Employee Emergency Information Form
Name:
Date
Month Day Year
Date
Email
example@example.com
Department:
Site:
Phone Number
Please enter a valid phone number.
List information below regarding persons whom you wish to be notified in the event of injury, illness, or emergency.
Name:
Address:
City:
State:
Zip Code:
Phone Number
Please enter a valid phone number.
Email
example@example.com
You are responsible for informing persons at your worksite if you have a medical condition that may require immediate first aid. The personnel and/or safety officer in your agency can help you identify and inform these persons of your first aid requirements. Medical information is confidential. It is your decision and responsibility to inform others if you believe it necessary for your health and safety while at work.
Signature
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Date
Month Day Year
Date

Employment Eligibility Verification

START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically, during the completion of this form. Employers are liable for errors in the completion of this form.
ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the documentation presented has a future expiration date may also constitute illegal discrimination.

Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form I-9 no later than the first day of employment, but not before accepting a job offer.)
Last Name:
First Name:
Middle Initial:
Other Last Names Used (if any)
Address (Street Number & Name):
Apartment Number:
City or Town:
State:
Zip Code:
Date
Month Day Year
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.
I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form.
I attest, under penalty of perjury, that I am (check one of the following boxes):
1. A citizen of the United States 2. A noncitizen national of the United States (See instructions above) 3. A lawful permanent resident 4. An alien authorized to work
If you chose number 3. please type in your Alien Registration Number/USCIS Number):
If you chose number 4. please list your work expiration date, if applicable, mm/dd/yyyy. If N/A, please type that below)
Signature
Clear
Date
Month Day Year
Date
Did you use a preparer and/or translator in completing Section 1?
I did not use a preparer or translator A preparer(s) and/or translator(s) assisted me with completing Section 1.
The fields below must be completed and signed when a preparer and/or translator assisted the employee with completing Section 1. If you did not receive help, please go to the next page. The person who assisted must fill out the information below:

I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct.
Signature of Preparer or Translator
Clear
Date
Month Day Year
Date
Lase Name:
First Name:
Address (Street Number and Name):
City or Town:
State Initial:
Zip Code:

Direct Deposit Information
Direct Deposit is required by CSRA EOA, INC. If you currently do not have banking services, please contact the fiscal office(Payroll) at 706-722-0493.
If applicable, please upload a copy of a voided check or a copy of a direct deposit authorization form from the bank.
Cancelof
I have given the following Direct Deposit Information to the fiscal office (Payroll)
Voided Check Direct Deposit Authorization Form from the bank I will provide the Fiscal Office (Payroll) with Direct Deposit information on or before the first day of work.
Signature
Clear
Print Name:
Date
Month Day Year
Date

Room for information about filling out W-4 form i.e.(Information on where to go, forms to put into this spot, etc.)

Employee's Withholding Certificate (W-4 Form)
Complete this W-4 Form so that CSRA EOA, INC. can withhold the correct federal income tax from your pay.
STEP 1: Enter Personal Information
First name and Middle initial:
Last Name:
Address:
City or town, state, and ZIP code:
Please choose an option
Singe or Married filing separately Married filing jointly or Qualifying widow(er) Head of household( Check only if you're unmarried and pay more than half the costs of keeping up a home for yourself and a qualifying individual.)
Complete Steps 2-4 ONLY if they apply to you; otherwise skip to Step 5. See page 2 for more information on each step, who can clam exemption from withholding, when to use the estimator at www.irs.gov/W4App, and privacy.
STEP 2: Multiple Jobs or Spouse Works
Complete this step if you (1) hold more than one job at a time, or (2) are married filing jointly and your spouse also works. The correct amount of withholding depends on the income earned from all of these jobs.

Do ONLY ONE of the following:
(a) Use the esitmator at www.irs.gov/W4App for most accurate withholding for this step (and Steps 3-4)
(b) Use the Multiple Jobs Worksheet on page 3 and enter the result in Step 4(c) below for roughly accurate withholding
(c) If there are only two jobs total, you may check the box below. Do the same on Form W-4 for the other job. This option is accuate for jobs with similar pay; otherwise, more tax than necessary may be withheld.
Option C
Complete Steps 3-4(b) on Form W-4 for only ONE of these jobs. Leave those steps blank for the other jobs. (Your withholding will be most accurate if you complete Steps 3-4(b) on the Form W-4 for the highest paying job).
STEP 3: Claim Dependents
If your total income will be $200,000 or less ($400,000 or less if married filing jointly):
Multiply the number of qualifying children under the age 17 by $2,000:
Multiply the number of other dependents by $500:
Add the amounts above and enter the total here:
STEP 4: (optional) Other Adjustments
4(a) Other income (not from jobs). If you want tax withheld for other income you expect this year that won't have withholding, enter the amount of other income here. This may include interest, dividends, and retirement income.
4(b) Deductions. If you expect to claim deductions other than the standard deduction and want to reduce your withholding, use the Deductions Worksheet on page 3 and enter the result here.
4(c) Extra withholding. Enter any additional tax you want withheld each pay period.
STEP 5: Sign Here
Employee's Signature (This form is not valid unless you sign it.)
Clear
Date
Month Day Year
Date
State of Georgia Employee's Withholding Allowance Certificate
Full Name:
Home Address (Number, Street, Route)
City, State, & Zip Code
FINISH UP PAGE

