CHECKLIST FOR NEW HIRES (Full-time)

FORMS TO COMPLETE: OTHER INFORMATION:

Employee Information Form (benefits)

W-4

I-9 (verification of eligibility to work)

Previous Coverage card

Travel Accident card

Worker’s Compensation Information

Worker’s Compensation Panel Listing

ID card

Receipt of Important Documents

Chaplain’s Welcome

FERPA form

Direct Deposit

Self ID

Hepatitis B (Plant Operations, Campus Safety, Athletics)

Post Employment

Residency Certification Form

Drug Free Consent Form

Handbook Receipt (non-faculty)

Vehicle Registration (online)

Life/LTD enrollment form

LST (Local Services Tax)

• If already paid, provide receipt or copy of pay stub

Annual Notices Flyer

Benefit Summary/Rate Sheet

Campus Map

COBRA Notice

Credit Union Information

Discriminatory Harassment Policy

Drug-Free Workplace Policy

FMLA Information

New Hire Information Brochure

Employee Health Affidavit

Open Enrollment Flyers

PPO/Vision/Dental Benefit Summaries

Preventive Schedule (if enrolling in health care)

Summary of Benefits and Coverage (if enrolling in health care)

Summary of Privacy Practices (if enrolling in health care)

LTC (Long term care) Insurance Information

Faculty/Staff Campaign

Safety Video

EMPLOYMENT INQUIRY RELEASE

In connection with your application for/continued employment with Muhlenberg College, on their behalf, CBY Systems Inc. will make inquiries, including but not limited to, your consumer credit history, education, professional licensing, criminal history, driving history, your personal character, abilities, work habits, residence, immigration status, general reputation, performance, experience and other qualities pertinent to your qualifications for employment, including reasons for termination of past employments. In compliance with the Fair Credit Reporting Act (FCRA), you are entitled to be informed if an offer of employment is withheld because of information obtained from CBY Systems Inc. and, in that event, upon your written request, we will provide a copy of the report we receive and the FTC notice, “A Summary of Your Rights Under the Fair Credit Reporting Act”. Please complete and sign the form which follows, authorizing, without reservation, any party, including, but not limited to, employers, consumer reporting agencies, law enforcement agencies, state agencies, institutions and private information bureaus or repositories, contacted by CBY System Inc. to furnish any or all of the above mentioned information. Your signature allows a photocopy or fax copy of this authorization to be as valid as the original. PRINT FULL NAME *DATE OF BIRTH SOCIAL SECURITY # DRIVER LICENSE # STREET ADDRESS ___ ___ CITY, STATE, ZIP MAIDEN OR OTHER NAMES USED GRADUATION DATE: HIGH SCHOOL COLLEGE APPLICANT SIGNATURE: *Date of birth is being requested only for the purposes of identification in obtaining accurate retrieval of records and it will not be used for discriminatory purposes. Revised 10/2012

Human Resources Office

Full-Time Employee Information Form &

Benefits Enrollment Form

Section 1.

Name: Hire Date:

Home Address: Home Phone:

City, State, Zip Work Phone:

Would you like your home address & home phone included in the Faculty/Staff Employee Directory? Yes No

Marital Status: Single Married Divorced Separated Widowed

Include Spouse Name: Yes No Spouse Name (if applicable)

Date of Birth: Sex: Male Female

Berg ID: Department:

Acct. No.

Instructions: Make your selection by checking the plan and your coverage choice for each section. If you do not select a benefit option, write “Waive”.

Section 2. Benefits Complete if eligible (signature required at the end of the form) Highmark Blue Shield PPO MEDICAL: Employee Only - Includes Vision 2 Party (Employee + Spouse*) Add Vision 2 Party (Employee + Child ) Add Vision 3 or More (Employee + Spouse*/Child(ren) Add Vision 3 or More (Employee + Children) Add Vision ***************************************************************************** Waiver: (Complete the next page) ***************************************************************************** Concordia Preferred PPO DENTAL: Employee Only Employee/Spouse Employee/Child(ren) Employee/Family

Certification Regarding Tobacco Use: • Fradulent certification of my status regarding tobacco

use is grounds for termination. Rates for health insurance are different for tobacco users versus non-users; that difference is currently $75 per month.

