notice to employees If a work injury occurs California law guarantees certain benefits to employees who are injured or become ill because of their jobs. Any job related injury or illness is covered. Types of injuries and illnesses covered include, but may not be limited to, strains, sprains, cuts, cumulative or repetitive fractures, illnesses and aggravations. Some injuries from voluntary, off duty, recreational, social or athletic activity may not be covered. Check with your supervisor or claims administrator if you have questions. All work related injuries must be reported to your supervisor or employee representative immediately. If you wait too long, you may lose your right to benefits. Your employer is required to provide you a claim form within one working day after learning about your injury. It is illegal for your employer to punish or fire you for having a work injury or illness, for filing a claim, or testifying in another person’s workers’ compensation case. If proven, you may receive lost wages, job reinstatement, increased benefits, and costs and expenses up to limits set by the state.

Workers’ Compensation Benefits include MEDICAL CARE - All medical treatment - without a deductible or dollar limit. Within one working day after you file a claim form, treatment must be authorized, consistent with the applicable treating guidelines, for your alleged injury up to ten thousand dollars ($10,000) until the claim has been accepted or rejected. Costs are paid directly by the claim administrator, so you should never see a bill. For dates of injury on or after1/1/04 there is a limit on some medical treatment. You may be eligible to treat with your personal physician should you become injured on the job. If eligible, you must notify your employer in writing before you are injured. If you have questions please contact your employer who is required to provide written information regarding workers’ compensation benefits to all new employees. MEDICAL PROVIDER NETWORKS - Your employer may be using an MPN, which is a selected network of healthcare providers to provide treatment to workers injured on the job. If you have predesginated a personal physician prior to your work injury, then you may receive treatment from your predesignated doctor or medical group. If you have not predesignated and your employer is using an MPN, you are free to choose an appropriate provider from the MPN list which will be you primary treating physician. This is the doctor with overall responsibility for treating your injury or illness. If you are treating with a non-MPN doctor for an existing injury, you may be required to change to a doctor within the MPN. PAYMENT FOR LOST WAGES - If you’re temporarily disabled by a job injury or illness, you’ll receive tax-free income, subject to state limits, until your doctor says you are able to return to work. Payments are two-thirds of your average weekly pay, up to a maximum set by state law. Payments aren’t made for the first three days unless you’re hospitalized as an inpatient or unable to work more than 14 days. If the injury or illness results in permanent disability, additional payments will be made after recovery. If the injury results in death, benefits will be paid to surviving dependents. SUPPLEMENTAL JOB DISPLACEMENT BENEFIT - You may be entitled to a Supplemental Job Displacement Voucher, if your employer is not able to return you to work within 30 days after temporary disability ends. SJDB is a non-transferrable voucher payable to a state approved school.

In the event of a work injury 1. 2. 3. 4.

Be sure first aid is given. If emergency medical treatment is needed call 911. See that the injured employee is taken to a doctor or hospital, if necessary. Yanet Romero Report all injuries immediately to your supervisor or Employer Representative

5.

Contact your employer representative or claim administrator if you have questions about workers’ compensation. You may also contact an Information and Assistance Officer at the State Division of Workers’ Compensation at

at (530) 532-5765 Phone Number

1 800 736 7401

6.

Hear recorded information and a list of local offices by calling toll-free 800 736-7401 or visit www.dir.ca.gov.

Claims Administered by:

Emergency numbers:

Claims Administrator:

Keenan & Associates Address: PO Box 1538

City, State, Zip Code: Rancho Cordova 95670 Phone Number: 1 800 343 0694 Ext 4129

MPN Toll Free Number: MPN Website:

911 911

Police:

911

Hospital

911 Physician 911 or Chico Immediate Care 530 891 1676

Carrier/Self Insured: PIPS Policy expiration date: 6.30.16

Ambulance: Fire Department:

If this policy has expired contact the labor commissioner (213) 620-6630.