CSRA EOA, Inc. Standards of Conduct
CSRA EOA, Inc. ensures that all staff, consultants, and volunteers will abide by the program's standards of conduct. These standards must specify that:
1. I will respect and promote the unique identity of each child and family and reframe from stereotyping on the basis of gender, race, ethinicity, culture, religion, or disability.
2. I will follow program confidentiality policies concering information about children, families, and other staff members.
3. No child will be left alone or unsupervised while under my care
4. I will use positive methods of child guidance and I will not engage in coporal punishment, emotional or physical abuse, or humiliation. In addition, I will not employ methods of discipline that involve isolation, the use of food as punishment or reward, or the denial of basic needs.
5. I will conduct myself in a professional manner at all times.
6. I will not interfer with the work of ohter staff
7. I will not harass fellow employees
I have read and understand the Standards of Conduct, and I understand that anu vilation of this code will result in the termination of my employment.
Employee Name:
Signature
Clear
Date
Month Day Year
Date

CSRA EOA, Inc. Code of Ethics
By signing a copy of this code of ethics, I as an employee at this Agency, affirm that:
I have read and understand the Code of Ethics, and I understand that any violation of this code will result in the termination of my employment.
Employee Name
Employee Signature
Clear
Date
Month Day Year
Date

Consent to Release Information
I hereby authorize CSRA Economic Opportunity Authority, Inc. to reveive all Motor Vehicle Record informaiton pertaining to myself, which may include files from any State and/or Local Criminical Justice Agency in Georgia.
I expressly release the Department fof Public Safety and Richmond County Sheriffs Department from any and all liablitiy cliams relating to the acquisitoin and the release of any information pertaining to me.
Employee Name:
Signature
Clear
Date
Month Day Year
Date
Address (Street, City, State, Zip Code)
Driver License Number:
Race:
Gender
Male Female

Substance Abuse Policy Acknowledgement and Consent
I do hereby certify that I have received and read the CSRA EOA, Inc. Substance Abuse (and Drug Testing) Policy and have had the Drug Free Workplace Program explained to me. I understand that yearly and random drug tests are performed. I understand that failure to comply with a drug testing request or a positive result will lead to a termination of employment. I further understand that nothing in this policy is to be interpreted as a contract, or any aspect of a contract of employment. I understand that I must abide by the terms of this policy as a condition of my employment and will notify my supervisor of any criminal drug arrest of conviction no later than five (5) days after such events occur. I further realize that federal law may mandate that my employer commincate conviction infromation to a federal agency and I hereby waive any and all claims that may arise from conveying this information to a federal agency.
Employee Name:
Signature
Clear
Date
Month Day Year
Date

Revised Disciplinary Action Acknowledgment For Substance Abuse Policy

Disciplinary Actions for Safety-Sensitive Positions
An employee who refuses upon Agency request to submit to a drug/alcohol screening or tampers with the testing procedures shall be terminated.
An employee engaged in a safety-sensitive position who receives a confirmed positive controlled substance test or who has a blood-alcohol level of 0.02 or higher shall be terminated.
Safety sensitive positions include but are not limited to, Bus Driver/Maintenance, Van Drivers, Truck Drivers, (Weatherization), Subsistitue Drivers, Teachers, Teacher Aides, Family Service Workers, Cooks, Cook Aides, Parent Aides, Community Developer, NSC Coordinator, Homeless Coordinator, and EAP Workers.
Any employee who tests positive for a controlled substance or alcohol will be advised of where they can get assistance for alcohol and/or drug abuse and will be terminated.