I am a Tobacco User Non-Tobacco User (I have not used tobacco for at least the 90 days immediately prior to the insurance effective date.) My spouse is employed and is eligible for medical Insurance through his/her employer. ($50 surcharge applies.)* My spouse is eligible for Medicare. ($50 surcharge applies.)* If your spouse does not have medical benefits through his/her employer, this surcharge does not apply. ************************************************************************ Flexible Spending Account: Medical FSA Annual Election Dependent Care FSA Annual Election (maximum annual contribution is $5,000 for Dependent FSA; $2,550 for Medical FSA

HR USE ONLY Life Insurance Eligibility Date:___________________ Not Eligible:_____ cc: Payroll LTD Eligibility Date: ___________________ Not Eligible: _____ Finance Retirement Annuity Eligibility Date: ___________________ Not Eligible: _____

Other Coverage Information: Complete this section if WAIVING coverage or maintaining dual coverage 1. Are you or your dependents covered under another health or dental plan? Yes No Name of Plan: Group Number: 2. If yes, name of policyholder Date of birth: 3. Who will be covered? 4. Will you or your dependents have Medicare coverage? Yes No 5. If yes, name of covered, Medicare claim number & effective date: Section 3. Dependent Information: Complete this section even if you are NOT covering dependents on your insurance

Dependent Name Social

Security Number

Legal Relationship (Spouse, Child, Step-

Child, Etc.)

Gender (M/F)

Date of Birth

Insurance Plan(s) Full Time Student (Y / N)

Medical (Y / N)

Dental (Y / N)

Section 5. I authorize Muhlenberg College to adjust my paycheck Section 6. Declination of pre-tax option As an eligible participant in Muhlenberg College Section 125 Plan, I have enrolled in the coverage(s) indicated on this form. I authorize Muhlenberg College to adjust my paycheck (pre-tax) by the amount of my required contribution for these coverage(s). I understand that I cannot change or revoke this agreement at any time during the Plan Year unless I have a change in family status, as defined by the Plan. Deductions will continue for each pay period until this agreement is amended or terminated.

If you are making eligible premium contributions for insurance, such as health and/or dental, your premiums will automatically be deducted on pre-tax basis unless you decline. Should you not want to take advantage of the opportunity to pay for your eligible insurance premiums with pre-tax dollars, sign below.

Signature:

Date: Signature: Date:

Human Resources Office

Receipt of Important Documents

I have received a copy of the following policies and/or important new hire information regarding my employment at Muhlenberg College. Annual Notices Flyer COBRA Notice Policy Statement on Discriminatory Harassment Drug Free Work Place Policy Statement FERPA (Family Educational Rights and Privacy Act) Problem Resolution and Complaint Procedures (non-faculty) Muhlenberg College Safety, Security & Fire Safety Annual Information Report http://www.muhlenberg.edu/pdf/main/aboutus/campus-safety/Full20132014AnnualReportwithStatistics.pdf Name: ____________________________________________ Date: _________________ Please Print Signature: __________________________________________

LOCAL EARNED INCOME TAXRESIDENCY CERTIFICATION FORM

DCED-CLGS-06 (1-11) COMMONWEALTH OF PENNSYLVANIA

DEPARTMENT OF COMMUNITY & ECONOMIC DEVELOPMENT

GOVERNOR’S CENTER FOR LOCAL GOVERMENT SERVICES

EMPLOYEE INFORMATION - RESIDENCE LOCATION

TO EMPLOYERS/TAXPAYERS:

This form is to be used by employers and/or taxpayers to report essential information for the collection and distribution of Local Earned Income Taxes.

This form must be utilized by employers when a new employee is hired or when a current employee notifies employer of a name and/or address change.

