TO BE COMPLETED BY THE EMPLOYEE. Employee Name Social Security Number Job Title: Phone: Amount of Educational Assistance Requested: Tuition: $ Date of Course(s): Fees: $ Date Course(s) Completed: Textbooks: $ Total: $ Information on course(s): Employee Signature Date To Be Completed by the Administrator: I verify that this class is a work-related class. Administrator's Name (please print) Administrator's Signature Date **********(For Human Resources Use Only)********** Amount Reimbursed $ Director, Human Resources Processor: Date of Reimbursement: 4/02 KEP FOOTHILL - DE ANZA COMMUNITY COLLEGE DISTRICT PROFESSIONAL GROWTH AWARD Application Form To be filled in by employee and submitted to Professional Growth Review Panel upon completion of requirements (see attached "Guidelines for Professional Growth Award"). Please review the attached CHECKLIST and make sure you have included all necessary paperwork when submitting your application packet for review. Name Social Security No. Position Campus Department Date of Hire Office Phone No.
TO BE COMPLETED BY THE EMPLOYEE. I have reviewed the information provided in Part 1 and select the following option with respect to my request to transfer: (Please indicate the option you wish to select.)
TO BE COMPLETED BY THE EMPLOYEE. _______I have reviewed this evaluation with my supervisor and have been given a copy. _______I will attach a personal statement to this evaluation. ____________________________________________________________________ Signature of Employee Date The presence of the employee’s signature indicates that the evaluation form has been reviewed by the employee -- it does not imply agreement with the evaluation OVERALL EVALUATION RATING FOR THIS EMPLOYEE’S JOB EFFECTIVENESS: ____________________________________________________________________ Signature of Administrator Conducting the Evaluation Date DISTRIBUTION: Employee Administrator/Supervisor Employee’s personnel file (original) #108seceval/pz Attachment A association dues deduction, 6 release time, 7 rights for building use, 8 association membership, 4 condition of employment, 4 attendance incentive program, 23 bargaining unit classification, 48 change of, 34 compensatory time, 21 conference attendance, 45 special, 44 conference attendance, 9 discipline association representation, 15 grievance, 15 progressive, 15 duration, 46 evaluation, 49 by immediate supervison, 44 member rebuttal, 45 procedure, 45 holidays, 32 inclement weather, 35 inservice, 9 insurance dental, 28 health, 26 life, 26 long term disability, 29 option to health, 29 Insurance Health reimbursement Account, 31 job description/duties, 10 just cause, 15 layoff defined, 16 notice, 17 recall list, 17 reduction in work force, 16 leave of absence eligibility, 18 notification, 18 notification to return, 19 salary schedule advancement, 19 lunch period, 20 medication dispensation, 10 member defined, 3 paid leave days jury duty, 24 Index payroll deductions, 10 premium pay, 34 recall notice of, 17 notification of change of address, 17 probationary members, 17 relief time, 20 resignation, 16 salary 2007-2008, 47 longevity, 31 seniority, 11 defined, 11 lottery, 12 no bumping, 12 sick bank, 25 committee, 25 sick leave, 22 accumulation, 22 doctor's note, 23 family illness, 22 holiday pay, 24 workers compensation, 24 sick leave days funeral, 23 graduation, 22 sick leave payoff, 34 special pay plan, 35 strike no, 42 substitute secretary, 36 terminal leave pay, 34 transfer defined, 12 duration, 13 notification, 14 probationary period, 14 trial period, 13 tuition reimbursement, 45 vacancies posted, 14 vacancy defined, 14 vacation, 33 work conditions change of, 36 work day, 19 overtime, 21 shift hours, 20 work hours summer, 20 work schedule
TO BE COMPLETED BY THE EMPLOYEE. The purpose of this report is to assess your situation in order to help you return to work at the earliest possible date. In order to accomplish this it is necessary for you to fill in Section 1 and give the form to your doctor so that he/she may complete Section II. Employee Name: Position: Branch: Date Absence Began: Name of Physician: I request the physician to complete the information listed below and I authorize its release to my employer. Employer Signature: Date:
