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VOLUN
NTEER APPLICATION
N
School Site 1. ___________________________________
Student Nam e:
School Site 2.
Student Nam e:
School Site:3.
Student Nam e:
INSTRUCTIONS: Please fill out this form completely. TYPE OR PRINT IN INK. Sign the form at the bottom.
Name
Last
First
Address:
Phone #
Middle
Number & Street
City
Zip
List activities in which you would like to assist
a
(refer to prrocess chart)
NOTE: Individuals who regularly perform one or more hours per week of any specific volunteer service with or around students shall be
required to sign a loyalty oath and provide evidence that they are free of active tuberculosis. Additionally, all volunteers must follow student
confidentiality requirements as defined by the Family Education Rights and Privacy Act of 1974 (FERPA).
Noo
Are you phyysically able to perfoorm the functions of this position with/or without accommodaation? Yes
Have you eever been convicted of a felony or misdeemeanor, or do you currently
c
have a feloony or misdemeanorr charge pending? C onvictions include a plea of guilty, nolo ccontendere (no
contest) annd/or a finding of guillty by a judge or a jury. (Exclude convicttions for marijuana-reelated offenses for m
more than two yearss old.) Yes
No
If “Yes,” list all convictionns including, but nott limited to convictionns for “driving under the influence,” and convictions for sex aand/or drug offensess listed in California Education Code
Sectiions 44010 and 44011, except for convicctions related to marrijuana if it is more thhan two years after tthe date of the convviction. Include any sserious or violent feloony conviction in anyy
statee or jurisdiction as ennumerated in California Penal Code secttions 667.6 (c) and 1192.7
1
(c). (Use a seeparate sheet of papper to explain detailss—a conviction will nnot constitute an
autom
matic bar from selecction as a volunteer)..
m all liability personss and organizations
I HEREBY CERTIFY that all staatements made heroon are true and correect and authorize invvestigation of all stattements herein recoorded. I release from
reporting innformation required by
b this application.
I AFFIRM
M that I have reaad and understtand all of the attached
a
annuall notifications aand requiremennts for LEUSD uunpaid volunteeers .
Signature of Applicant
Date
Ob
btain Teacher an
nd Principal Sig
gnatures BEFO
ORE bringing coompleted appliccation to Safetyy/Risk Servicess
Volunnteers shall not be used
u
to displace reguularly authorized schhool personnel (Educcation Code 35021) . Projects assigned to volunteers are thhose which supplement and enrich the
regullar school program and
a which would nott be offered without volunteer
v
assistancee. Volunteers shall w
work under the immeediate supervision oof a regular District employee.
✔
Teaccher/Supervisor 1.
Date:
Approved:
Yess
No
o
Princcipal/Administrator:
Date:
Approved:
Yes
No
o
Teaccher/Supervisor 2.
Date:
Approved:
Yess
No
o
Princcipal/Administrator:
Date:
Approved:
Yes
No
o
Teaccher/Supervisor 3.
Date:
Approved:
Yess
No
o
Princcipal/Administrator:
Date:
Approved:
Yes
No
o
7/12
E 1240 (a)
LEUSD Volunteer Process Chart for First Time Volunteers:
DESCRIPTION
STEPS TO TAKE
Volunteer A:
□ Helps in classroom, office, or
library under direct supervision of
LEUSD employee
□ Helps out as needed on a
school site unsupervised but
without LEUSD students present
(example: workroom)
□ PTA or Booster Club parent
who volunteers in and around
LEUSD students supervised by an
LEUSD employee or Volunteer B
□ Read application and all attachments.
□ Application--fill out and obtain teacher and then
Principal signature.
□ Obtain TB Testing current within last 12 months
□ Bring completed application, picture ID and TB test
results to Safety/Risk Services, LEUSD District Office,
545 Chaney St., Building B.
We will:
□ Check Megan’s Law web site.
□ Make ID Badge w/ red background after all items
above and below are verified.
Volunteer B:
□ Helps in classroom or on
playground and might be left
alone with children
□ Goes on field trip where given
a “student group” to monitor
alone
□ Parent sponsor for overnight
trip where he/she might be left
alone with student(s) other than
their own
□ PTA or Booster Club parent
who volunteers in and around
LEUSD students without
supervision
□ Application (Fill out and obtain teacher and then
Principal signature)
□ Read application and all inserts.
□ Obtain TB Testing current within last 12 months
□ Bring completed application, picture ID and TB test
results to Safety/Risk Services, LEUSD District Office,
545 Chaney St., Bldg. B
We will:
□ Check Megan’s Law web site.
□ Have you complete the Request for Live Scan
Service paperwork. You will then take that paperwork
with you to have your fingerprints done. A list of
locations will be provided to you.
□ Make ID Badge w/ purple background after all
items above are verified and fingerprint results have
been received by the Safety/Risk Office.
Volunteer, walk-on coach or anyone who
supervises or directs a student activity program
sponsored by or affiliated with the district (such as ASB,
PTA, or Booster Club) whether or not a stipend is offered
or received must be cleared through Personnel Services
and may be required to meet the requirements of AB
1025 and obtain an Activity Supervisor Clearance
Certificate from the Commission on Teacher
Credentialing (CTC).