The word "suspension" "suspended" or "leave of absence" as stated in this policy means Suspended without pay, and that I will not be paid at any time during my leave of absence.
I understand that nothing in this manual is to be interpreted as a contract, or any aspect of a contract of employment.
Employee Name:
Employee Signature
Clear
Date
Month Day Year
Date

Grievances

The Grievances Procedure is a way of helping you and your supervisor work together in solving work-related problems. Your supervisor and department head want you to understand the Grievance Procedures and to feel free to use it if a problem is not settled to your satisfaction. Remember, we are interested in seeing that you are treated fairly and with respect. Our goal is to find equitable solutions at the lowest possible level.

What is a Grievance?
A Grievance is a complaint you may have about your hours of work, your rights under personnel policies, your wages, seemingly unfair or unequal treatment of discipline, or other problems related to your employment.

Who can use this Grievance Procedure?
The Grievance Procedure can be used by all regular employees.

How does this Grievance Procedure Work?
If you have a problem, you should talk with your immediate supervisor as soon as possible and explain how you feel. It is very important that you do this, as it is only by hearing about your problem and talking with you that your supervisor can help you. Your supervisor will, in all cases, take prompt action to answer your questions and solve your complaint. The informal Grievance steps are outlined in the Agency's Personnel Policies and Procedures Manual in Section 16.0

Acknowledgement of Receipt of Grievance Procedure
I have reviewed and received my personal copy of the Grievance Procedures. I hereby acknowledge that I have read it or will have it read to me carefully.
Employee Name:
Employee Signature
Clear
Date
Month Day Year
Date
Please sign to acknowledge that you have been made aware and received a copy of the new Grievance Procedures.
Employee Name:
Date
Month Day Year
Date
Signature
Clear

CSRA Economic Opportunity Authority, Inc.
Whistleblower Policy Acknowledgement
I, blanks , hereby state that I have read the Whistleblower Policy of CSRA Economic Opporutnity Authority, Inc. I agree to act in good faith and have reasonable grounds for believing the information disclosed indicates a violation or suspected violation. I understand that any allegations that prove not to be substantiated and which prove to have been made maliciously or knowing to be false will be viewed as a serious offense and will be subject to disciplinary actions up to an including termination.

If I become aware of an actual or suspected violation, I will notify the Executive Director (if staff) or the chairperson of the Board of Directors.
Name:
Signature
Clear
Date
Month Day Year
Date

401k Retirement Plan
CSRA EOA, Inc. 401k Retirement Plan is open to all Employees who work 20 hours or more per week. The match is 6%. The Employee is vested from day one. The employee is eligible after being removed from probation. It is up to the Employee to complete the enrollment form online. The Employee will see the 401k deduction on their payroll history within two weeks after enrollment. If the deduction does not appear contact the HR Department immediately.
I have read and understand that it is my responsibility to complete the enrollment form for the 401 programs. If you need information on how to enroll please see the HR Department.
Employee Name:
Employee Signature
Clear
Date
Month Day Year
Date

Receipt of Policy Manual
I have received a copy of the revised Personnel Policies and Procedures Manual and have either read it or will have it read to me carefully. I agree that my employment is terminable - at will so that both the Agency and I remain free to end our work relationship. I understand that this manual has been prepared for the information and guidance of employees working at this Agency. It is intended to cover procedures, rules, and policies most often applied to day-to-day work activities. Some of the information will change from time to time since our policies are under constant review and revised when appropriate. I understand that I will be notified in writing of such changes.
I understand that there is no guarantee of employment made by any staff member, either expressly or implied in this manual.
Employee Name:
Employee Signature
Clear
Date
Month Day Year
Date

Acknowledgment of Receipt
I have received copies of the following information presented in Orientation.
1. Agency Mission Statement
2. Substance Abuse Policy
3. Grievance Procedures
4. Head Start Dress Code (HS Employees Only)
5. Whistleblowers Policy
6. Code of Ethics
7. Standards of Conduct
8. Corporal Punishment Policy
9. Health Examination Information (HS employees only)
10. Benefits Information (eligible employees only)

I have received the recommendation for my hourly rate of pay and notified that I must provide information to Payroll for Direct Deposit.
Employee Name:
Signature
Clear
Date
Month Day Year
Date

Orientation Checklist

Please type your initials to check off what you have gone over or done during the online orientation.

	Initials Here
Application for Employement
Criminal Background Check
Acknowledgment- Receipt of Substance Abuse Policy
Employment Eligibility Verification
Consent Form (Approved Driver)
Corporal Punishment Prohibition
Declaration of Prospective Employee
Recommendation Letter
New Tax Forms
Medical Insurance Enrollment Form
Certificates, Trainings, CRC, Records, & Reports
Code of Ethics
Grievance Procedures
Job Description
Policy Manual
Whistleblower Policy
Drug Screen Results

Employee Signature
Clear
Date
Month Day Year
Date
Should be Empty: