan carriers
Information Disclosure
Portions of this information may be transferred
to other state agencies (such as your employer),
physicians, and insurance carriers, but only
in strict accordance with current statutes
regarding confidentiality.
Your Rights
You have the right to review your membership
files maintained by the System. For questions
about this notice, our Privacy Policy, or your rights,
please write to the CalPERS Privacy Officer at
400 Q Street, Sacramento, CA 95811 or call us
at 888 CalPERS (or 888-225-7377).
May 2016
Grossmont-Cuyamaca Community College District
HUMAN RESOURCES
VERIFICATION OF MEMBERSHIP IN A CALIFORNIA
PUBLIC RETIREMENT SYSTEM
PLEASE TYPE OR PRINT CLEARLY IN BLACK INK.
NAME:
(Please Print)
Last
Social Security No.
First
/
M.I.
/
Birthdate:
/
/
Are you now or have you ever been a member of the California State Teachers Retirement System (STRS)? (Check One):
Yes
No (If "no" is checked, sign and date below.)
If "yes" marked above, please complete the following:
In what California county did you last serve?
Agency last served?
In what year?
Under what name?
In what position?
hourly substitute, child care.)
(If as a teacher indicate contract,
If monthly employee, what percent were you employed?
(30%)
(50%) (75%)
etc.
Are you currently a member of the STRS?
Yes
No
If you checked NO: List date you withdrew your funds:
OR
**List date you retired:
(Retired means receiving a monthly benefit payment)
**The Education Code prohibits employment in a classified position while a retiree of STRS. You may be employed in any
certificated position, kindergarten through community college; however, there is a restriction on the amount you can earn
without affecting your STRS retirement allowance. In addition, a Form I-30 must be submitted to the County Department of
Education prior to your return to employment in a certificated position.
The facts you have furnished as to your public agency retirement membership status are to enable the GrossmontCuyamaca Community College District and the San Diego County Office of Education to determine and verify your
retirement status with the retirement system.
If you are a current member of STRS and have not indicated so on this form, you are immediately liable for retirement
contributions not deducted from your earnings. Your status in STRS will determine whether ARS retirement contributions
will be deducted.
Signature
Rev. 1/2013
Date
MEMORANDUM
TO:
All District Employees
FROM:
Kim Frost
Payroll Services Supervisor
SUBJECT:
Direct Deposit
Direct Deposit is available to every employee - Full Time, Part Time, Adjunct, and hourly so sign up today!
Direct Deposit is Simple
● Signing up is easy, you will fill out the form once and it’s done!
● Making changes is simple! You are always in control!
● Multiple bank accounts- no problem!
Direct Deposit is Convenient
● Once you have signed up, no need to go to the bank to make deposits!
● Save yourself the time and hassle of standing in long lines at the bank!
● Your money is automatically deposited on payday – on time – every time!
● No hassles during emergencies- your paycheck will always be there!
● It does not matter where you are on payday! Your check is deposited for you!
● You have 24 Hour access to view your paystubs on line!
Direct Deposit is Safe
● Direct Deposit never gets lost!
● It is confidential and transfers electronically!
● Paper checks potentially can be lost or damaged and take some time to replace!
Complete the attached form and submit to payroll. Forms are also available at
http://www.gcccd.edu/formsdepot
If you have any questions, please contact Payroll Services at (619)644-7902.
GROSSMONT-CUYAMACA COMMUNITY COLLEGE DISTRICT
DIRECT DEPOSIT AUTHORIZATION
PRINT or TYPE
NAME
SOCIAL
SOCIAL
SECURITY
SECURTIY
NUMBER
NO.
WORK SITE
PHONE EXT./VOICE MAIL #
I hereby authorize the above named District and/or their agents, to initiate electronic deposits via the Automated Clearing House
(ACH) and, as necessary, debit corrections to previous deposits, to the following account(s).
I understand:
 I must submit a new authorization form if I close/change my account (name, branch, etc.); failure to do so may result in a
deposit delay.
 Direct deposit status may be temporarily suspended if wages are garnished.
 It is my responsibility to keep apprised of any deposit(s) made to my account(s) including dates and amounts of any such
deposit(s).
 This document must be received in Payroll no later than the 10th of the month in which it will be effective.
I agree to hold harmless and indemnify the District and their officers, employees and agents from any claim or demand of
whatever nature, including those based upon negligence of the District and their officers, employees, and agents for failure or
delay in making deposits and/or corrections to deposits as herein authorized.
This authorization replaces any previously made by me and is to remain in effect until changed or canceled by submission of a
new Direct Deposit Authorization form.
Signature
Date
DEPOSIT INSTRUCTIONS:
New ACH Set Up
ACH Amount Change
ACH Cancellation
Name of Financial Institution
Address of Financial Institution
Financial Institution Transit Routing No
(Check with financial institution to confirm Transit Routing Number and Account Number for accuracy.)
CHECKING:
NET CHECK
ACCOUNT NUMBER:
OR
$
(ATTACH VOIDED BLANK CHECK)
SAVINGS:
NET CHECK
ACCOUNT NUMBER:
OR
$
SIGNED ORIGINAL – RETURN TO PAYROLL OFFICE
Grossmont-Cuyamaca Community College District
EMPLOYEE’S DESIGNATION OF BENEFICIARY
Designation of person to receive and negotiate warrants after death under
Government Code Section 53245*
Employee name
Social Security Number
This is to inform you that in the event of my death I hereby designate:
Name
as the person entitled to receive and negotiate all warrants or checks that will be payable
to me from the Grossmont-Cuyamaca Community College District.
This designee is:
Spouse
Parent
Child
(other)
He/she may be identified as follows:
Date of birth
Place of birth
I understand that it is my responsibility to keep this designation current, and further, I
understand that this designation is in addition to , and separate from, the beneficiary
designation filed with the State Teachers’ Retirement System, the Public Employees’
Retirement System, the County Employees’ Retirement System, or in any other will,
codicils or like documents.
Signature
Date filed
* Government Code, Section 53245 – “Any person now or hereafter employed by a county, city, municipal
corporation, district or other public agency may file with his/her appointing power a designation of a person
who, notwithstanding any other provision of law, shall, on the death of the employee, be entitled to receive
all warrants or checks that would have been payable to the decedent had he/she survived. The employee
may change the designation from time to time. A person so designated shall claim such warrants or checks
from the appointing power. On sufficient proof of identity, the appointing power shall deliver the warrants or
checks to the claimant. A person who received a warrant or check pursuant to this section is entitled to
negotiate it as if he/she were the payee.”
Original – Human Resources
Copy - Employee
Grossmont-Cuyamaca Community College District
RECEIPT OF WORKERS’ COMPENSATION INFORMATION
By signing below, I acknowledge that I have received the WellComp MPN – Informational
Pamphlet and the Facts about Workers’ Compensation and Pre-designation of
Personal Physician Form, documents that contain important information regarding
workers’ compensation.
Date
1/2013
Rev. 10/2013
Print Name
Signature
ID#
The physician is not required to sign this form, however, if the physician or
designated employee of the physician or medical group does not sign, other
documentation of the physician’s agreement to be pre-designated will be
required pursuant to Title 8, California Code of Regulations, section
9780.1(a)(3). (Optional DWC Form 9783 July 1, 2014)
(Physician or Designated Employee of the Physician)
Signature:________________________________Date____________
Physician: I agree to this Pre-designation:
Employee #_________________________ Date_________________
Employee Signature__________________________________________
Note to Employee: Unless you agree in writing, neither your employer or
York may contact your personal physician to confirm a pre-designation. If
your physician does not sign this form, other documentation that they agreed
to be pre-designated prior to the injury will be required. If you agree, your
employer or York may contact your personal physician to confirm this predesignation, sign and date below:
Employee Signature:_______________________Date__________
________________________________________________________
Name of Insurance Company, Plan, or Fund providing health coverage for
nonoccupational injuries or illnesses: _____________________________
Employee’s Address:_________________________________________
Employee Name (please print): _________________________________
_______________________________________________________
(telephone number)
_______________________________________________________
(street address, city, state, zip)
If I have a work-related injury or illness, I choose to be treated by:
_______________________________________________________
(Name of doctor) (M.D., D.O., or medical group)
Employer ________________________________________________
Notice Of Pre-designation Of Personal Physician
Employee: Complete this section
You may use this form, a form provided by your employer or provide all the
information in writing to notify your employer if you wish to have your personal medical doctor or a doctor osteopathic medicine treat you for a workrelated injury/illness and the above requirements are met.
In the event you sustain an injury or illness related to your employment, you
may be treated for such injury/illness by your personal medical doctor (M.D)
or doctor of osteopathic medicine (D.O.) or medical group if: You have health
care insurance for injuries/illness that are not work related, the doctor is your
regular physician, who shall be either a physician who has limited his or her
practice of medicine to general practice or who is a board-certified or boardeligible internist, pediatrician, obstetrician-gynecologist, or family practitioner,
and has previously directed your medical treatment, and retains your medical
records; your “personal physician” may be a medical group if it is a single
corporation or partnership composed of licensed doctors of medicine or
osteopathy, which operates an integrated multispecialty medical group providing comprehensive medical services predominantly for non-occupational illnesses and injuries; prior to the injury your doctor agrees to treat you for
work injuries or illnesses; prior to the injury you provided your employer the
following in writing: (1) notice that you want your personal doctor to treat
you for a work-related injury/illness, and (2) your personal doctor’s name and
business address.
Pre-designation Of Personal Physician
Call 9-1-1 for help immediately if emergency medical care is
needed.
Immediately report injuries to your supervisor or employer
representative at __Company Nurse 888/770-0929 OR Benefits


© 7/1/14 YORK. All rights reserved
Employer MUST complete this information
__________________________________________________________
_______________________________________________________________
Information & Assistance Office:___7575 Metropolitan Drive Suite 202, _
_
__San Diego, CA 92108-4424_____619/767-2082______________________
619/644-7643________________________
Quickly seek first aid.

WHEN A WORK INJURY OCCURS…
Date:________________________________________________
Title 8, California Code of Regulations, section 9783.1
(Optional DWC Form 9783.1 Effective date July 1, 2014)
Employee’s Signature:___________________________________
___________________________________________________
Employee’s Address:____________________________________
Employee Name (Please Print):_____________________________
____________________________________________________
(telephone number)
__________________________________________________
(street address, city, state, zip code)
__________________________________________ ________
Name of chiropractor or acupuncturist (D.C., L.AC.)
If your employer or your employer’s insurer does not have a Medical Provider
Network (MPN), you may be able to change your treating physician to your
personal chiropractor (D.C.) or acupuncturist (L.AC.) following a work-related
injury/illness. In order to be eligible to make this change, you must give your
employer the name and business address of a personal D.C. or L.AC. in writing
prior to the injury/illness. York generally has the right to select your treating
physician within the first 30 days after your employer knows of your injury/illness. After your employer or York has initiated your treatment with
another physician during this period, you may then, upon request, have your
treatment transferred to your personal D.C. or L.AC. You may use this form
to notify your employer of your personal D.C. or L.AC., or your employer may
have their own form. The D.C. or L.AC. must be your regular D.C. or L.AC.
who has directed your treatment and retains your chiropractic records and
history. If your employer has an MPN, you may only switch to a D.C. or L.AC.
within the MPN. A chiropractor cannot be your treating physician after 24
visits. If you still require medical treatment thereafter, you will have to select a
physician who is not a chiropractor. This prohibition shall not apply to visits for
postsurgical physical medicine visits prescribed by the surgeon, or physician
designated by the surgeon, under the postsurgical component of the Division of
Workers’ Compensation’s Medical Treatment Utilization Schedule.
 Or Personal Acupuncturist
Notice Of Personal Chiropractic
Approved by Division of Workers’ Compensation
York Risk Services Group, Inc.
P.O. Box 619079
Roseville, CA 95661
Phone (866) 221-2402
Fax (866) 548-2637
The Facts About
Workers’
Compensation
Medical Care: Medical treatment that is reasonably required to cure or relieve
the injured worker from the effects of the injury/illness. There is no deductible or
co-payment. These medical benefits may include lab tests, physical therapy, hospital services, medication and treatment by a doctor.
What are the benefits? You may be entitled to various kinds of benefits under
California workers’ compensation law including:
Within one working day, upon knowledge or notice from any source of a work
injury/illness greater than first-aid, provide the employee with a Claim Form
(DWC-1) and authorize medical treatment and report the claim to York Risk
Services Group.
Duty of the Employer: Provide this form to every employee at the time of hire
or by the end of their first pay period.
Your claim benefits do not start until your employer knows about your injury, so
report and file the DWC-1 as quickly as possible. California law requires your
employer to authorize medical treatment within one working day of receipt of
your Claim Form. Employers are liable for up to $10,000 in treatment pending a
decision by York for a claim to be accepted or rejected. Waiting to report may
delay workers’ compensation benefits. You may not receive benefits if you fail to
file a claim within one year of the date of injury, the date you know the injury was
work related, or the date benefits were last provided.
Duty Of The Employee. Immediately notify your employer or York so you can
get the medical help that you need without delay. If your injury is greater than a
first-aid injury, your supervisor will give you a Claim Form (Form DWC-1) for
you to describe where, when and how it happened. To submit a claim, fill out the
“Employee” section of the DWC-1. Keep one copy of this form and give the
remaining pages to your supervisor. Your employer will fill out the “Employer”
section and return a signed and dated copy of the form to you. Your employer
will keep a copy of this form and forward another to York. York is in charge of
handling your claim and informing you about your eligibility for benefits.
What Does Workers’ Compensation Cover? If you have an injury/illness due to
your job, it is covered. The cause can be a single event, like a fall or it can be due
to repeated exposures, such as hearing loss due to constant loud noise. Injuries
ranging from first-aid to serious accidents are covered. Even injuries related to a
workplace crime, such as psychological or physical injuries, are covered under
workers’ compensation. Some injuries that result from voluntary activity, such as
off duty social or athletic activities may not be covered. Check with your employer or York if you have questions. Coverage begins the moment you start your
job. There is no probationary period or wage rate.
Am I Covered? Nearly every person employed in California is protected by
workers’ compensation, however there are a few exceptions. People that are selfemployed or volunteer workers may not be covered. Similar laws cover federal
and maritime workers. York Risk Services Group (York) is your employer’s
claims administrator. Your employer or York can answer any questions you might
have about coverage.
What is workers’ compensation? Its purpose is to insure that an employee who
is found to sustain an industrial injury or illness will be provided with benefits to
medically cure or relieve them from the effects of the injury/illness, provide temporary compensation when they are medically unable to perform any occupational
function, compensation for any residual handicap and/or impairment of bodily
function, benefits for dependents if an employee dies as a result of an injury/illness, protection from discrimination by his/her employer because of the
injury/illness.
Permanent Disability: If your doctor says your injury will always leave you with
some permanent impairment of bodily function(s), you may receive permanent
disability (PD) payments. The amount depends on the doctor’s report, how much
of the PD was directly caused by your work, and factors such as your age,
occupation, type of injury, and date of injury. State law determines minimum and
maximum amounts, and they vary by injury date. If you are entitled to PD, York
will send you a letter explaining how the benefit was calculated. If the injury
Temporary Disability Benefits: If you are not medically able to work for more
than three days due to your work-related injury, counting weekends, you have a
right to temporary disability (TD) payments to assist substituting your lost wages.
After two weeks from reporting the injury, you will receive a check. If your
employer has a salary continuation plan, your benefit may be included in your
regular paycheck. TD is payable every 14 days until the doctor states you can
return to work (Payments won’t be made for the first three days, though, unless
you’re hospitalized as an inpatient or unable to work more than 14 days). The
amount of the payments will be two-thirds of your average wage, subject to
minimums and maximums set by the state legislature. Although the TD payment
will not be the full amount of your regular paycheck, there are no deductions and
the payments are tax-free. For injuries occurring on or after January 1, 2008, TD
payments are limited to 104 compensable weeks within five years of date of
injury. For a few long-term injuries such as chronic lung disease or severe burns,
TD payments can last up to 240 weeks within five years from the date of injury.
If you reach the maximum TD payment period before you can return to work or
before your condition becomes permanent and stationary. See the “Other Benefits” section of this pamphlet for additional in information. A timely filing with
Employment Development Department may result in additional State Disability
benefits when TD benefits are delayed, denied, or terminated.
If you give the name of your personal chiropractor or acupuncturist, different
rules apply, and you may need to see an employer-selected physician first.
You can be treated by your personal physician or medical group immediately if
you have health care insurance for injuries or illness that are not work related,
and your physician agrees in advance to treat you for any work injuries/illnesses
and has previously directed your treatment and retains your medical records and
agrees, prior to your injury/illness, to treat you for workplace injuries/illnesses
and you gave your employer your physician’s name and address in writing before
the injury. You may use the form inside of this pamphlet or your employer may
have a form for you to use.
The physician with overall responsibility for treating your injury/illness is your
primary treating physician (PTP). The PTP decides what kind of medical care you
need and if you have work restrictions. If necessary, the PTP will review your job
description with you and your employer to define any limitation or restrictions
that you may have. This doctor also is responsible for coordinating care between
other medical providers and will write reports about any permanent impairment
of bodily function(s) or the need for future medical care. Generally, your employer selects the PTP you will see for the first 30 days, but if you want to change
doctors for any reason, ask your employer or York. They’re as interested as you
are in your prompt recovery and return to work and will select a different doctor for you. If your employer has a Medical Provider Network (MPN) you will be
directed to treat with a physician within the MPN and different rules apply regarding changing your physician.
State law limits certain medical services as of January 1, 2004. You should never
receive a medical bill. If additional treatment is necessary, York will coordinate
medical care that meets applicable treatment guidelines for the injury. The doctor
may be a specialist for your specific type of injury, and he or she will be familiar
with workers’ compensation requirements and will report promptly to York so
your benefits can be paid.
Anyone who makes or causes to be made any knowingly false or fraudulent material statement for the purpose of obtaining or denying workers’
compensation benefits or payments is guilty of a felony. Fines can be up
to $150,000 and imprisonment up to five years.
WORKERS’ COMPENSATION FRAUD IS A FELONY
If You Still Have Questions…ask your supervisor or employer representative. Or contact York at the number indicated on workers’ compensation
posters at work and on this brochure. You can also contact the State Division
of Workers’ Compensation (DWC) and speak with an Information and Assistance Officer. These officers are available to review problems, answer questions and provide additional written information about workers’ compensation at no charge. The local office is listed below and posted at your workplace. You can also call 800-736-7401 or visit the DWC website at:
http://www.dir.ca.gov/dwc.
You may be eligible to access the return-to-work fund, for the purposes of
making supplemental payments to injured worker’s whose PD benefits are
disproportionately low in comparison to their earnings loss. If you have questions or think you qualify, contact the Information & Assistance office listed in
this pamphlet or visit the DIR website at: www.dir.ca.gov.
Other Benefits: Sometimes people confuse workers’ compensation with
State Disability Insurance (SDI). Workers’ compensation covers on-the-job
injuries/ illnesses and is paid for by your employer or their insurance. On the
other hand, SDI covers off-the-job injuries or sicknesses, and is paid for by
deductions from your paycheck. If you are not getting workers’ compensation
benefits, you may be able to get State Disability benefits. Contact the local
office of the State Employment Development Department listed in the government pages of your phone book for more information.
Discrimination: It a violation of Labor Code Section 132(a) and illegal for
your employer to punish or fire you for having a workplace injury/illness, for
filing a claim or for testifying in another person’s workers’ compensation case.
If your employer is found guilty of discrimination, you would be entitled to
increased benefits, reinstatement and reimbursement for lost wages and
benefits.
Death Benefits: If the injury/illness causes death, payments may be made to
your dependents. State law sets these benefits and the total benefit depends
on the number of dependents. The payments are made at the same rate as TD
payments. In addition, workers’ compensation provides a burial allowance.
Supplemental Job Displacement Benefit (SJDB): If you have a permanent
whole person impairment, the eligibility for SJDB begins when your employer
does not offer regular work, permanent, modified, or alternative work within
60 days of the receipt of a doctor’s Medical Maximum Improvement (MMI)
report. This is a nontransferable voucher for education-related retraining
and/or skill development at state-approved schools, tools, licensing, certification fees and other resources as possible benefits. If you qualify for the supplemental job displacement benefit, York will provide a voucher up to a maximum
of $6,000.
causes PD, the first payment of PD benefits is made within 14 days after the
last payment of TD, unless your employer has offered you a position that pays
at least 85% of your date of injury wages or if you are returned to a position
that pays you 100% of the wages and, compensation paid to you on the date of
injury, the PD would be paid after an Award issues.
If the second opinion, third opinion or IMR agrees with your
treating doctor, you will need to continue to receive medical
treatment with a network physician. If the IMR does not agree
with your treating network physician, you will be allowed to
receive that medical treatment from a provider either inside or
outside of the WellComp Network.
If you disagree with the diagnosis or treatment plan
determined by the third opinion physician, you may file the
completed Independent Medical Review Application form
with the Administrative Director of the Division of Workers’
Compensation. You may contact your claims examiner or the
WellComp Patient Services Department for information about
the Independent Medical Review process and the form to request
an Independent Medical Review.
Review (IMR)
n Obtaining an Independent Medical
ü Notify your claims examiner who will provide you
with a regional area listing of physicians and/or
specialists within the WellComp Network who have
the recognized expertise to evaluate or treat your
injury or condition.
ü Select a physician or specialist from the list.
ü Within 60 days of receiving the list, schedule
an appointment with your selected physician or
specialist from the list provided by your claims
examiner. Should you fail to schedule an appointment
within 60 days, your right to seek another opinion
will be waived.
ü Inform your claims examiner of your selection and
the appointment date so that we can ensure your
medical records can be forwarded in advance of
your appointment date. You may also request a copy
of your medical records.
ü You will be provided information and a request
form regarding the Independent Medical Review
(IMR) process at the time you select a third opinion
physician. Information about the IMR process can
be found in the MPN Employee Handbook.
If you disagree with the diagnosis or treatment plan
determined by your treating physician or your second
opinion physician, and would like a second or third
opinion, you must take the following steps:
n Obtaining Second and Third Opinions
If you disagree with your doctor or do not like your
doctor for any reason, you may always choose another
doctor in the MPN.
Second Opinion, Third
Opinion and Independent
Medical Review Process:
Emergency services including outpatient
and out-of area emergency care
Examples of ancillary care providers include:
diagnostic lab or x-ray services, physical
medicine, occupational therapy, medical and
surgical equipment, counseling, nursing, medically
appropriate home care, medication.
Ancillary Care services
Examples of inpatient hospital and outpatient
surgery center providers include: acute hospital
services, general nursing care, operating room and
related facilities, intensive care unit and services,
diagnostic lab or x-ray services, necessary
therapies.
Inpatient Hospital and Outpatient
Surgery Center services
Examples of primary treating or specialty
providers include: general medical practitioners,
chiropractors, dentists, orthopedists, surgeons,
psychologists, internists, psychiatrists,
cardiologists, neurologists.
Primary treating and specialty services
including consultations and referrals
The following is a summary of Workers’
Compensation medical services that are available to
employees covered by the WellComp Network.
Covered Medical Services:
WellComp has providers throughout California. If a
situation arises which takes you out of the coverage
area, such as temporary work, travel for work, or living
temporarily or permanently outside the MPN geographic
service area, please contact the WellComp Patient
Services Department, your claims examiner, or your
primary treating provider, and they will provide you with
a selection of at least 3 approved out-of-network providers
from whom you can obtain treatment or get second and
third opinions from the referred selection of physicians.
n Treatment Outside of the Geographic Area
Rev 6/10
Este folleto esta disponible en el Español. Para
una copia gratis, favor de llamar a WellComp.
This pamphlet is available in Spanish. For a
free copy, please contact WellComp.
Patient Services Department
P.O. Box 59914
Riverside, CA 92517
Toll Free (800) 544-8150
fax: (888) 620-6921 or
e-mail: [email protected]
WellComp
To access more information, regarding the
WellComp Network, go to www.WellComp.
net/download/. You can download the Employee
Handbook, Transfer of Care Policy or the
Continuity of Care Policy. To receive a hard copy
of this information please contact WellComp.
MPN Liaison: Gale Chmidling, MPN Manager
(800) 544-8150
WellComp Information
To access a directory of medical providers in the
WellComp Network, go to www.WellComp.net
where you can search by medical specialty, zip
code, physician or provider group. To receive
a hard copy of the regional area listing or the
complete WellComp directory, please contact
WellComp (your employer’s designated
medical provider network administrator):
WellComp Provider Directory
Medical Treatment for Workers’ Compensation
MPN Liaison, Gale Chmidling, MPN Manager
P.O. Box 59914 Riverside, CA 92517
Toll Free (800) 544-8150
fax: (888) 620-6921 or
e-mail: [email protected]
Employee Name: __________________
Employer Name: __________________
Date of Injury: __________________
ü
Find out if you are covered
ü Access medical care
ü Learn about continuity of care
ü Choose your own physician
ü Transfer into the WellComp Network
ü Contact WellComp
This pamphlet contains important
information on accessing the WellComp
Medical Provider Network:
For treatment authorization
contact WellComp Provider Services.
For WellComp Patient Services:
Toll Free (800) 544-8150
fax: (888) 620-6921
For emergency care or necessary treatment while the employee is outside of the
state of California, please notify WellComp to facilitate authorization, billing
and payment, as well as transfer of care.
This employee is covered by the WellComp Network for workers’ compensation
medical care. Possession or use of this card does not guarantee eligibility for benefits.
Treatment must be furnished or referred by a WellComp medical provider with the
exception of emergency care or necessary treatment while the employee is out of the
state of California. All treatment requires pre-authorization except for emergency care.
#
This card is not required to receive medical services.
In the event that you have an injury or illness,
please complete the front of this card and carry
it with you to present to your medical service
providers for access to care.
Your employer has elected to provide you
with the choice of a broad scope of medical
services for work-related injuries and illnesses
by implementing a Medical Provider Network
(MPN), called WellComp. WellComp delivers
quality medical care through your choice
of a provider who is part of an exclusive
network of healthcare providers, each of
whom possess a deep understanding of the
California workers’ compensation system and
the impact their decisions have on you. Your
employer has received the approval from the
State of California to cover your workers’
compensation medical care needs through the
WellComp Network. You are automatically
covered by the WellComp Network if your
date of injury or illness is on or after your
employer’s implementation date and if you
have not properly pre-designated a personal
physician prior to your injury or illness.
Welcome to WellComp
If you are having difficulty scheduling an appointment
with your initial provider or subsequent provider, please
contact your WellComp Patient Services Department.
n Scheduling Appointments
If you still require treatment after your initial evaluation with your
employer’s designated provider, you may access the WellComp
Directory and select an appropriate physician of your choice who
can provide the necessary treatment for your condition or illness.
For assistance determining physician options, please contact the
WellComp Patient Services Department or discuss your options
with your initial care provider.
n Choosing a Treating Physician
Your primary treating provider in the WellComp Network
will make all of the necessary arrangements and referrals for
specialists, inpatient hospital, outpatient surgery center services,
and ancillary care services.
n Hospital and Specialty Care
In an emergency, defined as a medical condition starting with
the sudden onset of severe symptoms that without immediate
medical attention could place your health in serious jeopardy, go
to the nearest healthcare provider regardless of whether they are a
WellComp participant. If your injury is work-related, advise your
emergency care provider to contact WellComp to arrange for a
transfer of your care to a WellComp provider at the medically
appropriate time.
n Emergency Care
If you still need treatment following your initial evaluation,
you may be treated by a physician of your choice, or the initial
physician may refer you to a medically and geographically
appropriate specialist within the network who can provide the
appropriate treatment for your injury or condition. Your employer
is required to provide you with at least three physicians of each
specialty expected to treat common injuries experienced by
injured employees based on your occupation or industry. These
physicians will be available within 30 minutes or 15 miles of
your workplace or residence and specialists will be available
within 60 minutes or 30 miles of your residence or workplace.
For a directory of providers, please visit www.WellComp.net or
call WellComp Patient Services.
n Subsequent Care
In case of an emergency, you should call 911 or go to the
closest emergency room.
In the event that you experience a work-related injury or
illness, immediately notify your supervisor and obtain medical
authorization from your employer to designate an initial care
provider within the network. If you are unable to reach your
supervisor or employer, please contact the patient services
department at WellComp. For non-emergency services, the MPN
must ensure that you are provided an appointment for initial
treatment within 3 business days of your employer’s or MPN
receipt of request for treatment within the MPN.
n Initial Care
If the contract with your doctor was terminated or not renewed
by WellComp for reasons relating to medical disciplinary cause
or reason, fraud or criminal activity, you will not be allowed to
complete treatment with that doctor. For a complete copy of the
Continuity of Care policy, please visit www.WellComp.net or
call WellComp Patient Services.
If any of the above conditions exist, WellComp may require your
doctor to agree in writing to the same terms he or she agreed to when
he or she was a provider in the WellComp Network. If the doctor
does not, he or she may not be able to continue to treat you.
• (Acute) A medical condition that includes a sudden onset of symptoms that
require prompt care and has a duration of less than 90 days.
• (Serious or Chronic) Your injury or illness is one that is serious and continues
without full cure or worsens and requires ongoing treatment over 90 days.
You may be allowed to be treated by your current treating doctor for up to one
year, until a safe transfer of care can be made.
• (Terminal) You have an incurable illness or irreversible condition that is likely
to cause death within one year or less.
• (Pending Surgery) You already have a surgery or other procedure that has
been authorized by your employer or insurer that will occur within 180 days of
the MPN contract termination date.
If you are being treated for a work-related injury in the WellComp
Network and your doctor no longer has a contract with WellComp,
your doctor may be allowed to continue to treat you if your injury
or illness meets one of the following conditions:
What if I am being treated by a WellComp doctor and the
doctor leaves WellComp?
Your employer has a written “Continuity of Care” Policy that
may allow you to continue treatment with your doctor if your
doctor is no longer actively participating in WellComp.
n Continuity of Care
If your primary treating provider makes a referral to a type of specialist
not included in the network, you may select a specialist from outside
the network.
For non-emergency specialist services, the MPN must ensure that you
are provided an appointment within 20 business days of your employer’s
or MPN receipt of a referral to a specialist within the MPN.
1. Your primary treating provider in the WellComp Network can make all of
the necessary arrangements for referrals to a specialist. This referral will
be made within the network or outside of the network if needed.
2. You may select an appropriate specialist by accessing the WellComp
Directory.
3. You may contact WellComp Patient Services who can help coordinate
necessary arrangements.
As long as you continue to require medical treatment for your
injury or illness, there are alternatives for obtaining a referral to
a specialist:
n Obtaining a Specialist Referral
If you find it necessary to change your treating physician and it is
determined that you require ongoing medical care for your injury or
illness, you may select a new physician from the WellComp Directory
and schedule an appointment. Once your appointment is scheduled,
immediately contact WellComp Patient Services who will then
coordinate the transfer of your medical records to your new provider.
n Changing Primary Treating Physician
If your treating doctor believes that your condition does meet
one of those listed above, you may continue to treat with him
or her until the dispute is resolved. For a complete copy of the
Transfer of Care policy, please visit www.WellComp.net or call
WellComp Patient Services.
If your treating doctor agrees that your condition does not meet
one of those listed above, the transfer of care will go forward
while you continue to disagree with the decision.
If either WellComp or you do not agree with your treating
doctor’s report, this dispute will be resolved according to Labor
Code Section 4062. You must notify WellComp Patient Services
Department, if you disagree with this report.
If WellComp is going to transfer your care and you disagree, you
may ask your treating doctor for a report that addresses whether
you are in one of the categories listed above. Your treating
physician shall provide a report to you within twenty calendar
days of the request. If the treating physician fails to issue the
report, then you will be required to select a new provider from
within the MPN.
n Care Transfer Disputes
• (Acute) The treatment for your injury or illness will be completed in less than
90 days.
• (Serious or Chronic) Your injury or illness is one that is serious and continues
without full cure or worsens over 90 days. You may be allowed to be treated
by your current treating doctor for up to one year from the date of receipt of
the notification that you have a serious chronic condition.
• (Terminal) You have an incurable illness or irreversible condition that is likely
to cause death within one year or less. Treatment will be provided for the
duration of the terminal illness.
• (Pending Surgery) You already have a surgery or other procedure that has
been authorized by your employer or insurer that will occur within 180 days of
the MPN effective date.
You will not be transferred to a doctor in WellComp if your injury or
illness meets any of the following conditions:
If your current treating physician is not a participating physician within
WellComp, you are not covered under the MPN and your physician
can make referrals to providers within or outside the MPN.
If your current treating doctor is a member of WellComp, then
you may continue to treat with this doctor and your treatment
will be under WellComp. Your current doctor may be allowed to
become a member of WellComp.
Your employer has a “Transfer of Care” policy which describes
what will happen if you are currently treating for a work-related
injury with a physician who is not a member of the WellComp
Network.
What if you are already being treated for a work-related
injury before the WellComp Network begins?
n Transfer of Ongoing Care
Access to Medical Care
-14-
ACKNOWLEDGEMENT OF RECEIPT
SAFETY TIPS AND RIGHT TO KNOW
Employee:
I, the undersigned, hereby certify that I have received and read the booklet, Safety Tips and Right to
Know. I further understand that willfully neglecting the safety measures could lead to discipline.
Please check appropriate box:
Full-Time Academic
Full-Time Classified
Part-Time Academic (includes part-time instructors, part-time counselors, librarians, or hourly academic substitutes)
Part-Time Classified (i.e., work study, student worker, short term, classified substitutes and hire-a-youth)
Department
Grossmont
Cuyamaca
District
Print Name
Last
First
MI
ID #
Signed
Dated
RETURN WITH HIRE PACKET TO THE GROSSMONT-CUYAMACA COMMUNITY
COLLEGE DISTRICT HUMAN RESOURCES
Human Resources Use Only
Transposed to Insight; use LicnCert code “SK”
02-0153-014W (09/04/bg)
By: __________ (initials) Date:_____________
3121 Plan Overview
(For Employee Use)
Who Is Offering The San Diego County Schools FBC 3121 Plan?
It is a partnership between San Diego County Board of Education Fringe Benefits Consortium, Life Insurance of the
Southwest (LSW), and National Benefit Services, Inc.
What Is The San Diego County Schools FBC 3121 Plan?
The 3121 Plan is a savings program for employees who are not eligible to participate in the State Employees’ Retirement
System.
How the 3121 Plan Came About
The Omnibus Budget Reconciliation Act of 1990 (OBRA) Amended the Internal Revenue Code and the Social Security
Act to include employees of state and local governments. The Act authorized the Secretary of the Treasury to adopt
regulations and provide guidance to the Internal Revenue Service and Social Security Administration. The Act amended
Internal Revenue Code Section 3121, under which Social Security participation became mandatory for all employers.
However, the Internal Revenue Code Section 3121 says that part-time, temporary, and seasonal (PTS) employees are
exempt from the 3121 tax if they are provided a “comparable retirement system”. In response, the 3121 Plan was created to
meet those requirements. This alternative provides a retirement plan for PTS employees who are not normally covered like
full time employees. The adoption of the 3121 Plan provides an economic benefit for the employer and their PTS
employees.
How The 3121 Plan Benefits The Employee
Social Security Costs
Without the 3121 Plan, the employee must pay 6.2% after-tax into Social Security and the employer must also contribute
6.2% of pay.
Employee Account
With the 3121 Plan, the employee may be required to contribute up to 7.5% pre-tax (instead of 6.2% after tax) of gross
compensation. The district may choose to contribute a portion of the required 7.5%.
Employee Benefits
 Mandatory pre-tax contributions, which may reduce the amount of your current income which
is subject to tax
 Possible District contributions to your account
 Tax-deferred savings, which means you pay no taxes on your investment earnings as long as
they remain in the Plan
 Interest earnings are credited to employee
 24/7 access to account info by accessing the website www.fbcretire.com/3121
 Annual statement mailed to residence
 No front end sales charge
 No back end surrender charge
 Money available to withdraw on termination
 If you change jobs, you may be eligible to retain your funds in the plan until you request a
withdrawal
 No 10% premature distribution tax
 Rollover/Transfer options
 100% vested in account
Question and Answer Overview
(Employee Use)
1. What is the 3121 Plan?
The 3121 Plan is a savings program for employees who are not eligible to participate in the
State Employees’ Retirement System.
2. Why is this option different than paying Social Security?
You are assured that your contributions and earnings are available to you when you terminate
or retire and are no longer working for the school district.
3. Will my eligibility to receive Social Security benefits be affected by my participation in this Plan?
Your Social Security benefit and your eligibility to receive that benefit may be affected by your
participation in this plan. We suggest that you contact the Social Security Administration
Department with any questions regarding your benefit.
4. Who is eligible to participate in this Plan?
If your district has adopted this Plan, all part-time, temporary, or seasonal (PTS) employees are
automatically enrolled and contributing to the plan.
5. Can I choose not to participate in the Plan?
No. If your district adopts the plan, you must participate in this plan.
6. How much do I contribute?
You may be required to contribute up to 7.5% pre-tax (instead of 6.2% after tax) of gross
compensation. The district may choose to contribute a portion of the required 7.5%.
7. How will my money be invested?
Your account will be invested in a fixed account with Life Insurance of the Southwest (LSW).
The objective of this fund is to preserve principal while providing moderate growth.
8. Will I receive a statement of my account balance?
Yes, you will receive a semiannual statement from Life Insurance of the Southwest.
9. How do I change my name, address, or beneficiary?
a. The name reflected on the Payroll System is the “social security name”. In order to change your
name in the Payroll System, the Retirement department requires a copy of the social security
card (reflecting your new name). You are responsible for providing the Retirement department
with the social security card reflecting your name change.
b. To change your address, you must notify your district Payroll department. The district Payroll
department will then be responsible for notifying San Diego County Office of Education FBC
Deferred Compensation Plan of any address changes.
c. If you are no longer employed by the school district, you must contact the San Diego County
Office of Education at the address listed below:
San Diego County Office of Education
Attention Dan Puplava
6401 Linda Vista Road Room 505
San Diego, CA 92111-7399
(858) 292-3815
d. To change your beneficiary, you need to complete a new beneficiary form available at the San
Diego County Office of Education. You may also obtain this form from your FBC representative.
This form can be mailed directly to National Benefit Services, Inc. (Third Party Administrator) at
the address indicated on the bottom of the Beneficiary form.
10. Am I required to complete the beneficiary designation form?
No. If you are married, your beneficiary under the plan will automatically be your
spouse. Otherwise, your beneficiary is automatically your estate.
11. What happens if I change jobs?
a. If your new job is in the same district, no changes are required.
b. If your new job is in another district that also participates in this program, you will be assigned a
new account under that district. You will be eligible to take a distribution from your old account
with your former district.
c. If your new job is in a district that does not offer this program, you will not be able to continue
deposits into the plan with your former district, and are eligible for a distribution.
12. What happens if I accept additional employment at a second district that does participate in the 3121
Plan?
You must participate in each district’s 3121 Plan and will be subject to each district’s mandatory
contributions.
13. What happens if I become a member of PERS or STRS?
You will no longer be eligible to participate in the 3121 Plan. Contact the FBC office to
determine options of transfer funds to PERS or STRS, or the eligibility of obtaining your funds.
In accordance with the written policy upon becoming a permanent employee you are eligible for
withdraw two (2) years after becoming a PERS or STRS member.
14. What happens when I leave service?
You will no longer be eligible to participate in the 3121 Plan
15. What are my options when I am no longer eligible to participate?
a. You may retain your funds in the 3121 Plan.
b. You may transfer your 3121 account balance to PERS or STRS at any time if it is used to
purchase state retirement credits.
c. You may take an in-service withdrawal from your account balance if you have not made any
contributions to the 3121 plan for 2 years and have a balance that is less than $5,000.
16. When am I eligible for a distribution?
a. If you terminate from the school district or move to another district that does not participate in
this program, you can apply for a distribution.
b. If you retire, and are no longer working for your employer, you are eligible for a distribution.
c. You may take an in-service withdrawal from your account balance once if you have not made
any contributions to the 3121 plan for 2 years and have a balance that is less than $5,000.
d. You may transfer your 3121 account balance to PERS or STRS at any time if it is used to
purchase state retirement credits.
17. How do I apply for a distribution?
a. You may obtain a “Distribution Form” from your district or the FBC office (858) 292-3815
b. You may also access the “Distribution Form” at www.fbcretire.com/3121 .
18. How long will it take to process my distribution?
You qualify for a distribution three months after your district has established a termination date.
19. Am I eligible to participate in the Plan once I have taken a distribution?
You may not participate in the Plan for 12 months following the date of your distribution.
20. Are there any transaction fees?
A $10.00 fee will be deducted from your account for any distribution, transfer, or rollover.
21. Are distributions from the 3121 Plan subject to the premature distribution penalty tax?
No, they are not subject to the 10% excise tax on distributions to individuals who have not
attained 59 1/2.
22. Am I eligible to transfer my account to another 457(b) Plan offered by my employer?
Yes. You may transfer your funds to another 457(b) Plan offered by your employer at any time.
23. How do I apply for a transfer?
a. You may obtain a “Transfer Form’ from your district.
b. You may also access the “Transfer Form” at www.fbcretire.com/3121 .
If you have questions:
Participant Call Center: 1-800-274-0503 press 5
Fax your questions to: (858) 569-7851
E mail questions to:
www.fbcrtire.com/3121
Beneficiary Designation Form
1
Participant Information
Participant Name
Social Security Number
Participant Mailing Address City, State, Zip Code
Phone Number
Married
Single
Participant Email Address
Date of Birth
Marital Status
School District or Former School District
Broker/Financial Advisor Name
Broker/Financial Advisor Phone Number
2
Beneficiary Designation Information
Option 1
I am NOT MARRIED and designate the following person(s) to receive any death benefits.
I understand that if I marry, this designation becomes void one year after my marriage.
Primary/Secondary
Option 2
Name
SSN
Relationship
%
I am MARRIED and designate my spouse named below to receive ALL death benefits from the Plan.
Spouse Name
Spouse SSN
Spouse Address
If my spouse is not living, pay death benefits to:
Primary/Secondary
Option 3
Name
Relationship
%
Relationship
%
I am MARRIED and designate the following person(s) to receive death benefits from the Plan
(SPOUSAL CONSENT REQUIRED -- see below).
Primary/Secondary
3
SSN
Spousal Consent
Name
SSN
(Required for Option 3)
I consent to this designation which eliminates all or part of the benefits otherwise payable to me from the Plan if my spouse dies.
Spouse’s Signature
4
Date
Notary Public or Plan Administrator
Date
Participant Approval
Participant Signature (Required)
Date
Form 403-208FBC (08/2015)
8523 S Redwood Rd, West Jordan, UT 84088 ● (800) 274 0503 ext 5 ● Fax (800) 597-8206 ● www.FBCretire.com
GROSSMONT-CUYAMACA COMMUNTIY COLLEGE DISTRICT
Date:
June 13, 2012
To:
All District Employees
From:
Vice Chancellor, Human Resources
Subject:
Drug Free Environment and Drug Prevention Program
(Reference: Drug Free Schools and Communities Act, 20 U.S.C.)
Section 1145g and 34 C.F.R. Section 86.1 et seq.
Drug Free Workplace Act of 1988, 41 U.S.C. Section 702
It is the policy of Grossmont-Cuyamaca Community College District to maintain a work place environment free from
the illegal use, possession, or distribution of controlled substances. The Governing Board originally adopted a policy
relevant to this issue on May 9, 1989. The current Governing Board Policy (BP 3550), Drug Free Environment and
Drug Prevention Program, issued June 13, 2012, is stated below:
The Grossmont-Cuyamaca Community College District (District) is committed to providing its employees and
students with a drug free workplace and campus environment. It emphasizes prevention and intervention
through education.
The District has health events, workshops and exhibits throughout the academic year promoting educational
aspects of illicit drug use and alcohol abuse. The District provides students with prevention information and
referrals for treatment for students with drug and alcohol issues. The District works closely with their college
communities to share educational programs; and events to combat the use of illicit drugs and alcohol abuse by
District students. Students may call or come to Student Health Services, Student Affairs Office or Counseling
for additional information or help for illicit drug use or alcohol abuse.
The range of health risks associated with the use of illicit drugs and the abuse of alcohol are varied. These
health risks can include, but are not limited to: short term illnesses, long-term incurable diseases and/or can
result in death.
Prohibition of Drugs
The unlawful manufacture, distribution, dispensing, possession or use of alcohol or any controlled substance is
prohibited on District property, during District-sponsored field trips, activities or workshops, and in any facility or
vehicle operated by the District.
Anyone who has violated this policy is subject to disciplinary or other action in accordance with established
procedures set forth in BP 5500 Standards of Student Conduct and the District’s employee handbooks; which
may require satisfactory participation in an alcohol or drug abuse assistance or rehabilitation program.
As a condition of employment, employees must notify the District within five (5) days of any conviction for
violating a criminal drug statute while in the workplace. The District is required to inform any agencies that
require this drug-free policy within ten (10) days after receiving notice of a workplace drug conviction.
The Chancellor shall ensure that the District distributes annually to each student and employee the information
required by the Drug-Free Schools and Communities Act Amendments of 1989 and complies with other
requirements of the Act.
GROSSMONT-CUYAMACA COMMUNITY COLLEGE DISTRCIT
HUMAN RESOURCES
PAYROLL INFORMATION FOR PART-TIME (NON-FACULTY) HOURLY EMPLOYEES
A.
Instructions for completing time sheets. Use black ink and print legibly. Print the day of the week
opposite the corresponding date. List only actual hours worked. Any changes or corrections should be
initialed, (If you do not receive a pre-printed time sheet, be sure to use the appropriate blank time
sheet with your name, employee ID number, etc., clearly printed, and follow steps 2 – 4).
1.
Print your name as it appears on your Social Security card when completing the top portion of the
time sheet, and be sure your employee ID number is shown correctly.
2.
If you work under more than one budget number, you must fill out a separate time sheet for each
budget number.
3.
When time sheets are due, fill in the hours you worked, your hourly rate of pay and sign the time
sheet. Your supervisor is to verify correct budget number, rate of pay, initial holidays, if worked,
and sign the time sheet. After your supervisor has signed it, take it to the Dean/Director/Manager
for approval. All hourly time sheets are then submitted to the District Payroll Department.
Note: Grossmont College Teaching Assistant (TA) time sheets are submitted to the
Campus Business Office at Grossmont.
5.
B.
The due date for time sheets is the 10th of every month as indicated on the bottom of the time
sheet. Late time sheets may not be paid until the following month.
Paycheck Distribution:
Grossmont College: Pick up your paycheck on the last working day of every month at the Campus
Business Office. Checks picked up after the regular pay date will be available at the Campus
Business Office, according to Campus Business Office hours. Paychecks remain at the Campus
Business Office for thirty (30) days and then returned to the District Payroll Department for
distribution.
Cuyamaca College: Pick up your paycheck on the last working day of every month after 1:00 p.m.,
in the Cashier’s Office. Paychecks not picked up on the regular pay date will be available from
7:00 a.m. – 5:00 p.m., Monday through Thursday; Friday from 8:00 a.m. – 4:30 p.m. Unclaimed
paychecks will be returned to the District Payroll Department after thirty (30) days.
C.
Release of Paychecks:
Checks will not be released without a photo ID and/or student ID and another form of
identification. Payday is the last working day of the month, however if the last working day of the
month falls on a weekend or holiday, payday will normally be the preceding workday.
If it is absolutely impossible for you to pick up your paycheck within five days after payday, contact the District
Payroll department, in advance, to have your check mailed to you. Bring a self-addressed stamped envelop to
the District Payroll department before the last working day of the month.
Frequently Asked Questions for Employees
About the New Health Insurance Marketplace
1. Q: What is the “Exchange” or “Marketplace” that I’ve been hearing about?
A: The Exchange/Marketplace is a new health insurance marketplace in each state. The Marketplaces are
established under the Healthcare Reform Act that was passed in 2010. The Marketplace is an on-line site where
individuals and smaller employers may go to purchase health insurance coverage for 2014.
2. Q: How can I obtain more detailed information about the Marketplace?
A: Visit the California Marketplace online at www.coveredca.com/ or call (888)975-1142.
3. Q: Why is the Marketplace being established?
A: Under federal law, beginning January 1, 2014 individuals will be required to have minimum essential health
coverage, or else be subject to a penalty. This is referred to as the “individual mandate.” The Marketplace is
intended to help individuals meet the individual mandate requirement by providing another place to purchase
coverage, and possibly qualify for federal assistance to do so.
4. Q: Do I have to purchase health coverage through the Marketplace?
A: No. You may still obtain health coverage from other sources if you are eligible. To avoid the individual
mandate penalty, you will want to confirm that the coverage you obtain provides “minimum essential coverage”
under the rules.
5. Q: What are some possible other sources of coverage?
A: Your employer, your spouse’s employer, Medicare (if eligible in your state), the individual market, etc.
6. Q: What if I am covered under my employer’s plan? Can I keep it?
A: Yes. Most employer plans will qualify as the coverage required under the individual mandate requirements.
You do not need to purchase coverage through the Marketplace in order to avoid the individual mandate penalty.
You may, if you would like, however.
7. Q: Can I drop myself or my dependents from my group plan to purchase a plan through the Marketplace
or outside of the Marketplace?
A: Possibly. Employers and Marketplaces have very specific rules around enrollment and disenrollment. In
general, both have an annual open enrollment period (which will usually be different) and permit special
enrollments during the year based on events such as marriage or birth of a child. Although these rules are similar,
they are not identical. In addition, determining when you can change an election outside the annual open
enrollment period will be determined by IRS regulations and the terms of the group health plan. Generally,
employees may not change an election unless the employee experiences a change in status permitted by the IRS
and allowed by the group health plan. P:\
8. Q: How do I know if I qualify for assistance to purchase my coverage through the Marketplace?
A: Individuals who are not offered qualifying healthcare coverage through their employer may be eligible for
government subsidies to help pay for health insurance premiums for plans purchased in the Marketplaces (based
on income level and how many dependents you have). Generally, household income must be below 400% of the
federal poverty level (which in 2013 is about $46,000 for an individual, or about $78,000 for a family of three), in
addition to some other rules, in order to qualify. Whether you qualify will depend on what kind of coverage your
employer offers. If your job-based coverage is considered affordable and meets minimum value requirements, you
won't be able to get lower costs on premiums or out-of-pocket costs in the Marketplace. This is true no matter
what your income and family size are. As state Marketplace sites are launched over the next months, you will be
able to get details about a possible subsidy.
9. Q: Will my employer subsidize my health coverage if I purchase it through the Marketplace?
A: Employers are not required to help you pay for coverage that you purchase through the Marketplace. With
most employer-provided plans, the employer pays a portion of the premium cost. You should consider this when
making decisions about where to obtain your health coverage.
10. Q: Will I be able to see my same doctor if I purchase coverage through the Marketplace instead of at
work?
A: Possibly. Insurance purchased through the Marketplace may have different provider networks.
11. Q: When will the Marketplace in my state be open for business?
A: Open enrollment in the Marketplaces is scheduled to begin October 1, 2013, with coverage to generally
become effective January 1, 2014. Please refer to the Marketplace in your state for further information.
12. Q: Do I have to enroll by January 1, 2014 in order to get coverage through the Marketplace?
A: No. In this first year of Marketplace coverage, you may enroll until March 31, 2014. But if you enroll after
December 15th of this year, your coverage will have an effective date that is later than January 1, 2014. To avoid
not having coverage beginning January 1, 2014, and potentially incurring a penalty, you should enroll by
December 15, 2013 if you wish to satisfy the individual mandate with coverage obtained through the
Marketplace.
13. Q: Will my employer’s health benefits program be available for purchase through the Marketplace?
A: Possibly, if your employer is considered to be a small employer under the rules, and has chosen to purchase its
program for employees through the Marketplace. Generally, employers with over 100 employees, or in some
states 50 employees, may not purchase their programs for employees through the Marketplace yet. Employers of
any size may offer coverage through regular channels, however, just as they do today.
New Health Insurance Marketplace Coverage
Options and Your Health Coverage
Form Approved
OMB No. 1210-0149
H[SLUHV531
PART A: General Information
ΈΙΖΟ͑ΜΖΪ͑ΡΒΣΥΤ͑ΠΗ͑ΥΙΖ͑ΙΖΒΝΥΙ͑ΔΒΣΖ͑ΝΒΨ͑ΥΒΜΖ͑ΖΗΗΖΔΥ͑ΚΟ͑ͣͥ͑͢͡͝ΥΙΖΣΖ͑ΨΚΝΝ͑ΓΖ͑Β͑ΟΖΨ͑ΨΒΪ͑ΥΠ͑ΓΦΪ͑ΙΖΒΝΥΙ͑ΚΟΤΦΣΒΟΔΖ:͑ΥΙΖ͑͹ΖΒΝΥΙ͑
ͺΟΤΦΣΒΟΔΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑͟΅Π͑ΒΤΤΚΤΥ͑ΪΠΦ͑ΒΤ͑ΪΠΦ͑ΖΧΒΝΦΒΥΖ͑ΠΡΥΚΠΟΤ͑ΗΠΣ͑ΪΠΦ͑ΒΟΕ͑ΪΠΦΣ͑ΗΒΞΚΝΪ͑͝ΥΙΚΤ͑ΟΠΥΚΔΖ͑ΡΣΠΧΚΕΖΤ͑ΤΠΞΖ͑ΓΒΤΚΔ͑
ΚΟΗΠΣΞΒΥΚΠΟ͑ΒΓΠΦΥ͑ΥΙΖ͑ΟΖΨ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΒΟΕ͑ΖΞΡΝΠΪΞΖΟΥνΓΒΤΖΕ͑ΙΖΒΝΥΙ͑ΔΠΧΖΣΒΘΖ͑ΠΗΗΖΣΖΕ͑ΓΪ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑͟
͑
What is the Health Insurance Marketplace?
΅ΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΚΤ͑ΕΖΤΚΘΟΖΕ͑ΥΠ͑ΙΖΝΡ͑ΪΠΦ͑ΗΚΟΕ͑ΙΖΒΝΥΙ͑ΚΟΤΦΣΒΟΔΖ͑ΥΙΒΥ͑ΞΖΖΥΤ͑ΪΠΦΣ͑ΟΖΖΕΤ͑ΒΟΕ͑ΗΚΥΤ͑ΪΠΦΣ͑ΓΦΕΘΖΥ͑͟΅ΙΖ͑
;ΒΣΜΖΥΡΝΒΔΖ͑ΠΗΗΖΣΤ͓͑ΠΟΖ͞ΤΥΠΡ͑ΤΙΠΡΡΚΟΘ͓͑ΥΠ͑ΗΚΟΕ͑ΒΟΕ͑ΔΠΞΡΒΣΖ͑ΡΣΚΧΒΥΖ͑ΙΖΒΝΥΙ͑ΚΟΤΦΣΒΟΔΖ͑ΠΡΥΚΠΟΤ͑͟ΊΠΦ͑ΞΒΪ͑ΒΝΤΠ͑ΓΖ͑ΖΝΚΘΚΓΝΖ͑
ΗΠΣ͑Β͑ΟΖΨ͑ΜΚΟΕ͑ΠΗ͑ΥΒΩ͑ΔΣΖΕΚΥ͑ΥΙΒΥ͑ΝΠΨΖΣΤ͑ΪΠΦΣ͑ΞΠΟΥΙΝΪ͑ΡΣΖΞΚΦΞ͑ΣΚΘΙΥ͑ΒΨΒΪ͑͟΀ΡΖΟ͑ΖΟΣΠΝΝΞΖΟΥ͑ΗΠΣ͑ΙΖΒΝΥΙ͑ΚΟΤΦΣΒΟΔΖ͑
ΔΠΧΖΣΒΘΖ͑ΥΙΣΠΦΘΙ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΓΖΘΚΟΤ͑ΚΟ͑΀ΔΥΠΓΖΣ͑ͣͤ͑͢͡ΗΠΣ͑ΔΠΧΖΣΒΘΖ͑ΤΥΒΣΥΚΟΘ͑ΒΤ͑ΖΒΣΝΪ͑ΒΤ͑ͻΒΟΦΒΣΪ͑͑ͣͥ͑͢͢͟͝͡
Can I Save Money on my Health Insurance Premiums in the Marketplace?
ΊΠΦ͑ΞΒΪ͑΢ΦΒΝΚΗΪ͑ΥΠ͑ΤΒΧΖ͑ΞΠΟΖΪ͑ΒΟΕ͑ΝΠΨΖΣ͑ΪΠΦΣ͑ΞΠΟΥΙΝΪ͑ΡΣΖΞΚΦΞ͑͝ΓΦΥ͑ΠΟΝΪ͑ΚΗ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑ΕΠΖΤ͑ΟΠΥ͑ΠΗΗΖΣ͑ΔΠΧΖΣΒΘΖ͑͝ΠΣ͑
ΠΗΗΖΣΤ͑ΔΠΧΖΣΒΘΖ͑ΥΙΒΥ͑ΕΠΖΤΟ͘Υ͑ΞΖΖΥ͑ΔΖΣΥΒΚΟ͑ΤΥΒΟΕΒΣΕΤ͑͟΅ΙΖ͑ΤΒΧΚΟΘΤ͑ΠΟ͑ΪΠΦΣ͑ΡΣΖΞΚΦΞ͑ΥΙΒΥ͑ΪΠΦ͘ΣΖ͑ΖΝΚΘΚΓΝΖ͑ΗΠΣ͑ΕΖΡΖΟΕΤ͑ΠΟ͑
ΪΠΦΣ͑ΙΠΦΤΖΙΠΝΕ͑ΚΟΔΠΞΖ͑͟
Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace?
ΊΖΤ͑͟ͺΗ͑ΪΠΦ͑ΙΒΧΖ͑ΒΟ͑ΠΗΗΖΣ͑ΠΗ͑ΙΖΒΝΥΙ͑ΔΠΧΖΣΒΘΖ͑ΗΣΠΞ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑ΥΙΒΥ͑ΞΖΖΥΤ͑ΔΖΣΥΒΚΟ͑ΤΥΒΟΕΒΣΕΤ͑͝ΪΠΦ͑ΨΚΝΝ͑ΟΠΥ͑ΓΖ͑ΖΝΚΘΚΓΝΖ͑
ΗΠΣ͑Β͑ΥΒΩ͑ΔΣΖΕΚΥ͑ΥΙΣΠΦΘΙ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΒΟΕ͑ΞΒΪ͑ΨΚΤΙ͑ΥΠ͑ΖΟΣΠΝΝ͑ΚΟ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͘Τ͑ΙΖΒΝΥΙ͑ΡΝΒΟ͑͟͹ΠΨΖΧΖΣ͑͝ΪΠΦ͑ΞΒΪ͑ΓΖ͑
ΖΝΚΘΚΓΝΖ͑ΗΠΣ͑Β͑ΥΒΩ͑ΔΣΖΕΚΥ͑ΥΙΒΥ͑ΝΠΨΖΣΤ͑ΪΠΦΣ͑ΞΠΟΥΙΝΪ͑ΡΣΖΞΚΦΞ͑͝ΠΣ͑Β͑ΣΖΕΦΔΥΚΠΟ͑ΚΟ͑ΔΖΣΥΒΚΟ͑ΔΠΤΥ͞ΤΙΒΣΚΟΘ͑ΚΗ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑ΕΠΖΤ͑
ΟΠΥ͑ΠΗΗΖΣ͑ΔΠΧΖΣΒΘΖ͑ΥΠ͑ΪΠΦ͑ΒΥ͑ΒΝΝ͑ΠΣ͑ΕΠΖΤ͑ΟΠΥ͑ΠΗΗΖΣ͑ΔΠΧΖΣΒΘΖ͑ΥΙΒΥ͑ΞΖΖΥΤ͑ΔΖΣΥΒΚΟ͑ΤΥΒΟΕΒΣΕΤ͑͟ͺΗ͑ΥΙΖ͑ΔΠΤΥ͑ΠΗ͑Β͑ΡΝΒΟ͑ΗΣΠΞ͑ΪΠΦΣ͑
ΖΞΡΝΠΪΖΣ͑ΥΙΒΥ͑ΨΠΦΝΕ͑ΔΠΧΖΣ͑ΪΠΦ͙͑ΒΟΕ͑ΟΠΥ͑ΒΟΪ͑ΠΥΙΖΣ͑ΞΖΞΓΖΣΤ͑ΠΗ͑ΪΠΦΣ͑ΗΒΞΚΝΪ͚͑ΚΤ͑ΞΠΣΖ͑ΥΙΒΟ͖͑ͪͦ͑͟ΠΗ͑ΪΠΦΣ͑ΙΠΦΤΖΙΠΝΕ͑
ΚΟΔΠΞΖ͑ΗΠΣ͑ΥΙΖ͑ΪΖΒΣ͑͝ΠΣ͑ΚΗ͑ΥΙΖ͑ΔΠΧΖΣΒΘΖ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑ΡΣΠΧΚΕΖΤ͑ΕΠΖΤ͑ΟΠΥ͑ΞΖΖΥ͑ΥΙΖ͓͑ΞΚΟΚΞΦΞ͑ΧΒΝΦΖ͓͑ΤΥΒΟΕΒΣΕ͑ΤΖΥ͑ΓΪ͑ΥΙΖ͑
ͲΗΗΠΣΕΒΓΝΖ͑ʹΒΣΖ͑ͲΔΥ͑͝ΪΠΦ͑ΞΒΪ͑ΓΖ͑ΖΝΚΘΚΓΝΖ͑ΗΠΣ͑Β͑ΥΒΩ͑ΔΣΖΕΚΥ͑͟͢
͑
ͿΠΥΖͫ͑ͺΗ͑ΪΠΦ͑ΡΦΣΔΙΒΤΖ͑Β͑ΙΖΒΝΥΙ͑ΡΝΒΟ͑ΥΙΣΠΦΘΙ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΚΟΤΥΖΒΕ͑ΠΗ͑ΒΔΔΖΡΥΚΟΘ͑ΙΖΒΝΥΙ͑ΔΠΧΖΣΒΘΖ͑ΠΗΗΖΣΖΕ͑ΓΪ͑ΪΠΦΣ͑
ΖΞΡΝΠΪΖΣ͑͝ΥΙΖΟ͑ΪΠΦ͑ΞΒΪ͑ΝΠΤΖ͑ΥΙΖ͑ΖΞΡΝΠΪΖΣ͑ΔΠΟΥΣΚΓΦΥΚΠΟ͙͑ΚΗ͑ΒΟΪ͚͑ΥΠ͑ΥΙΖ͑ΖΞΡΝΠΪΖΣ͞ΠΗΗΖΣΖΕ͑ΔΠΧΖΣΒΘΖ͑͟ͲΝΤΠ͑͝ΥΙΚΤ͑ΖΞΡΝΠΪΖΣ͑
ΔΠΟΥΣΚΓΦΥΚΠΟ͑͞ΒΤ͑ΨΖΝΝ͑ΒΤ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΖ͑ΔΠΟΥΣΚΓΦΥΚΠΟ͑ΥΠ͑ΖΞΡΝΠΪΖΣ͞ΠΗΗΖΣΖΕ͑ΔΠΧΖΣΒΘΖ͑͞ΚΤ͑ΠΗΥΖΟ͑ΖΩΔΝΦΕΖΕ͑ΗΣΠΞ͑ΚΟΔΠΞΖ͑ΗΠΣ͑
ͷΖΕΖΣΒΝ͑ΒΟΕ͑΄ΥΒΥΖ͑ΚΟΔΠΞΖ͑ΥΒΩ͑ΡΦΣΡΠΤΖΤ͑͟ΊΠΦΣ͑ΡΒΪΞΖΟΥΤ͑ΗΠΣ͑ΔΠΧΖΣΒΘΖ͑ΥΙΣΠΦΘΙ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΒΣΖ͑ΞΒΕΖ͑ΠΟ͑ΒΟ͑ΒΗΥΖΣ͞
ΥΒΩ͑ΓΒΤΚΤ͑͟
͑
How Can I Get More Information?
ͷΠΣ͑ΞΠΣΖ͑ΚΟΗΠΣΞΒΥΚΠΟ͑ΒΓΠΦΥ͑ΪΠΦΣ͑ΔΠΧΖΣΒΘΖ͑ΠΗΗΖΣΖΕ͑ΓΪ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑͝ΡΝΖΒΤΖ͑ΔΙΖΔΜ͑ΪΠΦΣ͑ΤΦΞΞΒΣΪ͑ΡΝΒΟ͑ΕΖΤΔΣΚΡΥΚΠΟ͑ΠΣ͑
Jenny Aquino, District Benefits Technician, [email protected] , (619)644-7643
ΔΠΟΥΒΔΥ͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͟
͑
΅ΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΔΒΟ͑ΙΖΝΡ͑ΪΠΦ͑ΖΧΒΝΦΒΥΖ͑ΪΠΦΣ͑ΔΠΧΖΣΒΘΖ͑ΠΡΥΚΠΟΤ͑͝ΚΟΔΝΦΕΚΟΘ͑ΪΠΦΣ͑ΖΝΚΘΚΓΚΝΚΥΪ͑ΗΠΣ͑ΔΠΧΖΣΒΘΖ͑ΥΙΣΠΦΘΙ͑ΥΙΖ͑
;ΒΣΜΖΥΡΝΒΔΖ͑ΒΟΕ͑ΚΥΤ͑ΔΠΤΥ͑͟΁ΝΖΒΤΖ͑ΧΚΤΚΥ͑͹ΖΒΝΥΙʹΒΣΖ͟ΘΠΧ͑ΗΠΣ͑ΞΠΣΖ͑ΚΟΗΠΣΞΒΥΚΠΟ͑͝ΚΟΔΝΦΕΚΟΘ͑ΒΟ͑ΠΟΝΚΟΖ͑ΒΡΡΝΚΔΒΥΚΠΟ͑ΗΠΣ͑ΙΖΒΝΥΙ͑
ΚΟΤΦΣΒΟΔΖ͑ΔΠΧΖΣΒΘΖ͑ΒΟΕ͑ΔΠΟΥΒΔΥ͑ΚΟΗΠΣΞΒΥΚΠΟ͑ΗΠΣ͑Β͑͹ΖΒΝΥΙ͑ͺΟΤΦΣΒΟΔΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΚΟ͑ΪΠΦΣ͑ΒΣΖΒ͑͟
͑͢ͲΟ͑ ΖΞΡΝΠΪΖΣ͞ΤΡΠΟΤΠΣΖΕ͑ ΙΖΒΝΥΙ͑ΡΝΒΟ͑ΞΖΖΥΤ͑ΥΙΖ͑ ͓ΞΚΟΚΞΦΞ͑ ΧΒΝΦΖ͑ΤΥΒΟΕΒΣΕ͓͑ ΚΗ͑ ΥΙΖ͑ΡΝΒΟ͘Τ͑ΤΙΒΣΖ͑ΠΗ͑ ΥΙΖ͑ΥΠΥΒΝ͑ΒΝΝΠΨΖΕ͑ΓΖΟΖΗΚΥ͑ΔΠΤΥΤ͑ΔΠΧΖΣΖΕ͑
ΓΪ͑ ΥΙΖ͑ΡΝΒΟ͑ΚΤ͑ ΟΠ͑ ΝΖΤΤ͑ΥΙΒΟ͑ͧ͑͡ΡΖΣΔΖΟΥ͑ΠΗ͑ ΤΦΔΙ͑ΔΠΤΥΤ͑͟
PART B: Information About Health Coverage Offered by Your Employer
΅ΙΚΤ͑ΤΖΔΥΚΠΟ͑ΔΠΟΥΒΚΟΤ͑ΚΟΗΠΣΞΒΥΚΠΟ͑ΒΓΠΦΥ͑ΒΟΪ͑ΙΖΒΝΥΙ͑ΔΠΧΖΣΒΘΖ͑ΠΗΗΖΣΖΕ͑ΓΪ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑͟ͺΗ͑ΪΠΦ͑ΕΖΔΚΕΖ͑ΥΠ͑ΔΠΞΡΝΖΥΖ͑ΒΟ͑
ΒΡΡΝΚΔΒΥΚΠΟ͑ΗΠΣ͑ΔΠΧΖΣΒΘΖ͑ΚΟ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑͝ΪΠΦ͑ΨΚΝΝ͑ΓΖ͑ΒΤΜΖΕ͑ΥΠ͑ΡΣΠΧΚΕΖ͑ΥΙΚΤ͑ΚΟΗΠΣΞΒΥΚΠΟ͑͟΅ΙΚΤ͑ΚΟΗΠΣΞΒΥΚΠΟ͑ΚΤ͑ΟΦΞΓΖΣΖΕ͑
ΥΠ͑ΔΠΣΣΖΤΡΠΟΕ͑ΥΠ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΒΡΡΝΚΔΒΥΚΠΟ͑͟
3. Employer name
4. Employer Identification Number (EIN)
956006652
Grossmont-Cuyamaca Community College District
5. Employer address
6. Employer phone number
(619)644-7639
8800 Grossmont College Drive
7. City
8. State
CA
El Cajon
9. ZIP code
92020
10. Who can we contact about employee health coverage at this job?
Jenny Aquino, District Benefits Technician
11. Phone number (if different from above)
͑
(619)644-7643
12. Email address
[email protected]
͹ΖΣΖ͑ΚΤ͑ΤΠΞΖ͑ΓΒΤΚΔ͑ΚΟΗΠΣΞΒΥΚΠΟ͑ΒΓΠΦΥ͑ΙΖΒΝΥΙ͑ΔΠΧΖΣΒΘΖ͑ΠΗΗΖΣΖΕ͑ΓΪ͑ΥΙΚΤ͑ΖΞΡΝΠΪΖΣͫ͑
x ͲΤ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑͝ΨΖ͑ΠΗΗΖΣ͑Β͑ΙΖΒΝΥΙ͑ΡΝΒΟ͑ΥΠͫ͑
… ͲΝΝ͑ΖΞΡΝΠΪΖΖΤ͑͑͟ͶΝΚΘΚΓΝΖ͑ΖΞΡΝΠΪΖΖΤ͑ΒΣΖͫ͑
͑
✔
͑
͑
Full-Time͑ Contract Academic, Classified, Supervisor, and Confidential employees. Classified employees who are
contracted
50% or greater.
͑
… ΄ΠΞΖ͑ΖΞΡΝΠΪΖΖΤ͑͟ͶΝΚΘΚΓΝΖ͑ΖΞΡΝΠΪΖΖΤ͑ΒΣΖͫ͑͑
͑
͑
✔
͑
͑
Legal spouse, legal dependent child(ren), step child(ren), state certified domestic partner, legal dependent of an official
͑
dependent, and certified disabled dependent children.
x ΈΚΥΙ͑ΣΖΤΡΖΔΥ͑ΥΠ͑ΕΖΡΖΟΕΖΟΥΤͫ͑
… ΈΖ͑ΕΠ͑ΠΗΗΖΣ͑ΔΠΧΖΣΒΘΖ͑͟ͶΝΚΘΚΓΝΖ͑ΕΖΡΖΟΕΖΟΥΤ͑ΒΣΖͫ͑
͑
͑
✔
͑
͑
… ΈΖ͑ΕΠ͑ΟΠΥ͑ΠΗΗΖΣ͑ΔΠΧΖΣΒΘΖ͑͟
͑
… ͺΗ͑ΔΙΖΔΜΖΕ͑͝ΥΙΚΤ͑ΔΠΧΖΣΒΘΖ͑ΞΖΖΥΤ͑ΥΙΖ͑ΞΚΟΚΞΦΞ͑ΧΒΝΦΖ͑ΤΥΒΟΕΒΣΕ͑͝ΒΟΕ͑ΥΙΖ͑ΔΠΤΥ͑ΠΗ͑ΥΙΚΤ͑ΔΠΧΖΣΒΘΖ͑ΥΠ͑ΪΠΦ͑ΚΤ͑ΚΟΥΖΟΕΖΕ͑
ΥΠ͑ΓΖ͑ΒΗΗΠΣΕΒΓΝΖ͑͝ΓΒΤΖΕ͑ΠΟ͑ΖΞΡΝΠΪΖΖ͑ΨΒΘΖΤ͑͟
͑
͛͛͑ ͶΧΖΟ͑ΚΗ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑ΚΟΥΖΟΕΤ͑ΪΠΦΣ͑ΔΠΧΖΣΒΘΖ͑ΥΠ͑ΓΖ͑ΒΗΗΠΣΕΒΓΝΖ͑͝ΪΠΦ͑ΞΒΪ͑ΤΥΚΝΝ͑ΓΖ͑ΖΝΚΘΚΓΝΖ͑ΗΠΣ͑Β͑ΡΣΖΞΚΦΞ͑
ΕΚΤΔΠΦΟΥ͑ΥΙΣΠΦΘΙ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑͟΅ΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΨΚΝΝ͑ΦΤΖ͑ΪΠΦΣ͑ΙΠΦΤΖΙΠΝΕ͑ΚΟΔΠΞΖ͑͝ΒΝΠΟΘ͑ΨΚΥΙ͑ΠΥΙΖΣ͑ΗΒΔΥΠΣΤ͑͝
ΥΠ͑ΕΖΥΖΣΞΚΟΖ͑ΨΙΖΥΙΖΣ͑ΪΠΦ͑ΞΒΪ͑ΓΖ͑ΖΝΚΘΚΓΝΖ͑ΗΠΣ͑Β͑ΡΣΖΞΚΦΞ͑ΕΚΤΔΠΦΟΥ͑͟ͺΗ͑͝ΗΠΣ͑ΖΩΒΞΡΝΖ͑͝ΪΠΦΣ͑ΨΒΘΖΤ͑ΧΒΣΪ͑ΗΣΠΞ͑
ΨΖΖΜ͑ΥΠ͑ΨΖΖΜ͙͑ΡΖΣΙΒΡΤ͑ΪΠΦ͑ΒΣΖ͑ΒΟ͑ΙΠΦΣΝΪ͑ΖΞΡΝΠΪΖΖ͑ΠΣ͑ΪΠΦ͑ΨΠΣΜ͑ΠΟ͑Β͑ΔΠΞΞΚΤΤΚΠΟ͑ΓΒΤΚΤ͚͑͝ΚΗ͑ΪΠΦ͑ΒΣΖ͑ΟΖΨΝΪ͑
ΖΞΡΝΠΪΖΕ͑ΞΚΕ͞ΪΖΒΣ͑͝ΠΣ͑ΚΗ͑ΪΠΦ͑ΙΒΧΖ͑ΠΥΙΖΣ͑ΚΟΔΠΞΖ͑ΝΠΤΤΖΤ͑͝ΪΠΦ͑ΞΒΪ͑ΤΥΚΝΝ͑΢ΦΒΝΚΗΪ͑ΗΠΣ͑Β͑ΡΣΖΞΚΦΞ͑ΕΚΤΔΠΦΟΥ͑͟
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ͺΗ͑ΪΠΦ͑ΕΖΔΚΕΖ͑ΥΠ͑ΤΙΠΡ͑ΗΠΣ͑ΔΠΧΖΣΒΘΖ͑ΚΟ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑͝͹ΖΒΝΥΙʹΒΣΖ͟ΘΠΧ ΨΚΝΝ͑ΘΦΚΕΖ͑ΪΠΦ͑ΥΙΣΠΦΘΙ͑ΥΙΖ ΡΣΠΔΖΤΤ͑͟͹ΖΣΖ͘Τ͑ΥΙΖ͑
ΖΞΡΝΠΪΖΣ͑ΚΟΗΠΣΞΒΥΚΠΟ͑ΪΠΦ͘ΝΝ͑ΖΟΥΖΣ͑ΨΙΖΟ͑ΪΠΦ͑ΧΚΤΚΥ͑͹ΖΒΝΥΙʹΒΣΖ͟ΘΠΧ͑ΥΠ͑ΗΚΟΕ͑ΠΦΥ͑ΚΗ͑ΪΠΦ͑ΔΒΟ͑ΘΖΥ͑Β͑ΥΒΩ͑ΔΣΖΕΚΥ͑ΥΠ͑ΝΠΨΖΣ͑ΪΠΦΣ͑
ΞΠΟΥΙΝΪ͑ΡΣΖΞΚΦΞΤ͑͟
͑
TO:
All Non Bargaining Unit Employees
FROM: Tim Corcoran, Vice Chancellor of Human Resources
RE:
Notice of Healthy Workplace Healthy Family Act of 2014 Paid Sick Leave (AB1522)
Important Notice regarding new law affecting Non-Bargaining Unit Employees
On September 10, 2014, Governor Brown signed into law the Healthy Workplaces, Healthy
Families Act of 2014 (known as Assembly Bill 1522 or AB1522). This bill provides paid sick
leave days to workers who do not currently earn this benefit. This bill specifically requires
employers to provide paid sick leave to employees who work 30 or more days within a year
from commencement of employment. Employees will earn a minimum of one hour of paid
sick leave for every 30 hours worked.
California’s AB1522 law went into effect on January 1, 2015. Entitlements of the paid sick
leave for employees will go into effect beginning July 1, 2015. Eligible employees will begin
receiving sick accruals based on the number of hours worked in the preceding pay period.
The group of employees affected by AB1522 are non-bargaining unit employees. This
category includes the following: substitutes, student workers, Federal Work Study, NANCE,
Professional Expert, etc. The district will implement the following entitlements and policies
beginning July 1, 2015.
ENTITLEMENT of PAID SICK LEAVE
Sick Plan Year – Begins July 1 – June 30 (same as fiscal year)
Eligible Employees – Only Employees solely hired in a non-bargaining unit position will be
eligible for this sick leave plan.

Note: Bargaining Unit employees with an additional non-bargaining position will not be
eligible for this plan.
Eligibility for the plan – Employees will be eligible for the sick leave plan 30 days from hire
date.


Existing employees hired prior to June 1, 2015 will be eligible on July 1, 2015
Employees hired after June 1, 2015 will be eligible 30 days from their hire date.
Accrual Rate – Paid sick leave accrues at the rate of one hour per every 30 hours worked
and recorded as paid time.


Example: Timesheet hours recorded as 30 hours of paid time will result in 1 hour of sick leave
accrual.
Example: Timesheet hours recorded as 40 hours of paid time will result in 1.33 hours of sick
leave accrual (40/30=1.33)
Accrual Maximum – Employees will be eligible for a maximum accrual of 48 hours per plan
year.
Vice Chancellor of Human Resources
8800 Grossmont College Drive, El Cajon, CA 92020-1799
Fax 619-644-7919
Phone 619-644-7572
Accrual Carryover Maximum – Employees can carryover a maximum of 48 hours from one
plan year to the next plan year.
Rate of pay for sick leave – Employees will be paid at the current rate of pay for any sick
leave usage.
First Accrual and Payroll period – Eligible employees will have the first accrual posted from
the hours reported based on the timesheet period in which the plan is in effect.


Accrual will be based on the hours submitted to payroll for hours worked on July 1, 2015 –
July 14, 2015.
All subsequent accruals will be based on hours worked relevant to the pay period submitted
o Subsequent accrual for hours worked during July 15, 2015 – August 14, 2015
USAGE
Usage of plan – Employees may begin using accrued sick leave on the 90th calendar day of
employment.
Usage of sick leave – Employees may use their paid sick leave for the following:


Themselves or a family member for the diagnosis, care or treatment of an existing health
condition or preventative care. Family member means the following:
o Child biological, adopted, or foster child, stepchild, legal ward or child to whom the
employee stand in loco parentis, regardless of the child’s age or dependence status
o Biological adoptive, or foster parent, stepparent or legal guardian of an employee or
the employee’s spouse or registered domestic partner, or a period who stood in loco
parentis when the employee was a minor child.
o A spouse, registered domestic partner, grandparent, grandchild, or sibling.
Specified purposes for an employee who is a victim of domestic violence, sexual assault or
stalking.
Yearly Limit on usage – Employees will be limited to a maximum of 24 hours of
paid sick leave per plan year.
Daily limit on usage – Employees will be required to use the sick leave in the following
increments of time so long as the employee has the available balance available.

Minimum of 2 hours
o Employees can use a minimum of 2 hours of paid sick leave up to scheduled hours.
o Employees using paid sick time will not be able to use the sick absence for any time
less than 2 hours per paid time off request such as 1 ½ hour, 1 hour, or ½ hour
Limit on available balance – In addition to the yearly limit, employees will not be able to use
paid sick leave when there is no sick leave balance available. Neither the district nor the
department may advance paid sick leave to an eligible employee of this plan.
How to use the benefit
If the use of sick leave is foreseeable, employees must provide their supervisor with
advance notice. If the need for the leave is unforeseeable, the employee shall provide
notice as soon as practicable and report their absence to their supervisor.
It will be the responsibility of the employee to enter and record their absence on their
timesheet. The employee’s supervisor may enter this absence on the behalf of the
employee when notified.
If the absence is not recorded on their timesheet, the absence will not be considered as paid
sick leave.
Permanent positions
Non-bargaining unit employees offered a permanent bargaining unit position will not have
this sick leave balance transferred to the new bargaining unit position. The employee will
be offered sick leave based on Education Code and benefits as listed in the collective
bargaining agreements.
Separation from employment
No Payoffs – This sick leave plan is not compensable wages at the time of termination.
Employees with a balance of this sick leave plan will not have any sick leave balance paid
out at the time of separation from the district.
Transfers of sick leave – This sick leave plan is not transferrable.
Balance Available – the sick leave balance will be available to the employee for one year
from the date of separation with the district. If the employee is rehired within one year into
a non-bargaining position they will have previously accrued and unused paid sick leave
balances reinstated and available for use upon re-employment. After one year of separation
the unused and accrued sick leave will be deleted from the employee’s previous sick leave
balance.
Pension Plan and Sick Leave
Service Credit – CalPERS will not recognize this paid time off as creditable service.
Employees who are also members of CalPERS will not have this paid time reported to
CalPERS for service during employment or reported as unused sick leave at the time of
retirement. Therefore, no retirement contributions will be withheld from the employee’s
paycheck for this sick leave plan.
Protection from Retaliation
Provisions of the law prohibit an employer from denying an employee the right to use the
paid sick leave, discharging, threatening to discharge, demoting, suspending, or in any
manner discriminating against an employee. There is a rebuttable presumption of unlawful
retaliation if the employer acts in a manner described above within 30 days of the
employee’s request for leave or other protected activity.
If you have any questions or concerns related to this new sick leave, please
call the payroll general number at 619-644-7902