MUST GO THROUGH PERSONNEL SERVICES
for further information and processing.
As an unpaid volunteer with the Lake Elsinore Unified School District, you are responsible to
follow all LEUSD Board policies (which can be accessed through the District’s website at
www.leusd.k12.ca.us ), Federal laws, and State laws including the following:
 District information on Bloodborne Pathogens
 California “Discrimination is Against the Law” information
 Child Abuse Reporting information
 California “Sexual Harassment is Against the Law”information
 MPN (medical provider network) Employee/Volunteer Notification for any volunteer
related injury.
 Volunteer Oath for Emergency Response is signed.
 Tobacco, drug, or alcohol use prohibited information is signed.
 FERPA confidentiality obligations as employee or volunteer is signed.
VOLUNTEER APPLICATION COMPLETE:
1240(a) E process chart 12-13
7/12
LAKE ELSINORE UNIFIED SCHOOL DISTRICT
FERPA AND DISASTER SERVICE WORKER DECLARATIONS
FERPA Statement of Understanding: I understand that by virtue of my employment (or
volunteer status) at the Lake Elsinore Unified School District, I may have access (in the course of
my duties) to student information, the disclosure of which is prohibited by the Family Education
Rights and Privacy Act of 1974 (FERPA). Along with the right to access comes the responsibility
to maintain the privacy rights of students. There is a responsibility to maintain confidentiality.
Grades, Social Security numbers, financial information, class schedules, and medical information
should never be released to anyone other than the student or parent/guardian while the student is
less than 18 years of age. I acknowledge that I fully understand that the disclosure by me of this
information to any unauthorized person could subject the District to administrative sanctions for
violating federal law. I have read the above and agree to maintain the confidentiality of student
records.
Signature: ____________________________________
Date: __________________________
Declaration of Public Employees as Disaster Service Workers: It is hereby
declared that the protection of the health and safety and preservation of the lives and property of
the people of the state from the effects of natural, manmade, or war caused emergencies which
result in conditions of disaster or in extreme peril to life, property, and resources is of paramount
state importance requiring the responsible efforts of public and private agencies and individual
citizens. In furtherance of the exercise of the police power of the state in protection of its citizens
and resources, all public employees (including registered volunteers) are hereby declared to be
disaster service workers subject to such disaster service activities as may be assigned to the by
their superiors or by law. (Required by Government Code 3100-3102 of the State of California)
Signature: ____________________________________
Date: __________________________
NOTICE TO EMPLOYEES/VOLUNTEERS REGARDING:
DRUG AND ALCOHOL-FREE WORKPLACE
YOU ARE HEREBY NOTIFIED that it is a violation of Board Policy for any employee or volunteer at a School
District Workplace to unlawfully manufacture, distribute, dispense, possess, use, or be under the influence of
any alcoholic beverage, drug, or controlled substance as defined in the Controlled Substances Act and Code of
Federal Regulations.
“School District Workplace” is defined as any place where school district work is performed, including a school
building or other school premises; any school-owned or school-approved vehicle used to transport students to
and from school or school activities; any off-school sites when accommodating a school-sponsored or schoolapproved activity or function, such as a field trip or athletic event, where students are under District jurisdiction;
or during any period of time when an employee or volunteer is supervising students on behalf of the District or
otherwise engaged in District business.
As a condition of your continued employment or volunteer status with the District, you will comply with the
District’s policy on Drug and Alcohol-Free Workplace and will, any time you are convicted of any criminal drug or
alcohol statute violation occurring in the workplace, notify your supervisor of this conviction no later than five
days after such conviction.
Pursuant to the federal Omnibus Transportation Employee Testing Act of 1991, school bus drivers shall be
subject to a drug and alcohol testing program that fulfills the requirements of the Code of Federal Regulations,
Title 49, Part 382.
Pursuant to California Education Code 44836 and 45123, the Board may not employ or retain in employment or
volunteer status persons convicted of a controlled substance offense as defined in Education Code 44011. If any
such conviction is reversed and the person is acquitted in a new trial or the charges are dismissed, his/her
employment is no longer prohibited.
Pursuant to California Education Code 48901, the use of all tobacco products by anyone on District property, in
District vehicles, or at District-sponsored events is prohibited. District employees, volunteers, students, and
members of the public are expected to observe this restriction.
Any employee, volunteer, or student who
violates the District’s tobacco-free schools policy shall be asked to refrain from smoking and shall be subject to
disciplinary action as appropriate.
Pursuant to Education Code 45123, the District may employ for classified service a person who has been
convicted of a controlled substance offense only if it determines, from evidence presented, that the person has
been rehabilitated for at least five years. The Board shall determine the type and manner of presentation of the
evidence, and the Board’s determination as to whether or not the person has been rehabilitated is final.
Pursuant to Education code 44425, whenever the holder of any credential issued by the State Board of Education
or the Commission for Teacher Preparation and Licensing has been convicted of a controlled substance offense
as defined in Education Code 44011, the commission shall forthwith suspend the credential. Pursuant to
Education Code 44065, the District may not employ non-certificated persons in positions requiring a certificate.
