Employee Confidentiality Invention Assignment Agreement by fmi50884

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									                                            Table of Contents


Chapter 1 — Recruitment and Hiring
Form
Number             Title                                                                                                           Page
1-1          College Recruitment Letter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1-18
1-2          Application for Employment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1-19
1-3          Application for Employment (with EEO Statement, alternative 1) . . . . . . . . . . .1-23
1-4          Application for Employment (with EEO Statement, alternative 2) . . . . . . . . . . .1-30
1-5          The Internet Applicant Regulations: A Roadmap for Compliance. . . . . . . . . . . .1-34
1-6          Employment Interview Questions: Acceptable and Unacceptable . . . . . . . . . . . .1-39
1-7          Candidate Evaluation Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1-42
1-8          Candidate Evaluation Form, alternate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1-44
1-9          Reference Check Consent Form & Release . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1-46
1-10         Telephone Reference Check Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1-47
1-11         Reference Request: Information from Former Employer . . . . . . . . . . . . . . . . . . .1-49
1-12         Reference Request: Educational Record . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1-50
1-13         Criminal Background Certification Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1-51
Fair Credit Reporting Act Forms (FCRA)
1-14         Summary of Rights (CAL Only) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1-52
1-15         Notice to Employee or Applicant of Adverse Action Taken Based on
                Consumer Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1-54
1-16         Letter to Employee Providing Consumer Report and Prior Notice of
                Potential Adverse Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1-56
1-17         Notice of Consumer Rights (FCRA and Some State Laws) . . . . . . . . . . . . . . . .1-57
1-18         Notice to Applicant Regarding Consumer Report or Investigative
                Consumer Report and Consent Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1-60
1-19         Employee Release and Authorization for Consumer Report or
                Investigatory Consumer Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1-61
1-20         Release and Authorization for Public Records (without Consumer
                Rights Agency) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1-63
1-21         Offer Letter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1-64
1-22         Offer Letter, alternative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1-66
1-23         Offer Letter with Compensation Elements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1-68
1-24         Rejection Letter (no interview) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1-70
1-25         Regret Letter (general) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1-71
1-26         New-Hire Orientation Checklist for Supervisors . . . . . . . . . . . . . . . . . . . . . . . . .1-72
1-27         Employee Confidentiality Agreement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1-73
1-28         Employee Confidentiality & Invention Assignment Agreement. . . . . . . . . . . . . .1-78

                                                                                                                                     xiii
Form
Number             Title                                                                                                           Page
1-29         Confidentiality & Noncompetition Agreement . . . . . . . . . . . . . . . . . . . . . . . . . . .1-83
1-30         Covenant Not to Compete and Not to Solicit . . . . . . . . . . . . . . . . . . . . . . . . . . . .1-89
1-31         Proprietary Information, Non-Competition/Non-Solicitation and Intellectual
             Property Agreement (California). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1-90
1-32         Employee Confidentiality Statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1-96
1-33         Employee Certification re Confidentiality and Invention Agreement on
             Termination of Employment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1-97
1-34         Written Notice to Employee re California Labor Code Restriction on
             Invention Assignment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1-98
1-35         Commission Sales Agreement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1-99
1-36         Executive Employment Agreement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1-101
1-37         Executive Employment Agreement for use Upon Sale of Company . . . . . . . . .1-108
1-38         Executive Employment Agreement (alternative) . . . . . . . . . . . . . . . . . . . . . . . .1-118
1-39         Generic Employment Agreement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1-128
1-40         Independent Contractor/Consultant Agreement . . . . . . . . . . . . . . . . . . . . . . . . .1-138
1-41         Consulting Agreememt . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1-142
1-42         Independent Contractor Agreement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1-147
1-43         Independent Contractor Clauses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1-153
1-44         Tear Off Acknowledgement of Receipt/At-will Statement for
             Employee Handbook . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1-154
1-45         Self-Identification Form for Applicants Including Request for
             Government Contractors Only . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1-155
1-46         Self-Identification Form for Employees and Applicants Including
             New EEO-1 Categories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1-157
Job Descriptions
1-47         Sample Job Description Outline and Forms . . . . . . . . . . . . . . . . . . . . . . . . . . . .1-159
1-48         File Clerk. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1-161
1-49         Sweeper . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1-162
1-50         Mainenance Supervisor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1-163
1-51         Manager, Personnel Financial Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1-164
1-52         Manager, Project Engineer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1-165
1-53         Final Asembly Processor, Lead . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1-167

Chapter 2 — Immigration
2-1                Employment Eligibility Verification (I-9) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
2-2                Petition for Non-immigrant Worker (I-129) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
2-3                Blanket L Petition (I-129S) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
2-4                Application for Employment Authorization (I-765) . . . . . . . . . . . . . . . . . . . . . . . . 78
2-5                Application to Extend/Change Non-immigrant Status (I-539) . . . . . . . . . . . . . . . . 90
2-6                Application to Register Permanent Residence or Adjust Status (I-485) . . . . . . . . . . . 104

xiv
Form
Number            Title                                                                                                          Page
2-7               Petition for Alien Relative (I-130) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .    120
2-8               Immigrant Petition for Alien Worker (I-140) . . . . . . . . . . . . . . . . . . . . . . . . . . . .            127
2-9               Application for Citizenship (N-400) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .        140
2-10              Immigrant Petition by Alien Entrepreneur (I-526) . . . . . . . . . . . . . . . . . . . . . . . .               157
2-11              Alien’s Change of Address Card (AR-11). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .            165
2-12              Alien’s Change of Address Special Registration (AR-11SR) . . . . . . . . . . . . . . .                         166
2-13              Request for Premium Processing Service (I-907) . . . . . . . . . . . . . . . . . . . . . . . . .               167
2-14              Application for Alien Employment Certification (ETA 750) . . . . . . . . . . . . . . . .                       174
2-15              Labor Certification Application Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .          177
2-16              Labor Condition Application for Non-immigrant Workers (ETA-9035) . . . . . . .                                 187