1 800 654 8102 www.keenan.com/providerlocator; Click onProvider Locator Tools; Then PRIME Advantage

MPN Effective Date: (cont. from above)Click on PRIME Advantage. 1.07.15 MPN Identification #: 2358 MPN’s Address:

Harbor Health Systems MPN Contact, PO Box 54770, Irvine, CA 92619-4770

Anyone who knowingly files or assists in the filing of a false workers’ compensation claim may be fined up to $150,000 and sent to prison for up to five years. (Insurance Code Section 1871.4) Your employer may not be liable for the payment of workers’ compensation benefits for any injury that arises from you voluntary participation in any off-duty, recreational, social, or athletic activity that is not part of your work-related duties

January 2016

pamphlet If a work injury occurs California law guarantees certain benefits to employees who are injured or become ill because of their jobs. Any job related injury or illness is covered. Types of injuries include, but may not be limited to, strains, sprains, cuts, cumulative or repetitive traumas, fractures, illnesses and aggravations. Some injuries from voluntary, off duty, recreational, social or athletic activity may not be covered. Check with your supervisor or Keenan & Associates if you have any questions. All work related injuries must be reported to your supervisor immediately. Don’t delay. There are time limits. If you wait too long, you may lose your right to benefits. Your employer is required to provide you a claim form within one working day after learning about your injury. It is a misdemeanor for an employer to discriminate against workers who are injured on the job or who testify in another employee’s case. Any such employee may be entitled to compensation, reinstatement and reimbursement for lost wages and benefits.

chiropractic, 24 physical therapy and 24 occupational therapy visits. However this limit does not apply for post surgical treatments. Costs are paid directly by Keenan & Associates, through your employer’s workers’ compensation program, so you should never see a bill. If emergency treatment is required go to the nearest emergency room or contact 911. Keenan & Associates will arrange medical treatment, often by a specialist for the particular injury. Preferred Provider Networks may be utilized for physicians as well as medical care centers. If you have health care coverage you are eligible to treatment with your personal physician or medical group should you become injured on the job. If you are eligible, before you are injured, you must notify your employer in writing and provide your employer written documentation from your personal physician or medical group that they agree to be predesignated. Your personal physician must be your regular primary care physician who previously directed your medical treatment, who retains your medical history and records. You may only predesignate your primary care physician if they are a family practitioner, general practitioner, board certified or board eligible internist, obstetrician-gynecologist, or pediatrician. Your personal physician may be a multispecialty medical group composed of licensed doctors or osteopathy providing

Workers’ compensation benefits include

medical services predominantly for nonoccupational illness and injuries.

Medical Care – All medical treatment, without a deductible or dollar limit. For dates of injury on or after 1/1/04 there is a limit of 24

Your employer may be using a Medical Provider Network (MPN), which is a selected group of health care providers to provide treatment to

July 2016

workers injured on the job. If you have predesignated a personal physician prior to your work injury, then you may receive treatment from your predesignated doctor. If you have not predesignated and your employer is using and MPN, you are free to choose an appropriate provider from the MPN list after the first medical visit directed by your employer or Keenan & Associates. If you are treating with a non-MPN doctor for an existing injury, you may be required to change to a doctor within the MPN. For more information, see the MPN contact information on reverse side. If your employer does not participate in a Medical Provider Network (MPN) you may be able to change your treating physician to your personal chiropractor or acupuncturist. Generally your employer, or Keenan, has the right to select your treating physician within the first 30 days after your employer knows of your injury or illness. After your employer, or Keenan, initiates treatment you may, upon request, have your treatment transferred to your personal chiropractor or acupuncturist. To be eligible you must notify your employer in writing prior to being injured. However, a chiropractor cannot be your treating physician after receiving 24 chiropractic office visit. Your employer will provide you with a form to use an optional method to predesignate your personal physician. Contact Keenan & Associates if you plan to change physicians at any time. Payment for Lost Wages - If you’re temporarily disabled by a job injury or illness, you’ll receive tax-free income until your doctor says you are able to return to work. Payments are two-thirds of your average weekly pay, up to

a maximum set by state law. Payments aren’t made for the first three days unless you are hospitalized in an inpatient basis or unable to work more than 14 days. If the injury or illness results in permanent disability, additional payments will be made after recovery. If the injury results in death, benefits will be paid to surviving, eligible dependents. Rehabilitation – For dates of injury on or after 1/1/04 - you may be entitled to a

Supplemental Job Displacement Voucher,

which entitles you to a voucher for educational training.