When the conviction becomes final or when imposition of sentence is suspended, the commission shall revoke
the credential. (Education Code 44425)
Pursuant to Education Code 44940 and 45304, the District must immediately place on compulsory leave of
absence any employee charged with involvement in the sale, use, or exchange to minors of certain controlled
substances.
Pursuant to Education Code 44940 and 45304, the District must immediately place on compulsory leave of
absence an employee charged with certain controlled substance offenses.
Drug and alcohol counseling, rehabilitation, and/or employee assistance programs are available for employees.
Employees may request additional information and/or assistance through the District Personnel Services Office.
Name (please print):______________________________________________________________________
Signature: ________________________________________Date: _________________________________
Revised 5/07
LAKE ELSINORE UNIFIED SCHOOL DISTRICT
BLOODBORNE PATHOGENS
The most dangerous pathogens that are carried by the
blood are HIV, the virus that causes AIDS, and
hepatitis B, or C, viruses that can damage your liver,
cause cancer or even kill you. This is an overview of
Lake Elsinore Unified School District’s “Exposure
Control Plan for Bloodborne Pathogens.”
90% effective, but should not be taken by those
allergic to yeast, pregnant, nursing mothers, or ill.
About 85-96% of adults achieve adequate antibody
protection from the vaccine but some of the side effects
of the vaccine include soreness, fatigue, redness,
swelling at site, fever, headache, or dizziness.
HEPATITIS B
The District has determined that the following
employees have the greatest potential for occupational
exposure to Hepatitis B and are given the option of
receiving the Hepatitis B vaccine at no cost to them or
signing a declination form:
• Nurses and health
aides
• Campus/study hall
supervisors
• Headstart preschool
staff
• M & O plumbers
• Athletic trainers
• Employees assisting with specialized health care
• TEAM school bus drivers
Other employees may request the vaccine if they
experience routine exposure to blood or other body
fluids.
By definition, hepatitis B is an infection of the liver
caused by a virus present in blood and other body
fluids of infected persons. The hepatitis B infection is
caused by a specific virus known as hepatitis B virus
(HBV). The incubation period for this virus can be as
long as 176 days with an average of 120. The
symptoms may include anorexia, malaise, nausea,
vomiting, abdominal pain, and jaundice. The disease is
always present in some individuals. The chronic stage
of the disease is more common in the younger
individual. The disease can be passed from one person
to another. The body fluids containing the highest
concentration of the virus are the blood and blood
fluids. HBV is most usually transmitted through the
use of contaminated needles or sexual contact. The
disease can be transmitted when the HBV infected
blood or body fluids of an infected individual come in
direct contact with: a break in the skin (sores, cuts,
needle punctures, etc.) or; mucus membranes (eyes,
nose, mouth, etc.) of a non-infected individual. This
virus can survive on environmental surfaces dried and
at room temperature for up to a week.
Less than 50% of those who become infected show
symptoms of illness. Some of the symptoms that
might be shown by the other 50% are fatigue, weight
loss, headache, dark urine, abdominal pain, loss of
appetite, nausea, jaundice or clay colored stools. The
virus can get into your body through needles, broken
skin, cuts, and membrane of the mouth, eyes or nose. It
is transmitted through the following body fluids: blood,
vaginal fluids, semen, breast milk, or saliva, vomit,
tears, mucous, urine and sweat that may have blood
mixed in with it.
The dangers of Hepatitis B are illness, loss of time at
work, becoming a chronic carrier, cirrhosis, liver
cancer, liver transplant, or death. There is however a
Hepatitis B vaccine given in three does over a sixmonth period of time. The vaccine is approximately
HEPATITIS C
Hepatitis C is a liver disease caused by infection with
the hepatitis C virus (HCV). The virus is found in the
blood of persons who have this disease and is spread
by contact with infected blood. Hepatitis C has been
added to the list of viruses included in Exposure
Control Plans for Bloodborne Pathogens, and has
similar features to Hepatitis B, but can remain in an
individual’s system for years with no apparent
symptoms. More information about hepatitis C can be
found at the following website:
www.cdc.gov/hepatitis.
HUMAN IMMUNODEFICIENCY VIRUS (HIV)
AIDS is caused by infection with the HIV Virus. This
virus causes the gradual breakdown of the immune
system which leads to a variety of unusual infections.
These infections lead to the diagnosis of AIDS.
Acquired Immunodeficiency Syndrome (AIDS) is a
medical condition associated with a loss of the body’s
A SAFETY & RISK SERVICES PUBLICATION
1 of 2
LAKE ELSINORE UNIFIED SCHOOL DISTRICT
BLOODBORNE PATHOGENS
natural immunity against disease. AIDS is
characterized by an often-fatal breakdown of the
body’s immune system – the biological defense that
helps protect us from illness. Once the condition
develops, a patient becomes susceptible to a variety of
opportunistic infections.
Some of the symptoms of HIV include severe weight
loss, a purplish rash, and/or swollen glands over the
body, constant fever, diarrhea, exhaustion, or unusual
infections. There is no vaccine for HIV. It is
transmitted through blood, semen, vaginal fluids and
breast milk.
UNIVERSAL PRECAUTIONS
Use of universal
precautions eliminates
much of the fear of not
knowing if a student in
the classroom or fellow
employee has an
infection. The most
basic universal
precaution is hand
washing. Hand
washing should
happen:
• Before eating,
drinking or
smoking
• Before handling cooking utensils or implements
• Before and after preparing food or assisting with
feeding
• Before and after assisting with toileting or
diapering
• After contact with body fluids such as respiratory
secretions, blood (including menstrual flow), urine,
feces, mucous, or drainage from wounds
• After close personal care of students, especially
those with nose, mouth, eye or ear drainage
• Before putting on and after removing disposable
gloves (gloves encourage moist environment
conducive to bacterial growth)
• After feeding, handling, or cleaning up after
animals in the classroom
• After using the toilet
Use all suggested personal protective equipment and
procedures. If you need protective equipment, contact
your site administrator or supervisor or Safety & Risk
Services. Remember, only you can protect yourself
against infection.
POST EXPOSURE PROCEDURES
If someone else’s blood or body fluids comes in
contact with your blood or body fluids through an
exposure incident while at work:
1) Wash the area immediately with soap and water
(depending on size of wound).
2) Report exposure/injury to your supervisor
immediately.
3) Complete Injury Report (site secretary has forms).
4) See doctor who will document exposure, identify if
possible the source individual, collect exposed
employee’s blood to test for HIV, HBV, and HCV,
and then counsel employee about options.
CONFIDENTIALITY
All results of an employee exposure incident are kept
in strict confidentiality. Adults must grant their own
written permission to share HIV status. Sharing
information about AIDS/HIV infection is prohibited by
law and subject to civil penalties with a fine up to
$5,000.
Current law does not require parents or physicians to
inform school officials of a student’s AIDS/HIV status.
Any disclosure by a student or parent must be kept
confidential unless written permission is given. A
parent or guardian may grant written permission to
share information on a student under 18, but
AIDS/HIV information may be shared only with
specifically named persons. Forms for authorizing
blanket permission to share AIDS/HIV status are
inadequate.
Students must not be excluded, or placed specially
solely because of AIDS or HIV status. A student’s
physician may determine school attendance
inappropriate due to the student’s vulnerability to
infections present at school.
A SAFETY & RISK SERVICES PUBLICATION
2 of 2
YOUR INVOLVEMENT
Involvement does not mean physical
intervention or snooping on your neighbor.
It simply means not ignoring the obvious.
Fear of involvement has resulted in family
tragedies in which neighbors reported
they knew what was going on, but declined to get involved.
If a member of the community, who is not
required by law to report, does not want
to identify himself or herself, the report
may be made anonymously.
AFTER YOUR REPORT
Many people are under the misconception
that if a family is reported for child abuse
the parent will always be arrested and the
child will be taken away from the family.
Although this may occur in serious abuse
cases, the family is usually referred to
services such as counseling or parenting
classes. In neglect cases, the family may
be referred to public assistance agencies.
However, the goal of child protective
agencies is to try to keep the family unit
intact unless the child is in danger. The
goal of all of us is to protect our children
and help them grow up healthy and
happy.
For more information, contact your Local
Child Abuse Council.
Riverside County: 1-800-442-4918
http://dpss.co.riverside.ca.us/ChildProtectiveServices.aspx#RCA
Local Child Abuse Council
or call the
National Child Abuse Hotline
at 1-800-4-A-CHILD
CHILD
ABUSE
For further information on this program
and other crime prevention material,
write to:
Crime and Violence Prevention Center
California Attorney General's Office
P.O. Box 944255
Sacramento, CA 94244-2550
This publication can be downloaded from
www.safestate.org
To report suspected child abuse contact
your local:
• Police or Sheriff’s Department;
• County Welfare Department; or
• County Juvenile Probation Department.
Crime and Violence Prevention Center
California Attorney General's Office
G1–7320
10/04
Bill Lockyer
Attorney General
It Shouldn’t Hurt To Be A Kid!
Yet, children continue to be hurt every
day. For these children there is no hope
unless each one of us realizes that our
most important duty is the protection,
welfare and growth of our children.
Child abuse can leave a scar that is carried
throughout life. In fact, statistics show
that the abused child all too often grows
up to be an abuser. We know that
breaking the cycle of abuse will not only
protect our children, but will reduce crime
now and in the future. Studies suggest
that 85 percent of convicted felons were
abused as children.
Without individual and community concern
and involvement, there are really three
“victims” of child abuse: the child, the
abuser, and the community. However,
each of us may make a valuable contribution to the protection of children and the
prevention of abuse. Our concern and
involvement are critical — it may save a
life.
WHAT IS CHILD ABUSE?
Child abuse is legally defined as:
• A physical injury which is inflicted by
other than accidental means on a child
by another person.
• Sexual abuse, including both sexual
assault and sexual exploitation.
• Willful cruelty or unjustifiable punishment of a child.