Chapter 3 — Performance Management
3-1          Checklist for Assessing Risk in Proposed PersonnelDecisions and
             Their Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3-14
Alternative Dispute Resolution Forms
3-2          Arbitration Agreement, Model 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3-18
3-3          Arbitration Agreement, Model 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3-20
3-4          Dispute Resolution Policy and Agreement . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3-22
3-5          Grievance Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3-26
Annual Performance Evaluation Forms
3-6          Annual Performance Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3-27
3-7          Annual Performance Evaluation, Alternative 2 . . . . . . . . . . . . . . . . . . . . . . . . . .3-30
3-8          Annual Performance Evaluation, Alternative 3 . . . . . . . . . . . . . . . . . . . . . . . . . .3-36
3-9          Interim Performance Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3-39
3-10         Performance Evaluation Policy Statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3-41
3-11         Employee Self-Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3-43
3-12         Bonus Award Letter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3-45
3-13         Bonus Award Letter — Section 401(k) Option . . . . . . . . . . . . . . . . . . . . . . . . . . .3-46
3-14         Conflict of Interest Statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3-47
Workplace Dress Codes
3-15         Dress Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3-48
3-16         Business Attire Dress Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3-51
3-17         Business Casual Dress Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3-54
3-18         Summer Dress Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3-55
Progressive Discipline
3-19         Performance Improvement Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3-56
3-20         Notice of Verbal Warning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3-58
3-21         Disciplinary/Counseling Report Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3-59
3-22         Written Warning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3-61
3-23         Written Warning: Three-Step Disciplinary Process . . . . . . . . . . . . . . . . . . . . . . .3-62
                                                                                                                                    xv
Form
Number            Title                                                                                                          Page
3-24              Notice of Suspension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3-63
3-25              Final Written Warning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3-64
3-26              Last Chance Agreement (General) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3-65
3-27              Last Chance Agreement (Substance Abuse) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3-67
3-28              Last Chance Agreement (Performance) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3-68

Chapter 4 — Workplace Investigations: Discrimination and Harassment
4-1          Workplace Investigation Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-10
Workplace Harassment Policy
4-2          Workplace Harassment Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-15
4-3          Confirmation of Receipt, Workplace Harassment Policy. . . . . . . . . . . . . . . . . . . . . 4-18
4-4          Sexual Harassment Policy and Acknowledgement Form . . . . . . . . . . . . . . . . . . .4-19
4-5          Incident Report — Harassment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4-21
Harassment and Discrimination Investigation Worksheet and Forms
4-6          Admonitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4-22
4-7          Complainant Interview Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4-23
4-8          Complainant Documentation Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4-26
4-9          Interview Form — Accused Employee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4-27
4-10         Witnesses Interview Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4-29
4-11         Follow-up with the Complainant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4-31
4-12         Follow-up with Accused . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4-32
4-13         Statement of Complainant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4-33
4-14         Employee Statement of Accused or Other Non-Managment Witness . . . . . . . . .4-34
4-15         Management Witness Statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4-35
4-16         Incident Report Log . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4-36
Assessment of Information Learned in the Investigation
4-17         Preliminary Assessment of Information Learned in the Investigation . . . . . . . . .4-37
4-18         Preliminary Report to Complainant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4-41
4-19         Preliminary Report to Accused Employee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4-43
4-20         Report of Investigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4-44
4-21         Report to Complainant Documenting Response to Complainant . . . . . . . . . . . . .4-45
4-22         Repost to Complainant After Harassment Investigation . . . . . . . . . . . . . . . . . . . .4-46
4-23         Report to Accused Employee Documenting Response to Complainant . . . . . . .4-47
4-24         Report to Accused Employee, Alternate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4-48
4-25         Sample Position Statement Responding to Discrimination Charge . . . . . . . . . . .4-49
4-26         Indemnification Clause for Management Employees, Executives and
             Board Members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4-53