MPN Information Harbor Health Systems MPN Contact (888) 626-1737 [email protected]

How to obtain additional information Contact your employer representative or Keenan & Associates if you have questions about workers’ compensation benefits. You may also contact an Information and Assistance Officer at the State Division of Workers’ Compensation. You can consult an attorney. Most attorneys offer one free consultation. If you decide to hire an attorney, his or her fee will be taken out of some of your benefits. For names of workers’ compensation attorneys, call the State Bar of California at 415-538-2120.

Department of Workers’ Compensation

Information and Assistance Offices You can get free information from a state Division of Workers’ Compensation Information & Assistance Officer. The phone numbers are listed below. Hear recorded information by calling toll-free 800-736-7401 or visit www.dwc.ca.gov. Anaheim Bakersfield Eureka Fresno Goleta Long Beach Los Angeles Marina Del Rey Oakland Oxnard Pomona Redding Riverside Sacramento Salinas San Bernardino San Diego San Francisco

714-414-1804 661-395-2514 707-441-5723 559-445-5355 805-968-4158 562-590-5001 213-576-7389 310-482-3858 510-622-2861 805-485-3528 909-623-8568 530-225-2047 951-782-4347 916-928-3158 831-443-3058 909-383-4522 619-767-2082 415-703-5020

San Jose San Luis Obispo Santa Ana

408-277-1292 805-596-4159 714-558-4597

Santa Rosa Stockton Van Nuys

707-576-2452 209-948-7980 818-901-5367

July 2016

Keenan & Associates adjusting locations Keenan & Associates Claims Processing Unit PO Box 2707 Torrance, CA 90509 Torrance 800-654-8102 Eureka 707-268-1616 Pleasanton 925-225-0611 Rancho Cordova 800-343-0694 Redwood City 650-306-0616 Riverside 800-654-8347 San Jose 800-334-6554

Anyone who knowingly files or assists in the filing of a false workers’ compensation claim may be fined up to $150,000 and sent to prison for up to five years. [Insurance Code Section 1871.4]

Folleto de información para los nuevos empleados Si sufre una lesión de trabajo Las leyes de California garantizan ciertos beneficios a los empleados que resultan lesionados o se enferman a causa de su trabajo. Cualquier lesión o enfermedad relacionada con el trabajo está cubierta. Entre los tipos de lesiones se incluyen, sin limitarse, torceduras, esguinces, cortaduras, traumas cumulativos o repetitivos, fracturas, enfermedades y agravamientos. Algunas lesiones de actividades voluntarias, fuera de turno, recreativas, sociales o atléticas puede que no estén cubiertas. Si tiene alguna pregunta consulte con su supervisor o con Keenan & Associates. Todas las lesiones relacionadas con el trabajo deben ser reportadas a su supervisor inmediatamente. No espere, hay un límite de tiempo para reportarlas. Si espera demasiado, puede perder su derecho a recibir beneficios. Su empleador tiene la obligación de darle un formulario de reclamos dentro de un día laboral desde que se enteró de su lesión. Es un delito menor que un empleador discrimine a trabajadores que se lesionaron en el trabajo o que testifiquen en el caso de otro empleado. Cualquier empleado en esas circunstancias puede tener derecho a una indemnización, restitución y reembolso por la pérdida de ingresos y beneficios.

Los beneficios de compensación a los trabajadores incluyen Atención médica – Todo tratamiento médico sin deducible ni cantidad límite. Para lesiones sufridas con fechas de o posteriores al 01/01/04 hay un límite de 24 visitas quiroprácticas, 24 visitas de terapia física y 24 visitas de terapia ocupacional.