• Cruel or inhuman corporal punishment
or injury.
• Neglect, including both severe and
general neglect.
• Abuse (all of the above) in out-of-home
care.
Below are some indicators of child abuse
which can help you recognize an existing
or potential problem of abuse.
Indicators of neglect:
• Child lacking adequate medical or
dental care.
• Child is always sleepy or hungry.
• Child is always dirty or inadequately
dressed for weather conditions.
• There is evidence of poor supervision.
• Conditions in home are extremely or
persistently unsafe or unsanitary.
Physical Abuse
Sexual Abuse
Physical abuse may be defined as any act
which results in a non-accidental physical
injury.
Indicators of physical abuse:
• Bruises, burns, abrasions, lacerations, or
swelling caused by other than accidental
means.
• Belt buckle marks, handprints, bite
marks, and pinches.
• Child states injury was caused by abuse.
• Injury unusual for a specific age group.
• A history of previous or recurrent
injuries.
• Unexplained injuries; conflicting explanations or reasons for injury.
• Child excessively passive, compliant or
fearful.
• Caretaker attempts to hide injuries.
Sexual abuse is defined as acts of sexual
assault on and the sexual exploitation of
minors.
Indicators of sexual abuse:
• Child reports sexual activities to a
trusted person.
• Detailed and age-inappropriate understanding of sexual behavior (especially
by younger children).
• Child wears torn, stained or bloody
underclothing.
• Child is victim of other forms of abuse.
INDICATORS OF CHILD ABUSE
Neglect
Neglect is essentially the negligent treatment or maltreatment of a child by a
parent or caretaker under circumstances
indicating harm or threatened harm to the
child’s health or welfare.
REPORTING
The law requires certain professionals to
report suspicion and/or knowledge of
child abuse, which includes physical
abuse, sexual abuse, neglect and cases of
severe emotional abuse that constitute
willful cruelty or unjustifiable punishment
of a child. But, community members also
have an important role in protecting
children from abuse and neglect. The life
of a child may be saved if community
members become involved and report
cases of suspected child abuse.
Harassment and discrimination in employment,
housing, public accommodations, and services
are against the law.
Department of Fair Employment and Housing
Hate Violence
Under the Ralph Civil Rights Act, it is against the
law for any person to threaten or commit acts of
violence against a person or property based on race,
color, religion, ancestry, national origin, age,
disability, gender, sexual orientation, political
affiliation, or position in a labor dispute.
Filing a Complaint
If you believe you are a victim of illegal discrimination or hate violence, you can file a complaint with
DFEH by following these steps:
• Contact us at (800) 884-1684 (employment,
public accommodation, and hate violence) and
(800) 233-3212 (housing)
• Be prepared to present specific facts about the
alleged harassment, discrimination, or denial
of leave
• Provide copies of documents that support the
charges in the complaint
• Keep records and documents about the
complaint, such as paycheck stubs, rent
receipts, membership applications, and other
materials
DFEH will conduct an impartial investigation.
We are not an advocate for either the person
complaining or the person complained against.
We represent the State of California. DFEH will,
if possible, try to assist both parties to resolve
the complaint.
If a voluntary settlement cannot be reached, and
there is sufficient evidence that establishes a
violation of the law, DFEH may issue an accusation
and litigate the case before the Fair Employment
and Housing Commission or in civil court. If the
Commission or a court decides in favor of the
complaining party, the following remedies can be
ordered:
• Award of the job or the housing denied to the
complainant, or similar relief
• Back pay or promotion for the complainant, or
compensation for moving and relocation
• Compensatory damages for the complainant,
including emotional distress damages
• Fines, penalties, or punitive damages
For more information, contact DFEH toll free at
(800) 884-1684
(employment, public accommodation, and hate
violence)
(800) 233-3212 (housing)
TTY number at (800) 700-2320
or visit our web site at www.dfeh.ca.gov
In accordance with the California Government Code
and ADA requirements, this publication can be made
available in Braille, large print, computer disk, or tape
cassette as a disability-related reasonable
accommodation for an individual with a disability. To
discuss how to receive a copy of this publication in an
alternative format, please contact DFEH at the numbers
above.
Discrimination is
Against the Law
Civil Rights in California
The Department of Fair Employment and
Housing (DFEH) enforces California state laws
that prohibit harassment and discrimination
in employment, housing, and public accommodations and that provide for pregnancy
leave and family and personal medical leave.
It also accepts and investigates complaints
alleging hate violence or threats of hate violence.
What DFEH Does
DFEH enforces these laws by
• Investigating harassment, discrimination,
and denial of leave complaints
• Assisting parties to voluntarily resolve
complaints involving alleged violations of
the laws enforced by DFEH
• Prosecuting violations of the law
• Educating Californians about the laws
prohibiting harassment and discrimination
by providing written materials and
participating in seminars and conferences
Discrimination in Employment
The California Fair Employment and Housing
Act (FEHA) prohibits harassment and
discrimination in employment based on the
following:
State of California
Department of Fair Employment & Housing
DFEH-151 (04/04)
• Race
• Color
The mission of the Department of Fair Employment and Housing is to protect the people of
California from unlawful discrimination in employment, housing and public accommodations, and
from the perpetration of acts of hate violence.
•
•
•
•
•
•
•
•
•
•
•
•
•
Religion
Sex (gender)
Sexual orientation
Marital status
National origin (including language use
restrictions)
Ancestry
Disability (mental and physical, including
HIV and AIDS)
Medical condition (cancer/genetic
characteristics)
Age (40 and above)
Request for family care leave
Request for leave for an employee’s own
serious health condition
Request for Pregnancy Disability Leave
Retaliation for reporting patient abuse in
tax-supported institutions
Discrimination is prohibited in all employment
practices, including the following:
• Advertisements
• Applications, screening, and interviews
• Hiring, transferring, promoting,
terminating, or separating employees
• Working conditions
• Participation in a training or apprenticeship
program, employee organization, or union
California workers are
• Guaranteed leaves if disabled because
of pregnancy
• Guaranteed reasonable accommodation
for pregnancy
• Guaranteed leaves for the birth or adoption of
a child; for the employee’s own serious health
condition; or to care for a parent, spouse, or
child with a serious health condition
• Protected from harassment because of their sex,
race, or any other category covered under the law
• Protected from retaliation for filing a complaint
with DFEH, for participating in the investigation of a complaint, or for protesting possible
violations of the law
Discrimination is prohibited in all aspects of the
housing business, including, but not limited to:
California workers with disabilities are also entitled
to reasonable accommodation when necessary in
order to perform the job.
Persons with disabilities are entitled to reasonable
accommodation in rules, policies, practices,
and services and are also permitted, at their own
expense, to reasonably modify their dwelling to
ensure full enjoyment of the premises.
Discrimination in Housing
FEHA also prohibits discrimination in the rental and
sale of housing based on the following:
•
•
•
•
•
•
•
•
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Race
Color
Religion
Sex (gender)
Sexual orientation
Marital status
National origin (including language use
restrictions)
Ancestry
Familial status (households with children
under age 18)
Source of income*
Disability (mental and physical, including
HIV and AIDS)
Medical condition (cancer/genetic
characteristics)
Age
*Until 12/31/04 unless extended by statute.
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Advertisements
Mortgage lending and insurance
Application and selection processes
Terms, conditions, and privileges of occupancy,
including freedom from harassment
• Public and private land-use practices, including
the existence of restrictive covenants
As in employment discrimination law, persons are
protected from retaliation for filing complaints.
Discrimination in Public Accommodations
and Services
Discrimination in public services and accommodations is prohibited under the Unruh Civil Rights Act.
The law requires “full and equal accommodations,
advantages, facilities, privileges, or services in all
business establishments.” Business establishments
covered by the law include, but are not limited to:
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Hotels and motels
Nonprofit organizations
Restaurants
Theaters
Hospitals
Barber shops and beauty salons
Housing accommodations
Local government and public agencies
Retail establishments
The mission of the Department of Fair Employment and Housing is to protect the people of
California from unlawful discrimination in employment, housing and public accommodations, and from
the perpetration of acts of hate violence.
Employers’ Obligations
All employers must take the following actions
against harassment:
• Take all reasonable steps to prevent
discrimination and harassment from
occurring. If harassment does occur,
take effective action to stop any further
harassment and to correct any effects
of the harassment.
• Develop and implement a sexual harassment prevention policy with a procedure
for employees to make complaints and
for the employer to investigate complaints.
Policies should include provisions to:
• Fully inform the complainant of
his/her rights and any obligations to secure those rights.
• Fully and effectively investigate. The investigation must be thorough, objective, and
complete. Anyone with information regarding the matter should be interviewed.
A determination must be made and the results communicated to the complainant,
to the alleged harasser and, as appropriate,
to all others directly concerned.
• Take prompt and effective corrective
action if the harassment allegations are
proven. The employer must take appropriate action to stop the harassment and ensure it will not continue. The employer
must also communicate to the com-
plainant that action has been taken to stop the
harassment from recurring. Finally, appropriate
steps must be taken to remedy the complainant’s
damages, if any.
• Post the Department of Fair Employment and
Housing (DFEH) employment poster (DFEH
- 162) in the workplace (available through the
DFEH publications line [916] 478-7201 or
Web site).
• Distribute an information sheet on sexual
harassment to all employees. An employer may
either distribute this pamphlet (DFEH 185)
or develop an equivalent document that meets
the requirements of Government Code section
12950(b). This pamphlet may be duplicated in
any quantity. However, this pamphlet is
not to be used in place of a sexual harassment
prevention policy, which all employers are
required to have.
• All employees should be made aware of the
seriousness of violations of the sexual harassment
policy and must be cautioned against using peer
pressure to discourage harassment victims
from complaining.
• Employers who do business in California and
employ 50 or more part-time or full-time
employees must provide at least two hours of
sexual harassment training every two years
to each supervisory employee and to all new
supervisory employees within six months of
their assumption of a supervisory position.
• A program to eliminate sexual harassment from
the workplace is not only required by law, but is
the most practical way for an employer
to avoid or limit liability if harassment should
occur despite preventive efforts.
Employer Liability
All employers, regardless of the number of employees,
are covered by the harassment section of the FEHA.
Employers are generally liable for harassment by
their supervisors or agents. Harassers, including both
supervisory and non-supervisory personnel, may be
held personally liable for harassing an employee or
coworker or for aiding and abetting harassment.
Additionally, the law requires employers to take
“all reasonable steps to prevent harassment from
occurring.” If an employer has failed to take such
preventive measures, that employer can be held liable for the harassment. A victim may be entitled to
damages, even though no employment opportunity
has been denied and there is no actual loss of pay or
benefits.
In addition, if an employer knows or should have
known that a non-employee (e.g. client or customer) has sexually harassed an employee, applicant, or
person providing services for the employer and fails
to take immediate and appropriate corrective action, the employer may be held liable for the actions
of the non-employee.
An employer might avoid liability if
• the harasser is not in a position of authority,
Important Information about Medical Care if you have
a Work-Related Injury or Illness
Complete Written MPN Employee Notification
(Title 8, California Code of Regulations section 9767.12)
California law requires your employer to provide and pay for medical treatment if you are injured at work. Your employer has chosen to
provide this medical care by using a Workers’ Compensation physician network called a Medical Provider Network (MPN). This MPN is
administered by TRISTAR Managed Care. Your employer’s workers’ compensation carrier is TRISTAR Risk Management. This
notification tells you what you need to know about the MPN program and describes your rights in choosing medical care for work-related
Injuries and illnesses.
What Is a MPN?
A Medical Provider Network (MPN) is group of health care providers (physicians and other medical providers) used by your employer to
treat workers injured on the job. Each MPN must include a mix of doctors specializing in work- related injuries and doctors with expertise in
general areas of medicine.
MPNs must allow employees to have a choice of provider(s).
How do I find out which doctors are in my MPN?
The MPN contact listed at the end of this notification will be able to answer your questions about the MPN and will help you obtain a
regional list of all MPN doctors in your area. At minimum, the regional listing must include a list of all MPN providers within 15 miles of your
workplace and/or residence or a list of all MPN providers within the county where you live and/or work. You may choose which list you wish
to receive.
You can get the list of MPN providers by calling the MPN contact or by going to our website at www.tristarmanagedcare.com. Click the
box labeled “TRISTAR CA MPN”.
You also have the right to a complete listing of all of the MPN providers upon request.
What happens if I get injured at work?
In case of an emergency, you should call 911 or go to the closest emergency room.
If you are injured at work, notify your employer as soon as possible. Your employer will provide you with a claim form. When you notify
your employer that you have had a work-related injury, your employer or insurer will make an initial appointment with a doctor in the MPN.
How do I choose a provider?
After the first medical visit, you may continue to be treated by this doctor, or you may choose another doctor from the MPN. You may
continue to choose doctors within the MPN for all of your medical care for this injury. If appropriate, you may choose a specialist or ask
your treating doctor for a referral to a specialist. If you need help in choosing a doctor you may call the MPN Contact listed above.
Can I change providers?
Yes. You can change providers within the MPN for any reason, but the providers you choose should be appropriate to treat your injury.
What standards does the MPN have to meet?
The MPN has providers for the following for the entire state of California.
The MPN must give you a regional list of providers that includes at least three physicians in each specialty commonly used to treat work
injuries/illnesses in your industry. The MPN must provide access to primary physicians within 15 miles and specialists within 30 miles. If
you live in a rural area there may be a different standard.
The MPN must provide initial treatment within 3 days. You must receive specialist treatment within 20 days of your request. If you have
trouble getting an appointment contact the MPN.
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What if there are no MPN providers where I am located?
If you are a current employee living in a rural area or temporarily working or living outside the MPN service area, or you are a former
employee permanently living outside the MPN service area, the MPN or your treating doctor will give you a list of at least three physicians
who can treat you. The MPN may also allow you to choose your own doctor outside of the MPN network. Contact your MPN for assistance
in finding a physician or for additional information.
What if I need a specialist not in the MPN?
If you need to see a type of specialist that is not available in the MPN, you have the right to see a specialist outside of the MPN.
What if I disagree with my doctor about medical treatment?
If you disagree with your doctor or wish to change your doctor for any reason, you may choose another doctor within the MPN.
If you disagree with either the diagnosis or treatment prescribed by your doctor, you may ask for a second opinion from another doctor
within the MPN. If you want a second opinion, you must contact the MPN and tell them you want a second opinion. The MPN should give
you at least a regional MPN provider list from which you can choose a second opinion doctor. To get a second opinion, you must choose a
doctor from the MPN list and make an appointment within 60 days. You must tell the MPN Contact of your appointment date, and the MPN
will send the doctor a copy of your medical records. You can request a copy of your medical records that will be sent to the doctor.
If you do not make an appointment within 60 days of receiving the regional provider list, you will not be allowed to have a second or third
opinion with regard to this disputed diagnosis or treatment of this treating physician.
If the second opinion doctor feels that your injury is outside of the type of injury he or she normally treats, the doctor’s office will notify your
employer or insurer. You will get another list of MPN doctors or specialists so you can make another selection.
If you disagree with the second opinion, you may ask for a third opinion. If you request a third opinion, you will go through the same
process you went through for the second opinion.
Remember that if you do not make an appointment within 60 days of obtaining another MPN provider list, then you will not be allowed to
have a third opinion with regard to this disputed diagnosis or treatment of this treating physician.
If you disagree with the third opinion doctor, you may ask for an Independent Medical Review (IMR). Your employer or MPN contact
person will give you information on requesting an Independent Medical Review and a form at the time you request a third opinion.
If either the second or third opinion doctor agrees with your need for a treatment or test, you will be allowed to receive that medical service
from a provider inside the MPN, including the second or third opinion physician.
If the Independent Medical Reviewer supports your need for a treatment or test, you may receive that care from a doctor inside or outside
of the MPN.
What if l am already being treated for a work-related injury before the MPN begins?
Your employer or insurer has a “Transfer of Care” policy, which will determine if you can continue being temporarily treated for an existing
work-related injury by a physician outside of the MPN before your care is transferred into the MPN.
If you have properly predesignated a primary treating physician, you cannot be transferred into the MPN. (If you have questions about
predesignation, ask your supervisor.) If your current doctor is not or does not become a member of the MPN, then you may be required to
see a M PN physician.
If your employer decides to transfer you into the MPN, you and your primary treating physician must receive a letter notifying you of the
transfer.
If you meet certain conditions, you may qualify to continue treating with a non-MPN physician for up to a year before you are transferred
into the MPN. The qualifying conditions to postpone the transfer of your care into the MPN are below:
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(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 for at least 90 days without full cure or
worsens and requires ongoing treatment. 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 effective date.
You can disagree with your employer’s decision to transfer your care into the MPN. If you don’t want to be transferred into the MPN, ask
your primary treating physician for a medical report on whether you have one of the four conditions stated above to qualify for a
postponement of your transfer into the MPN.
Your primary treating physician has 20 days from the date of your request to give you a copy of his/her report on your condition. If your
primary treating physician does not give you the report within 20 days of your request, the employer can transfer your care into the MPN
and you will be required to use a MPN physician.
You will need to give a copy of the report to your employer if you wish to postpone the transfer of your care. If you or your employer
disagrees with your doctor’s report on your condition, you or your employer can dispute it. See the complete transfer of care policy for
more details on the dispute resolution process.
For a copy of the entire transfer of care policy, ask your MPN Contact.
What if I am being treated by a MPN doctor who decides to leave the MPN?
Your employer or insurer has a written “Continuity of Care” policy that will determine whether you can temporarily continue treatment for an
existing work injury with your doctor if your doctor is no longer participating in the M PN.
If your employer decides that you do not qualify to continuing your care with the non-MPN provider, you and your primary treating
physician must receive a letter of notification.
If you meet certain conditions, you may qualify to continue treating with this doctor for up to a year before you must switch to MPN
physicians. These conditions are set forth below:
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(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 for at least 90 days without full cure or
worsens and requires ongoing treatment. 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 effective date.
You can disagree with your employer’s decision to deny you Continuity of Care with the terminated MPN provider. If you want to continue
treating with the terminated doctor, ask your primary treating physician for a medical report on whether you have one of the four conditions
stated in the box above to see if you qualify to continue treating with your current doctor temporarily.
Your primary treating physician has 20 days from the date of your request to give you a copy of his/her medical report on your condition. If
your primary treating physician does not give you the report within 20 days of your request, the employer can transfer your care into the
MPN and you will be required to use a MPN physician.
You will need to give a copy of the report to your employer if you wish to postpone the transfer of your care into the MPN. If you or your
employer disagrees with your doctor’s report on your condition, you or your employer can dispute it. See the complete Continuity of Care
policy for more details on the dispute resolution process.
For a copy of the entire Continuity of Care policy, ask your MPN Contact.
What if I have questions or need help?
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MPN Contact: You may always contact the MPN Contact if you need help or an explanation about your medical treatment for your work
related injury or illness. Please call the Medical Access Assistant phone number for assistance with locating a provider in the MPN.
Title:
Address:
Telephone Number:
Medical Access Assistant:
Email address:
Employer’s MPN website:
Cresence Boland
P.O. Box 2805, Clinton, IA 52733-2805
(888) 558-7478
(855) 828-5256
[email protected]
www.tristarmanagedcare.com
Division of Workers’ Compensation (DWC): If you have concerns, complaints, or questions regarding the MPN, the notification process, or
your medical treatment after a work-related injury or illness, you can call DWC’s Information and Assistance at 1-800-736-7401. You can
also go to DWC’s website at www.dir.ca.gov/dwc and click on “medical provider networks” for more information about MPNs.
Independent Medical Review: If you have questions about the Independent Medical Review process contact the Division of Workers’
Compensation’s Medical Unit at:
DWC Medical Unit
P.O. Box 71010
Oakland, CA 94612
(510) 286-3700 or (800) 794-6900
Keep this information in case you have a work-related injury or illness.
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