xvi
Form
Number            Title                                                                                                          Page
Chapter 5 — Wage and Hour Issues
5-1          FLSA Compliance Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5-20
5-2          Independent Contractor Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5-24
5-3          Minimum Wage Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5-26
5-4          Eligible Subminimum Wage Earners . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5-29
5-5          Survey to Determine the Hours an Employee Works . . . . . . . . . . . . . . . . . . . . .5-30
5-6          Survey to Determine Whether an Employee is Paid on a Salary Basis . . . . . . . . . .5-34
5-7          Wage Hour/Equal Pay Audit Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5-36
5-8          Position Analysis Information Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5-45
5-9          Exempt/Non-Exempt Employee Questionaire . . . . . . . . . . . . . . . . . . . . . . . . . . .5-48
The Executive Exemption
5-10         Checklist for the Executive Exemption “Standard” Test . . . . . . . . . . . . . . . . . . .5-58
5-11         Approval Form for Executive Exemption “Standard” Test . . . . . . . . . . . . . . . . .5-59
5-12         Checklist for the Executive Exemption “Highly Compensated”
                Employee Test. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5-60
5-13         Approval Form for Executive Exemption “Highly Compensated
                Employee” Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5-61
The Administrative Exemption
5-14         Checklist for Administrative Exemption “Standard” Test . . . . . . . . . . . . . . . . . .5-62
5-15         Approval Form for Administrative Exemption “Standard” Test. . . . . . . . . . . . . .5-63
5-16         Checklist for Administrative Exemption “Highly Compensated
                Employee” Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5-64
5-17         Approval Form for Administrative Exemption “Highly Compensated
                Employee” Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5-65
The Learned Professional Exemption
5-18         Checklist for the “Learned” Professional Exemption “Standard” Test . . . . . . . . .5-66
5-19         Approval Form for “Learned” Professional Exemption “Standard” Test . . . . . . .5-67
5-20         Checklist for “Learned” Professional Exemption “Highly Compensated
                Employee” Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5-68
5-21         Approval Form for “Learned” Professional Exemption “Highly
                Compensated Employee” Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5-69
The Creative Professional Exemption
5-22         Checklist for “Creative” Professional Exemption “Standard” Test . . . . . . . . . . .5-70
5-23         Approval Form for “Creative” Professional Exemption “Standard” Test . . . . . . . . . 5-71
5-24         Checklist for “Creative” Professional Exemption “Highly Compensated
                Employee” Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5-72
5-25         Approval Form for “Creative” Professional Exemption “Highly
             Compensated Employee” Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5-73
5-26         Approval Form for Classification of Workers in a Computer-Related
             Occupation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5-74

                                                                                                                                  xvii
Form
Number            Title                                                                                                             Page
5-27              Approval Form for Classification of Outside Sales Employees . . . . . . . . . . . . . .5-75
5-28              Approval Form for Commission Sales Employee in a Retail or Service
                  Establishment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5-76
5-29              Sales Commission Incentive Plan and Payment Schedule . . . . . . . . . . . . . . . . . .5-77
5-30              Acknowledgement of Change in Overtime Calculation . . . . . . . . . . . . . . . . . . .5-79
5-31              Computation of Regular Rate and Overtime Compensation. . . . . . . . . . . . . . . . .5-80
5-32              Calculating Half-Time. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5-81
5-33              Overtime Authorization Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5-85
5-34              Overtime Authorization Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5-87
5-35              Belo Plan Agreement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5-88
5-36              Guidelines for Compensating Nonexempt Business Travel . . . . . . . . . . . . . . . . .5-89
5-37              Half-Time Consent Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5-91
5-38              Hot Goods Clause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5-92
5-39              Volunteer Eligibility Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5-93

Chapter 6 — Workplace Accommodations and Leaves of Absence
6-1          Flow Chart of the Reasonable Accommodation Process . . . . . . . . . . . . . . . . . . .6-12
6-2          ADA Accommodation Request Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6-13
6-3          Employer’s Response to Initial ADA Accommodation Request . . . . . . . . . . . . .6-14
6-4          ADA Accommodation Request Approval Form . . . . . . . . . . . . . . . . . . . . . . . . .6-15
6-5          ADA Accommodation Request Denial Form . . . . . . . . . . . . . . . . . . . . . . . . . . . .6-16
6-6          ADA Disability Advisory to Supervisor/Company Health Representatives . . . . . . . 6-17
6-7          Employer’s Checklist for Including Individuals with Disabilities in Emergency
             Evacuation Plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6-18
Religious Accommodation
6-8          Religious Accommodation Request Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6-19
6-9          Employer Response to Religious Accommodation Request . . . . . . . . . . . . . . . . .6-20
Family and Medical Leave (FMLA)
6-10         FMLA Leave Decision Making Flow Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6-21
6-11         Family and Medical Leave Act Desk Aid – Time Guidelines. . . . . . . . . . . . . . . .6-23
6-12         FMLA Eligibility Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6-25
6-13         Family Medical Leave Log . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6-27
6-14         State Leave Laws – Public Sector Laws Comparison. . . . . . . . . . . . . . . . . . . . . .6-28
6-15         Family and Medical Leave Act Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6-34
6-16         Request for Non-Military Family/Medical Leave. . . . . . . . . . . . . . . . . . . . . . . . .6-42
6-17         Request for Qualifying Exigency Leave Under the Military Provisions
             of FMLA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6-44
6-18         Request for Military Caregiver Leave Under the Military Provisions
             of FMLA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6-47
6-19         Request for Extension of Non-Military Family/Medical Leave . . . . . . . . . . . . . .6-50
xviii
Form
Number             Title                                                                                                             Page
6-20         Request for Extension of Military Family/Medical Leave . . . . . . . . . . . . . . . . . .6-52
6-21         Notice of Eligibility and Rights & Responsibilities Family and
             Medical Leave Act . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6-55
6-22         Designation Notice Family and Medical Leave Act . . . . . . . . . . . . . . . . . . . . . . .6-59
6-23         Notice of Intention to Return From Leave . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6-61
6-24         Fitness-for-Duty Certification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6-62
6-25         Request for Additional Medical Information . . . . . . . . . . . . . . . . . . . . . . . . . . . .6-63
6-26         Request for Additional Medical Information for Qualifying
             Exigency Leave . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6-64
6-27         Request for Additional Medical Information for Military Caregiver
             Leave . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6-65
Medical Certifications
6-28         Certification of Health Care Provider for Employee’s Serious Health
             Condition Family and Medical Leave Act . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6-66
6-29         Certification of Health Care Provider for Family Member’s Serious
             Health Condition Family and Medical Leave Act. . . . . . . . . . . . . . . . . . . . . . . . .6-70
6-30         Certification for Serious Injury or Illness of Covered Servicemember –
             For Military Family Leave and Medical Leave Act . . . . . . . . . . . . . . . . . . . . . . .6-74
6-31         Release of Employee Medical Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6-79
6-32         Request for Second Medical Opinion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6-80
6-33         Request for Third Medical Opinion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6-81
6-34         Certification of Qualifying Exigency for Military Family Leave Family
             and Medical Leave Act . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6-82
6-35         Letter to Employee Requesting FMLA Leave Explaining Rights . . . . . . . . . . . .6-86
6-36         Letter Withdrawing Conditional Leave Grant. . . . . . . . . . . . . . . . . . . . . . . . . . . .6-87
6-37         Letter Granting Conditional Leave . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6-88
6-38         Notice of Potential Interruption of Health Care Coverage . . . . . . . . . . . . . . . . . .6-89
6-39         Communication to Employee at the Conclusion of FMLA Leave . . . . . . . . . . . .6-90
6-40         Return to Work Letter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6-91
6-41         Communication to Employee Regarding Intermittent Leave . . . . . . . . . . . . . . . .6-92
6-42         Military Family Relationships Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6-93
6-43         Application for Leave for Military Service. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6-95
6-44         Application for Reemployment Following Military Leave . . . . . . . . . . . . . . . . .6-96
6-45         Authorization to Donate Hours to the Compassionate Transfer of
             Leave Pool . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6-97
6-46         Request for Donated Hours from the Compassionate Transfer of
             Leave Pool. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6-98
General Leave Forms
6-47         Leave of Absence Request . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6-99
6-48         Leave Without Pay Request Form. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6-100
6-49         Personal and Vacation Days Request Form . . . . . . . . . . . . . . . . . . . . . . . . . . . .6-101
6-50         Parental Leave Request Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6-102
6-51         Request for Time Off (Jury Duty, Witness and Bereavement Leave) . . . . . . . . .6-103
                                                                                                                                        xix
Form
Number            Title                                                                                                        Page
Chapter 7 — Workplace Safety and Health
Accident & Illness Reporting Forms
7-1          Summary of Work-Related Injuries and Illnesses (OSHA Form 300A) . . . . . . . . .7-9
7-2          Log of Work-Related Injuries and Illnesses (OSHA Form 300) . . . . . . . . . . . . . .7-10
7-3          Injuries and Illnesses Incident Report (OSHA Form 301) . . . . . . . . . . . . . . . . . .7-12
7-4          Pandemic Preparedness Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7-13
7-5          Emergency Evacuation Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7-15
7-6          Workplace Safety Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7-17
7-7          Workplace Emergency Preparedness Checklist . . . . . . . . . . . . . . . . . . . . . . . . . .7-19
7-8          Emergency Contact Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7-20
Alcohol and Drug Testing
7-9          Alcohol & Drug Policies & Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7-21
7-10         Drug Testing Consent Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7-26
7-11         Substance Abuse Reasonable Suspicion Report . . . . . . . . . . . . . . . . . . . . . . . . . .7-27
7-12         Smoking Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7-30
7-13         Workplace Violence Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7-31
Bloodborne Pathogens Forms
7-14         Report to Healthcare Professional. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7-33
7-15         Post-exposure Medical Evaluation Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7-35
7-16         Confidential Disclosure Agreement to Medical Professional and
             Designated Representative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7-36
7-17         Employee Report of a Vehicle/Equipment Accident . . . . . . . . . . . . . . . . . . . . . . .7-37
Lockout/Tagout Forms
7-18         Lockout/Tagout Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7-40
7-19         Lockout/Tagout Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7-41
7-20         Annual Machine Inspection Certification Form . . . . . . . . . . . . . . . . . . . . . . . . . .7-42
7-21         Manager’s Accident Investigation Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7-43
Material Safety Data Sheet (“MSDS”) Requests
7-22         Request for MSDS for a Specific Product. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7-46
7-23         Request for an Updated MSDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7-47

Chapter 8 — Payroll
Payroll Processing
8-1          Pay Change Authorization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8-9
8-2          Employee Status Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8-11
8-3          Bi-Weekly Timesheet (Non-Exempt Employees) . . . . . . . . . . . . . . . . . . . . . . . .8-12
8-4          Time Card for Non-Exempt Employees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8-13
8-5          Bi-Weekly Time and Leave Report (Salaried/Exempt Employees) . . . . . . . . . . .8-14
8-6          Payroll Variance Approval Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8-15
8-7          Business Expense Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8-16
xx
Form
Number            Title                                                                                                      Page
8-8          Travel Advance Request . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8-18
8-9          Relocation Benefits Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8-19
8-10         Agreement for Reimbursement of Moving Expenses . . . . . . . . . . . . . . . . . . . . . .8-20
8-11         Tuition Reimbursement Policy and Request . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8-21
8-12         Authorization for Educational Assistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8-23
8-13         Tuition Reimbursement Log . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8-24
8-14         Check Request Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8-25
8-15         Direct Deposit Authorization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8-26
Payroll Overpayment Forms
8-16         Payroll Overpayment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8-27
8-17         Acknowledgement of Overpayment/Agreement to Repay . . . . . . . . . . . . . . . . . .8-28
8-18         Request and Authorization for the Payroll Deduction of Union Dues . . . . . . . . .8-29
8-19         Request for Salary Advance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8-30
8-20         Request for Employment Verification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8-31
8-21         Request for Replacement W-2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8-32
Flexible Scheduling
8-22         Flex Time Request Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8-33
8-23         Flexible Work Arrangement Agreement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8-34
8-24         Job Sharing Memorandum of Understanding . . . . . . . . . . . . . . . . . . . . . . . . . . . .8-35
8-25         Compensatory Time Off Agreement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8-36
8-26         Compensatory Time Off Tracking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8-37

Chapter 9 — Affirmative Action
9-1         OFCCP Compliance Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9-10
Equal Opportunity Clauses
9-2         EEO Clause for Executive Order 11246 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9-13
9-3         EEO Clause for Special Disabled Veterans and Veterans of the
              Vietnam Era . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9-14
9-4         EEO Clause for Individuals with Disabilities . . . . . . . . . . . . . . . . . . . . . . . . . . . .9-17
9-5         Sample Affirmative Action Plan (“AAP”) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9-19
9-6         Sample Functional Affirmative Action Plan (“FAAP”) . . . . . . . . . . . . . . . . . . . .9-69
9-7         OFCCP Compensation Audit Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9-75
9-8         New EEO-1 Forms and Instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9-77
9-9         The Beck Clause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9-85
9-10        Beck/NLRB Poster . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9-87
9-11        VETS-100 Contractor Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9-88

Chapter 10 — Technology in the Workplace
E-mail and Internet Usage Policies
10-1         E-Mail and Internet Use Policy and Acknowledgement . . . . . . . . . . . . . . . . . . .10-6
10-2         Computer and Electronic Communications System Policy . . . . . . . . . . . . . . . . .10-8
                                                                                                                               xxi
Form
Number            Title                                                                                                     Page
10-3        E-Mail, Voice Mail and Internet Usage Policy . . . . . . . . . . . . . . . . . . . . . . . . . .10-10
10-4        Computer Use Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10-11
10-5        E-Mail Use Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10-12
10-6        E-Mail Systems Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10-13
10-7        E-Mail and Computer System Release Form . . . . . . . . . . . . . . . . . . . . . . . . . . .10-15
10-8        Cell Phone Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10-16
10-9        Computer Loan Application, Loan Agreement . . . . . . . . . . . . . . . . . . . . . . . . . .10-17
Telecommuting
10-10       Teleworking Policy & Acknowledgement . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10-20
10-11       Telecommuting Application . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10-21
10-12       Telecommuting/Remote Work Agreement . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10-22
10-13       Employee Polygraph Protection Act Poster, U.S. Department of Labor . . . . . . . . . 10-24
10-14       Polygraph Consent Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10-26

Chapter 11 — Benefits: COBRA
11-1         COBRA Notification Timeline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11-14
Election Notices and Forms for Alternative Coverage and Health FSAs
11-2         Disability or Workers’ Compensation Leave Form. . . . . . . . . . . . . . . . . . . . . . .11-16
11-3         Disability or Workers’ Compensation Leave First Notice . . . . . . . . . . . . . . . . .11-19
11-4         Disability or Workers’ Compensation Leave Notice of End . . . . . . . . . . . . . . . .11-25
11-5         Federal Family and Medical Leave Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11-30
11-6         Federal Family and Medical Leave Notice . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11-33
11-7         Health Flexible Spending Arrangements (FSAs) Form . . . . . . . . . . . . . . . . . . .11-38
11-8         Health Flexible Spending Arrangements (FSAs) Notice . . . . . . . . . . . . . . . . . .11-41
COBRA and Retiree Medical Coverage
11-9         Retirement/Retiree Medical Coverage Form . . . . . . . . . . . . . . . . . . . . . . . . . . .11-45
11-10        Retirement/Retiree Medical Coverage First Notice . . . . . . . . . . . . . . . . . . . . . .11-48
11-11        Retirement/Retiree Medical Coverage Notice of End . . . . . . . . . . . . . . . . . . . .11-54
11-12        Revocation of Waiver for COBRA Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . .11-58
11-13        Waiver of COBRA Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11-59
COBRA Rights and Chapter 11 Bankruptcy
11-14        Chapter 11 Bankruptcy Filing Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11-61
11-15        Bankruptcy Qualifying Notice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11-64
Election Notices and Forms from Plan Administrator for Initial Qualifying Events
11-16        Cessation of Dependent Status Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11-68
11-17        Cessation of Dependent Status Notice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11-70
11-18        Death, Divorce, Legal Separation and Medicare Entitlement Form . . . . . . . . . .11-74
11-19        Death, Divorce, Legal Separation and Medicare Entitlement Notice . . . . . . . . .11-77
11-20        Termination or Reduction in Hours of Employment Form . . . . . . . . . . . . . . . . .11-81
11-21        Termination or Reduction in Hours of Employment Notice . . . . . . . . . . . . . . . .11-84
xxii
Form
Number            Title                                                                                                         Page
Model Election and General Notices and Forms
11-22         Model COBRA Continuation Coverage Election Notice
              (from DOL, for use by single-employer group health plans) . . . . . . . . . . . . . . .11-89
11-23         Model COBRA Election Notice in Spanish (from DOL, for use by
              single-employer group health plans) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11-96
11-24         Model General Notice of COBRA Rights in Spanish (from DOL, for
              use by single-employer health plans) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11-105
11-25         Model General Notice of COBRA Coverage Rights Under
              Health FSA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11-109
11-26         Model General Notice of COBRA Continuation Coverage Rights
              (from DOL, for use by single-employer group health plans) . . . . . . . . . . . . . . 11-111
Notice of Unavailability of COBRA Coverage
11-27         Based on Notice of Initial Event . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11-115
11-28         Based on Notice of Second/Multiple Event . . . . . . . . . . . . . . . . . . . . . . . . . . .11-116
11-29         Based on Notice of SSA Disability Determination . . . . . . . . . . . . . . . . . . . . . .11-118
11-30         Due to Gross Misconduct . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11-119
Notices for Termination of COBRA Coverage and Conversion Rights
11-31         Notice of Early Termination of COBRA Coverage . . . . . . . . . . . . . . . . . . . . .11-120
11-32         Notice of Early Termination of COBRA Coverage and
              Conversion Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11-121
Notices to Plan Administrator
11-33         Employee/Qualified Beneficiary Notice of a Qualifying Event . . . . . . . . . . . .11-123
11-34         Employee/Qualified Beneficiary Notice of a Multiple
                 Qualifying Event . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11-124
11-35         Employee/Qualified Beneficiary Notice of an SSA Disability
                 Determination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11-125
11-36         Employee/Qualified Beneficiary Notice of an SSA Revocation of
                 Disability Determination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11-126
11-37         Employer Notice of a Qualifying Event . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11-127
Optional Notices for COBRA Extension
11-38         Multiple Qualifying Event . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11-128
11-39         SSA Disability Determination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11-129
Payment
11-40         Notice of Late Payment of COBRA Premiums . . . . . . . . . . . . . . . . . . . . . . . .11-130
11-41         Notice of Underpayment of COBRA Premiums . . . . . . . . . . . . . . . . . . . . . . . .11-131
COBRA Premium Subsidy
11-42         Model ARRA General Notice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
11-43         Model Alternative ARRA Notice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
11-44         Model ARRA Notice of New Election Period . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
11-45         Model ARRA Notice on Supplemental Information . . . . . . . . . . . . . . . . . . . . . . 161
11-46         Model ARRA Notice of Extended Election Period . . . . . . . . . . . . . . . . . . . . . . . . 165
                                                                                                                                xxiii
Form
Number          Title                                                                                                             Page
11-47           Model ARRA Election Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .           173
11-48           ARRA Form for Switching COBRA Benefit Options . . . . . . . . . . . . . . . . . . . . .                            174
11-49           Summary of ARRA Subsidy Provision, as Amended . . . . . . . . . . . . . . . . . . . . .                            175
11-50           Request for Treatment as an Assistance Eligible Individual . . . . . . . . . . . . . . . . .                       176

Chapter 12 — Benefits: HIPAA
12-1         Certificate of Group Health Plan Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                   11
12-2         General Notice of Pre-existing Condition Exclusions . . . . . . . . . . . . . . . . . . . . . .                         14
12-3         Notice to Employee Regarding Pre-existing Condition (Substance Abuse) . . . . .                                         15
12-4         Notice of Adverse Coverage Determination Regarding A Pre-existing Condition . .                                         17
12-5         Certification to Group Health Plan, HMO or Health Insurer . . . . . . . . . . . . . . . . .                             18
12-6         Written Notice of Employee’s Decision to Decline Health Coverage . . . . . . . . . .                                    19
12-7         Notice of Privacy Practices for Protected Health Information . . . . . . . . . . . . . . . .                            20
12-8         Sample Employer Authorization Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                  24
Sample Individual Rights Forms
12-9         Employee Request to Inspect Protected Health Information . . . . . . . . . . . . . . . . .                              25
12-10        Employer Response to Inspection Request . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                   26
12-11        Employee Request to Correct or Amend a Record . . . . . . . . . . . . . . . . . . . . . . . . .                         27
12-12        Employer’s Response to Amendment or Correction Request . . . . . . . . . . . . . . . . .                                28
12-13        Employee Request Not to Use or Disclose Health Information . . . . . . . . . . . . . . .                                29
12-14        Sample Internal Log of Medical Record Disclosures . . . . . . . . . . . . . . . . . . . . . . .                         30
12-15        Employee Confidentiality Agreement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                31

Chapter 13 — Benefits: Domestic Partnerships
13-1            Acknowledgment of Domestic Partner Benefits . . . . . . . . . . . . . . . . . . . . . . . . . .13-7
13-2            Acknowledgement of FMLA-Style Leave . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13-8
13-3            Acknowledgement of “Grossed Up” Compensation. . . . . . . . . . . . . . . . . . . . . . .13-9
13-4            Acknowledgement of Non-ERISA Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . .13-10
13-5            Acknowledgement of Tax Treatment of Domestic Partner Benefits . . . . . . . . . .13-11
13-6            Declaration of Domestic Partnership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13-13
13-7            Defined Benefit Plan Language to Include a Domestic Partner
                Death Benefit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13-15
13-8            Domestic Partner Death Benefit Language . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13-16
13-9            Domestic Partner Statement and Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13-17
13-10           Termination of Domestic Partnership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13-19
13-11           Verification of Dependent Status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13-20

Chapter 14 — Benefits: Health Care, Dependent Care, and Other Matters
14-1            Checklist of Types of Employee Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14-13
14-2            Personalized Employee Benefits Statement . . . . . . . . . . . . . . . . . . . . . . . . . . . .14-14
14-3            Health Care Cost Cutting Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14-17
xxiv
Form
Number           Title                                                                                                   Page
14-4         Health Insurance Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14-19
14-5         Employee Agreement, Pre-Tax Payroll Deduction for Health Premiums . . . . . . .14-22
Flexible Spending Accounts
14-6         Flexible Spending Account Enrollment Form . . . . . . . . . . . . . . . . . . . . . . . . . .14-23
14-7         Flexible Benefit Accounts Enrollment Agreement . . . . . . . . . . . . . . . . . . . . . . .14-24
14-8         Automatic Dependent Care Reimbursement Agreement . . . . . . . . . . . . . . . . . .14-26
14-9         Flexible Spending Plan Election Change Request Form . . . . . . . . . . . . . . . . . .14-27
14-10        Flexible Spending Plan Change in Benefit Election . . . . . . . . . . . . . . . . . . . . . .14-29
14-11        Flexible Spending Plan Benefit Claim Form . . . . . . . . . . . . . . . . . . . . . . . . . . .14-30
Health Savings Accounts
14-12        General Application for Health Savings Account . . . . . . . . . . . . . . . . . . . . . . . .14-32
14-13        HSA Change of Address Notification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14-35
14-14        HSA Distribution Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14-36
14-15        HSA Employer Contribution Worksheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14-37
14-16        HSA E-Statement Application . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14-38
14-17        HSA Rollover Request Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14-39
14-18        HSA Funds Transfer Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14-40
14-19        Transfer from [Custodian] to HSA Sub-Account . . . . . . . . . . . . . . . . . . . . . . . .14-41
Insurance Coverage Issues
14-20        Health Insurance Coverage Statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14-42
14-21        Health Care Plan Waiver . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14-43
14-22        Health Care Spousal Surcharge Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14-44
14-23        Medical Insurance Option . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14-46
14-24        Benefits Changes Due to Reduction in Hours . . . . . . . . . . . . . . . . . . . . . . . . . . .14-47
14-25        USERRA Leave: Insurance Continuation Letter . . . . . . . . . . . . . . . . . . . . . . . .14-48
Other Benefits
14-26        Employee Referral Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14-49
14-27        Employee Referral Award Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14-50
14-28        Transportation Benefit Plan Enrollment/Change/Cancellation . . . . . . . . . . . . . .14-51
14-29        Transportation Benefit Plan Reimbursement Request . . . . . . . . . . . . . . . . . . . .14-53
14-30        Adult Immunization Consent Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14-54
14-31        Adoption Assistance Request Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14-55
Employee Assistance Programs (“EAPs”)
14-32        Employee Assistance Program Policy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14-57
14-33        Employee Assistance Program Policy, Alternate . . . . . . . . . . . . . . . . . . . . . . . .14-58
14-34        Memo to Management Introducing EAP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14-59
14-35        Supervisor Referral for EAP/Life Balance Services . . . . . . . . . . . . . . . . . . . . . .14-60
Health Care Reform
14-36        Model Statement of Grandfathered Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14-61

                                                                                                                          xxv
Form
Number            Title                                                                                                            Page
14-37             Model Notice of Opportunity to Enroll Related to Extension of
                   Dependent Coverage to Age 26 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14-62
14-38             Model Notice Related to Elimination of Benefit Limits and Enrollment
                   Opportunity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14-63
14-39             Model Notice of Patient Protection Disclosure. . . . . . . . . . . . . . . . . . . . . . . . . .14-64
14-40             Model Notice of Adverse Benefit Determination . . . . . . . . . . . . . . . . . . . . . . . .14-65
14-41             Model Notice of Final Internal Adverse Benefit Determination . . . . . . . . . . . .14-68
14-42             Model Notice of Final External Review Decision . . . . . . . . . . . . . . . . . . . . . . .14-71

Chapter 15 — Benefits: Savings, Pension and Profit-Sharing Plans
Plan Enrollment
15-1         Pension Plan Enrollment Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15-9
15-2         Profit-Sharing and Trust Enrollment and Election Form . . . . . . . . . . . . . . . . . .15-11
15-3         401(k) Automatic Enrollment Election for New Hires . . . . . . . . . . . . . . . . . . . .15-12
Plan Administration
15-4         Election for Directed Investment Selections . . . . . . . . . . . . . . . . . . . . . . . . . . . .15-13
15-5         Payroll Authorization, Investment Election, and Contribution
                Election Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15-14
15-6         Plan Fee Disclosure Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15-15
15-7         Summary Annual Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15-27
15-8         Election for Direct Rollover . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15-29
15-9         Rollover/Withholding Notice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15-30
15-10        Benefit Distribution Application Form (Employee) . . . . . . . . . . . . . . . . . . . . . .15-38
15-11        Profit-Sharing Plan and Trust Benefit or Withdrawal Request And
                Approval Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15-39
Beneficiary Designation Forms
15-12        Beneficiary Designation Form (General) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15-41
15-13        Beneficiary Designation Form – 401(k) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15-43
15-14        Group Profit Sharing and Savings Plan Beneficiary Designation Form . . . . . . . .15-44
15-15        Profit-Sharing Plan and Trust Beneficiary Designation Form . . . . . . . . . . . . . .15-45
Spousal Consent
15-16        Profit-Sharing Plan and Trust Spousal Consent Form . . . . . . . . . . . . . . . . . . . .15-46
15-17        Spousal Consent (General) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15-47
Loans to Plan Participants
15-18        Loan Application . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15-49
15-19        Loan Disclosure Statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15-50
15-20        Loan Agreement, Note and Pledge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15-51
15-21        Hardship Withdrawal Application . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15-52
15-22        QDRO (Plan Participant Vested, Long-time Marriage, Splits Future
                Benefits Payments) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15-53

xxvi
Form
Number            Title                                                                                                          Page
15-23             QDRO (Splits Plan Participant’s Accumulated Contributions Account) . . . . . . . .15-57
15-24             401(k) Plan Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15-60

Chapter 16 — For-Cause Termination
16-1       Termination Checklist (legal issues) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16-9
16-2       Termination Checklist (to-do list) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16-13
16-3       Administrative Leave Letter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16-15
16-4       Termination Letter (Misconduct) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16-16
16-5       Termination Letter (Performance). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16-17
16-6       Termination Information Letter. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16-19
16-7       Termination Information Letter, Alternate . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16-20
16-8       Termination Letter (Leave Expiration) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16-22
16-9       Job Abandonment Letter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16-23
16-10      Letter of Resignation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16-24
16-11      Voluntary Resignation Acceptance Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16-25
16-12      Termination Notice Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16-26
16-13      Exit Interview Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16-27
16-14      Termination Return of Property Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16-30
16-15      Post-termination Letter Demanding Return of Company Property . . . . . . . . . .16-31
References
16-16      Former Employee Reference Authorization Form . . . . . . . . . . . . . . . . . . . . . . .16-32
16-17      Reference Letter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16-33
16-18      Departure Announcement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16-34
Employee Requests for Access to Personnel Files
16-19      Request to View Personnel File . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16-35
16-20      Request to View Personnel File (with costs for photocopying) . . . . . . . . . . . . .16-36

Chapter 17 — Reductions in Force
17-1         Avoiding Liability in Mass Layoffs and Downsizing . . . . . . . . . . . . . . . . . . . . . .17-7
Reduction in Force Letters
17-2         Reduction in Force Letter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17-18
17-3         Reduction in Force Layoff Letter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17-19
17-4         Sample Notice of Mass Layoff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17-21
17-5         Sample Notice of Plant Closure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17-23
WARN Notices
17-6         WARN Notice to Employees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17-25
17-7         WARN Notice to State Dislocated Worker Unit . . . . . . . . . . . . . . . . . . . . . . . . .17-26
17-8         WARN Notice to Local Government . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17-27
17-9         WARN Notice to State Dislocated Worker Unit and Local Government . . . . . . . . . 17-28
17-10        WARN Notice 90 Day Aggregation Rule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17-29
                                                                                                                                xxvii
Form
Number            Title                                                                                                         Page
17-11             WARN Employee Acknowledgement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17-30
17-12             Intent to Retire/Separate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17-31

Chapter 18 — Releases and Other Severance Agreements
Releases for Employees Under 40
18-1          Release for Employees Under Age 40 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18-8
18-2          Settlement Agreement and General Release for Employees
                 Under Age 40 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18-13
Releases for Age-Protected Employees Over 40
18-3          Settlement Agreement and General Release for Employees Over 40 . . . . . . . . .18-18
18-4          Severance and Release Agreement for Over-40 Employee . . . . . . . . . . . . . . . .18-23
18-5          Separation Agreement and General Release Upon Termination . . . . . . . . . . . . .18-27
18-6          Release Agreement: Voluntary Retirement . . . . . . . . . . . . . . . . . . . . . . . . . . . .18-33
18-7          Intent to Retire/Separate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18-36
Reductions in Force Affecting a Group of Employees
18-8          OWBPA Disclosure Form for Group Terminations . . . . . . . . . . . . . . . . . . . . . .18-37
18-9          Reduction in Force Release of Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18-38
18-10         Reduction in Force Separation Agreement . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18-43
18-11         Change in Control Severance Agreement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18-48
18-12         Confidentiality in Release . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18-58
18-13         Separation Agreement for Use in California . . . . . . . . . . . . . . . . . . . . . . . . . . . .18-59
18-14         Settlement Agreement and General Release – Mutual . . . . . . . . . . . . . . . . . . . .18-63




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