Sin embargo, este límite no se aplica a los tratamientos post quirúrgicos. El costo es pagado directamente por Keenan & Associates, a través del programa de compensación de su empleador, de modo que usted nunca tendrá que ver una factura. Si necesita tratamiento de emergencia vaya a la sala de emergencias más cercana, o llame al 911. Keenan & Associates hará arreglos para el tratamiento médico con un especialista para la lesión correspondiente. Redes de proveedores preferenciales pueden ser utilizados por médicos como también centros de tratamiento médico.

trabajo. Si usted ha hecho una designación previa de un médico personal antes de lesionarse en el trabajo, entonces puede recibir tratamiento de su médico previamente designado. Si no ha hecho una designación previa y su empleador está usando una MPN, usted puede escoger un proveedor apropiado de la lista de la MPN después de la primera visita médica dirigida por su empleador o por Keenan & Associates. Si está recibiendo tratamiento de parte de un médico que no pertenece a la MPN para una lesión existente, es posible que tenga que cambiar a un médico dentro de la MPN. Para más información, consulte la información de la Red de Proveedores Médicos en el reverso.

Si usted tiene cobertura de seguro de salud, es elegible para recibir tratamiento con su médico personal o grupo médico si se lesiona en el trabajo. Si es elegible, deberá notificar a su empleador por escrito antes de que cualquier lesión ocurra , y deberá proporcionar a su empleador evidencia por escrito de su médico personal o grupo médico que indique que acepta esta designación anticipada. Su médico personal debe ser su médico de atención primaria regular que haya estado a cargo anteriormente de su tratamiento médico, y mantiene su historial y expedientes médicos. Solo puede predesignar a su médico de tratamiento primario si es un médico familiar, médico general, certificado o internista titulado, obstetra-ginecólogo o pediatra. Su médico personal puede ser un grupo médico multi-especial compuesto de médicos licenciados u osteópatas cuya práctica es predominantemente para lesiones y enfermedades no ocupacionales.

Si su empleador no participa en una Red de Proveedores Médicos, es posible que pueda cambiar su médico a su quiropráctico o acupunturista personal. Generalmente, su empleador o Keenan tienen el derecho a elegir al médico para su tratamiento durante los 30 días posteriores a la fecha en que su empleador supo de la lesión o enfermedad. Después de que su empleador o Keenan inicie su tratamiento, usted puede solicitar que dicho tratamiento sea transferido a su quiropráctico o acupunturista personal. Para que esto sea posible usted deberá notificar a su empleador, por escrito, antes de la ocurrencia de cualquier lesión. Sin embargo, un quiropráctico no puede ser su médico personal después de recibir 24 visitas quiroprácticas.

Es posible que su empleador use una Red de Proveedores Médicos (por sus siglas en inglés MPN), que es un grupo selecto de proveedores de asistencia médica seleccionados para dar tratamiento a los trabajadores lesionados en el

Comuníquese con Keenan & Associates si piensa cambiar de médico en cualquier momento.

JULIO DE 2016

Su empleador le dará un formulario para que usted use como método optativo para predesignar a su médico personal.

Pago de ingresos perdidos – Si usted resulta temporalmente incapacitado debido a una lesión o enfermedad relacionada con el trabajo, recibirá ingresos libres de impuestos hasta que su médico indique que puede volver a trabajar. Los pagos serán dos terceras de su pago semanal normal, hasta un máximo establecido por la ley estatal. No se paga por los primeros tres días a no ser que usted sea internado en el hospital o no pueda trabajar por más de 14 días. Si la lesión o enfermedad resulta en una incapacidad permanente, se le harán pagos adicionales después de recuperarse. Si la lesión resulta en su fallecimiento, se le pagarán los beneficios a sus dependientes sobrevivientes elegibles. Rehabilitación – Para fechas de lesión del 01/01/04 y posteriores – Podría tener derecho a un Vale de desplazamiento de trabajo, el cual le da derecho a un vale para recibir entrenamiento educativo.

Información de MPN Harbor Health Systems MPN Contact (888) 626-1737 [email protected]

Cómo obtener información adicional Comuníquese con el representante de su empleador, o en caso de tener alguna pregunta acerca de sus beneficios de compensación a los trabajadores con Keenan & Associates. También puede comunicarse con un Funcionario de Información y Asistencia de la División Estatal de Compensación a los Trabajadores. Puede consultar con un abogado. La mayoría de los abogados ofrecen una primera consulta gratuita.

Si desea contratar a un abogado, los honorarios serán deducidos de algunos de los beneficios que le correspondan. Para obtener los nombres de abogados de compensación a los trabajadores, llame al State Bar of California al teléfono 415-538-2120.

Oficinas de Información y Asistencia del Departamento de Compensación a los Trabajadores Puede recibir información gratuita de un Funcionario de Información y Asistencia de la División de Compensación a los Trabajadores del estado. A continuación incluimos los números de teléfono. También puede escuchar información grabada llamando gratis al 800-7367401 o visitando www.dwc.ca.gov. Anaheim Bakersfield Eureka Fresno Goleta Long Beach Los Angeles Marina Del Rey Oakland Oxnard Pomona Redding Riverside Sacramento Salinas San Bernardino San Diego San Francisco San Jose San Luis Obispo Santa Ana Santa Rosa

714-414-1801 661-395-2514 707-441-5723 559-445-5355 805-968-4158 562-590-5001 213-576-7389 310-482-3858 510-622-2861 805-485-3528 909-623-8568 530-225-2047 951-782-4347 916-928-3158 831-443-3058 909-383-4522 619-767-2082 415-703-5020 408-277-1292 805-596-4159 714-558-4597 707-576-2452

JULIO DE 2016

Stockton Van Nuys

209-948-7980 818-901-5367

Oficinas de los ajustadores de Keenan & Associates Keenan & Associates Claims Processing Unit PO Box 2707 Torrance, CA 90509 Torrance 800-654-8102 Eureka 707-268-1616 Pleasanton 925-225-0611 Rancho Cordova 800-343-0694 Redwood City 650-306-0616 Riverside 800-654-8347 San Jose 800-334-6554 Cualquier persona que con conocimiento, presenta o ayuda en la presentación de una demanda falsa de compensación laboral puede ser multada con una suma de hasta $150,000 y hasta 5 años en prisión. [Código de seguros sección 1871.4]

Human Resources Department 1859 Bird Street Oroville, CA 95965 (530) 532-5765 Fax (530) 532-5787

STEP-BY-STEP REPORTING PROCEDURES FOR ALL INCIDENTS INVOLVING POTENTIAL OR ACTUAL INJURY TO AN EMPLOYEE If immediate medical attention is needed, go to the nearest emergency room or call 911. 1. Employee notifies Supervisor of injury right away. 2. Employee completes HR-122 form. The HR-122 form is available on our web site (found in the Forms Index under Human Resources Forms – workers’ comp forms) a. Please use the form from the web site. Since the online form is the most current version, this eliminates the possibility of using out-dated material. b. All areas of the form are important and need to be completed. DO NOT leave any field blank – if it does not apply, mark it as “N/A.”

3. Completed HR-122 form is IMMEDIATELY faxed to HR at (530) 5325787. DO NOT DELAY IN REPORTING INJURIES TO THE HUMAN RESOURCES DEPARTMENT. Do not wait to get Supervisor signature. Put original in mail to HR after securing signatures. Stop here if no medical attention is sought at time of injury. Proceed to step #4 if medical attention is necessary. 4. If non-emergency medical attention is required, or if unsure if medical treatment should be obtained, contact Company Nurse Injury Hotline at 1877-518-6702 – available 24 hours a day. Company Nurse gathers information over the phone and helps the employee access appropriate medical treatment. 5. If medical attention is required, employee must receive treatment from a medical facility within BCOE’s established Medical Provider Network (MPN). Company Nurse will refer the employee to the proper medical facility considering the employee’s work or home location. ***If a properly completed Physician Pre-designation is on file, the employee may seek treatment from his/her designated physician.

6. All work status reports issued by a medical facility are to be faxed to HR immediately (1-530-532-5787). Employee will also keep Supervisor apprised of work status at all times. 7. HR will report any work restrictions to Supervisor. Supervisor will notify HR whether work restrictions can be accommodated. a. If accommodated, employee may return to regular job. b. If accommodations cannot be made, employee may be temporarily assigned to alternate duty under BCOE’s Return-To-Work Program.

Every effort will be made to keep the employee working in some capacity, if possible, during the recuperative period. 8. Supervisor will be notified if doctor prohibits employee from returning to work. Payroll will determine salary continuation in conjunction with leave benefits. 9. Medical treatment and work status will be continually monitored until employee is released to full regular duty or until a determination is made that employee cannot return to work.

OTHER IMPORTANT POINTS: The BCOE reporting processes detailed here are not optional. Any extra reporting procedures imposed by an individual Department cannot be used to replace the steps outlined above. Be advised that if a claim is reported as “work related” and is denied by our workers compensation carrier, any lost time due to the injury will be charged to the employees leave. Workers' Compensation benefits only cover doctor-ordered time off from work, not the time taken for medical appointments. Therefore, sick leave will be charged for these hours. It is advised that all medical or therapy appointments be made before or after work hours.

2

BUTTE COUNTY OFFICE OF EDUCATION Workers’ Compensation: Pre-Designation of Personal Physician If you have health insurance and you are injured on the job you have the right to be treated immediately by your personal physician (M.D., D.O), or medical group, if you notify your employer, in writing, prior to the injury. Per Labor Code 4600 to qualify as the your predesignated, personal physician, the physician must agree, in writing, to treat you for a work related injury, must have previously directed your medical care and must retain your medical history and records. Your predesignated physician must be a family practitioner, general practitioner, board certified or board eligible internist, obstetrician-gynecologist or pediatrician. Your “personal physician” may be a medical group if it is a single corporation or partnership composed of licensed doctors or medicine or osteopathy, which operates an integrated multi-specialty medical group providing comprehensive medical services predominantly for non-occupational illnesses and injuries. This is an optional form that can be used to notify your employer of your personal physician. You may choose to use another form, as long as you notify your employer, in writing, prior to being injured on the job and provide written verification that your personal physician meets the above requirements and agrees to be predesignated. Otherwise, you will be treated by one of your employers’ designated workers’ compensation medical providers.

EMPLOYEE NAME & ADDRESS: ______________________________________________________________________________  I acknowledge receipt of this form and elect not to predesignate my personal physician at this time. I understand that I will receive medical treatment from my employers’ medical provider. I understand that, at any time in the future, I can change my mind and provide written notification of my personal physician. I understand that the written notification must be on file prior to an industrial injury. Employee Signature: __________________________________________________________ Date: ______________  If I am injured on the job, I wish to be treated by my personal physician*: Name of Physician or Medical Group ________________________________________ Phone Number ___________________ Address _________________________________________________________________________ *This physician is my personal primary care physician who has previously directed my medical care and retains my medical history and records. Name of Insurance Company, Plan, or Fund providing health coverage for non-occupational injuries or illnesses: ________________________________________________________________________________________________________

Employee Signature: __________________________________________________________ Date: ______________

A Personal Physician must be willing to be predesignated and treat you for a workers’ compensation injury. The remainder of this form is to be completed by your physician and returned to your Employer. PERSONAL PHYSICIAN ACKNOWLEDGEMENT Per Labor Code 4600 to qualify you must meet the criteria outlined above. You are not required to sign this form, however, if you or your designated employee, does not sign, other documentation of the physicians’ agreement to be predesignated will be required pursuant to Title 8, California Code of Regulations, section 9780.1(a)(3). PERSONAL PHYSICIAN OR MEDICAL GROUP NAME: _________________________________________________________  I agree to treat the above named employee in the event of an industrial accident or injury. I meet the criteria outlined above. I agree to adhere to the Administrative Director’s Rules and Regulations, Section 9785, regarding the duties of the employee-designated physician.

______________________________________________________ (Physician or Designated Employee of the Physician or Medical Group)

Please return completed form to: Human Resources 1859 Bird Street, Oroville, Ca 95965 530-532-5787 HR-301-rev:6-2014

_______________________ Date

BUTTE COUNTY OFFICE OF EDUCATION 1859 Bird Street Oroville, CA 95965 NEW REQUEST

PAYROLL DEPARTMENT 530-532-5650 Fax 530-532-5779

ELECTRONIC DEPOSIT AUTHORIZATION

NAME CHANGE

Effective Date:

NET CHECK AUTHORIZATION I Authorize the Butte County Office of Education and the financial institution listed below to deposit my NET pay automatically to the account indicated each payday and, if necessary, to adjust or reverse a deposit for any payroll entry made to my account in error

Checking

Savings Account

Transit Routing #

Cancel

Change

Account #

NET PAY Financial Institution

VOLUNTARY DEDUCTION (Separate Checking or Savings Account, Deposit Flat amount only) Checking Savings Account Cancel Change Transit Routing #

Account #

Financial Institution

Amount to Deposit

VOLUNTARY DEDUCTION (Separate Checking or Savings Account, Deposit Flat amount only) Checking Savings Account Cancel Change Transit Routing #

Account #

Financial Institution

Amount to Deposit

VOLUNTARY DEDUCTION (Separate Checking or Savings Account, Deposit Flat amount only) Checking Savings Account Cancel Change Transit Routing #

Account #

Financial Institution

Amount to Deposit

VOLUNTARY DEDUCTION (Separate Checking or Savings Account, Deposit Flat amount only) Checking Savings Account Cancel Change Transit Routing #

Account #

Financial Institution

Amount to Deposit

VOLUNTARY DEDUCTION (Separate Checking or Savings Account, Deposit Flat amount only) Checking Savings Account Cancel Change Transit Routing #

Account #

Financial Institution

Amount to Deposit

For checking accounts, please attach a voided check to this form. For savings accounts, please contact your financial institution for the proper transit routing number and account number. Any missing or incorrect information will cause these transactions to be delayed. I understand that my first payroll check after this authorization will be mailed to my current mailing address while a test payroll is sent to my financial institution. This authorization will remain in effect until I have canceled it in writing. Name (Please Print)

Date

ID # (or Social Security )

Signature

HR 84: Electronic Deposit Authorization (Revised 10/12)

Butte Schools Self-Funded Program

Employee Assistance Program

1-800-523-5668

Up to four in-person sessions per year/per problem

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TO: RE:

Substitute, Temporary, Short-Term, Contracted for Temporary Service Employees

Paid Sick Leave (AB 1522 - Healthy Workplaces/Health Families Act, 2014) and Instructions for Usage

On September 10, 2014, Governor Jerry Brown signed into law the California Healthy Workplaces/Healthy Families Act of 2014 (AB 1522). This Act provides employees time off to attend to their own health care and the health care of family members to ensure a healthier and more productive workforce in California.

Individuals employed by the Butte County Office of Education (BCOE), who are not covered by a collective bargaining unit agreement or other Butte County Office of Education sick leave policy are entitled to rights to sick leave as outlined by the Act. BCOE recognizes the rights of these individuals and outlines the procedures for enacting this new law. Retired annuitants of a public entity and workers covered by the Railroad Unemployment Insurance Act are exempt from this coverage.

A. Eligibility: An individual who, on or after July 1, 2015, works thirty (30) days or more in California within a fiscal year is entitled to paid sick leave (does not have to be consecutive days).

B. Accrual: 1) Individuals who perform variable work as a substitute, temporary, short-term, or contracted for temporary service: a. Will accrue one (1) hour paid sick leave for every thirty (30) hours worked; and b. Will be allowed to carryover unused sick leave to the following year of employment but will not exceed forty-eight (48) hours in total at any given time. 2) Information related to sick leave balances, accrual, and usage covered by this policy will be maintained by the HR/PY office. C. Procedures: Beginning July 1, 2015, an individual covered by this policy shall be entitled to the following: 1) Use accrued sick leave on their ninetieth (90th) day of employment with BCOE. 2) Will be limited to twenty-four (24) hours of sick leave use in any given fiscal year. 3) All Sick leave absence request(s) covered by this policy must be reported on a Variable Employee Attendance Monthly Report form (HR-045A). 4) If the use of the sick leave is foreseeable (e.g., a pre-scheduled doctor’s appointment), the employee shall provide reasonable advance notification to the supervisor at least two (2) days prior to usage. 5) The individual is not responsible for securing his or her own replacement worker for sick leave absences covered by this policy. 6) The rate of pay will be at the individual’s hourly wage. If the individual, in the 90 days of employment before taking accrued sick leave had different hourly pay rates, then the rate of pay shall be calculated by dividing the individual’s total wages, not including overtime pay, by the total hours worked in the pay periods of the prior 90 days of employment. D. Employment Separation: 1) Individuals covered by this policy will not be paid or compensated for accrued, unused paid sick days upon termination, resignation, retirement, or other separation of employment. 2) Sick leave under this policy is non-transferable to another employer or employee. 3) If an individual separates from BCOE and is rehired within one year from the date of separation, previously accrued and unused paid sick days shall be reinstated. a. The individual shall be entitled to use those previously accrued and unused paid sick days. Rev. 1//2017

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An individual rehired under Section B.1, would accrue additional paid sick days upon rehiring, not to exceed forty-eight (48) hours in total at any given time. 4) BCOE shall keep records documenting the hours worked, paid sick days accrued and used by an employee for three (3) years. 5) BCOE shall allow the Labor Commissioner and the employee to access these records.

E. General Information: 1) Paid sick leave is used for the diagnosis, care, or treatment of an existing health condition, as well as preventive care, for the employee or family member. 2) Sick leave covered by this policy may be used for a victim of domestic violence, sexual assault, or stalking. However, an individual who requests sick leave covered by this Section E.2 is required to provide certification as outlined in Labor Code sections 230 and 230.1. 3) BCOE provides electronic access to payroll information via Employee Online (EO). 4) BCOE shall not deny an individual the right to use accrued sick leave, discharge, threaten to discharge, demote, suspend, or in any manner discriminate against an individual for using accrued sick leave, attempting to exercise the right to use accrued sick leave, filing a complaint with the Butte County Superintendent of Schools or alleging violation of this Act, cooperating in an investigation or prosecution of an alleged violation of the Act, or opposing any policy or practice or act that is prohibited by this Act. 5) For purposes of this policy, family member is defined as: a. A child means a biological, adopted, or foster child, stepchild, legal ward, or a child to whom the employee stands in loco parentis, regardless of age or dependency status. b. A biological, adoptive, or foster parent, stepparent, or legal guardian of an employee or the employee’s spouse or registered domestic partner, or a person who stood in loco parentis when the employee was a minor child c. A spouse d. A registered domestic partner e. A grandparent f. A grandchild g. A sibling

F. Sick Leave Balances: 1) Sick leave balances are available by logging into Employee Online 2) From the www.bcoe.org page click “Employee Online” from the Quick Links on the left side of the home page 3) During your first visit your User Name will be your BCOE ID#; your Password will be the last 4 digits of your social security number. You will be asked to change your password when you log in for the first time. 4) Once logged in click the “Leave Tracking” tab at the top of the page (you can also click “Leave Tracking” under “Pay Information” 5) You will select “Sick Leave Balances” from the Leave Type drop down

Any questions regarding the information and procedures provided in this memorandum should be directed to either Allison Bubier, Payroll Manager, 530-532-5816, [email protected] or Debbie Haggard, 530532-5765, [email protected].

Rev. 1//2017