NAME (Last, FIrst, Middle Initial) SOCIAL SECURITY NUMBER

FIRST LINE OF ADDRESS (If PO Box, please include actual street address)

SECOND LINE OF ADDRESS

CITY STATE ZIP CODE DAYTIME PHONE NUMBER

CERTIFICATION

SIGNATURE OF EMPLOYEE DATE

PHONE NUMBER EMAIL ADDRESS

MUNICIPALITY (City, Borough, Township)

COUNTY PSD CODE TOTAL RESIDENT EIT RATE

EMPLOYER INFORMATION - EMPLOYMENT LOCATION

EMPLOYER NAME (Use Federal ID Name) EMPLOYER FEIN

FIRST LINE OF ADDRESS (IIf PO Box, please include actual street address)

SECOND LINE OF ADDRESS

CITY STATE ZIP CODE PHONE NUMBER

MUNICIPALITY (City, Borough, Township)

COUNTY PSD CODE MUNICIPAL NON-RESIDENT EIT RATE

For information on obtaining the appropriate MUNICIPALITY (City, Borough, Township), PSD CODES and EIT (Earned Income Tax) RATES,

please refer to the Pennsylvania Department of Community & Economic Development website:

www.newPA.com

Select Get Local Gov Support, >Municipal Statistics

Form W-4 (2016)Purpose. Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. Consider completing a new Form W-4 each year and when your personal or financial situation changes.Exemption from withholding. If you are exempt, complete only lines 1, 2, 3, 4, and 7 and sign the form to validate it. Your exemption for 2016 expires February 15, 2017. See Pub. 505, Tax Withholding and Estimated Tax.Note: If another person can claim you as a dependent on his or her tax return, you cannot claim exemption from withholding if your income exceeds $1,050 and includes more than $350 of unearned income (for example, interest and dividends).

Exceptions. An employee may be able to claim exemption from withholding even if the employee is a dependent, if the employee:• Is age 65 or older,

• Is blind, or

• Will claim adjustments to income; tax credits; or itemized deductions, on his or her tax return.

The exceptions do not apply to supplemental wages greater than $1,000,000.Basic instructions. If you are not exempt, complete the Personal Allowances Worksheet below. The worksheets on page 2 further adjust your withholding allowances based on itemized deductions, certain credits, adjustments to income, or two-earners/multiple jobs situations.

Complete all worksheets that apply. However, you may claim fewer (or zero) allowances. For regular wages, withholding must be based on allowances you claimed and may not be a flat amount or percentage of wages.Head of household. Generally, you can claim head of household filing status on your tax return only if you are unmarried and pay more than 50% of the costs of keeping up a home for yourself and your dependent(s) or other qualifying individuals. See Pub. 501, Exemptions, Standard Deduction, and Filing Information, for information.Tax credits. You can take projected tax credits into account in figuring your allowable number of withholding allowances. Credits for child or dependent care expenses and the child tax credit may be claimed using the Personal Allowances Worksheet below. See Pub. 505 for information on converting your other credits into withholding allowances.

Nonwage income. If you have a large amount of nonwage income, such as interest or dividends, consider making estimated tax payments using Form 1040-ES, Estimated Tax for Individuals. Otherwise, you may owe additional tax. If you have pension or annuity income, see Pub. 505 to find out if you should adjust your withholding on Form W-4 or W-4P.Two earners or multiple jobs. If you have a working spouse or more than one job, figure the total number of allowances you are entitled to claim on all jobs using worksheets from only one Form W-4. Your withholding usually will be most accurate when all allowances are claimed on the Form W-4 for the highest paying job and zero allowances are claimed on the others. See Pub. 505 for details.Nonresident alien. If you are a nonresident alien, see Notice 1392, Supplemental Form W-4 Instructions for Nonresident Aliens, before completing this form.Check your withholding. After your Form W-4 takes effect, use Pub. 505 to see how the amount you are having withheld compares to your projected total tax for 2016. See Pub. 505, especially if your earnings exceed $130,000 (Single) or $180,000 (Married).Future developments. Information about any future developments affecting Form W-4 (such as legislation enacted after we release it) will be posted at www.irs.gov/w4.

Personal Allowances Worksheet (Keep for your records.)A Enter “1” for yourself if no one else can claim you as a dependent . . . . . . . . . . . . . . . . . . A

B Enter “1” if: { • You are single and have only one job; or• You are married, have only one job, and your spouse does not work; or . . .• Your wages from a second job or your spouse’s wages (or the total of both) are $1,500 or less.

} B

C Enter “1” for your spouse. But, you may choose to enter “-0-” if you are married and have either a working spouse or more than one job. (Entering “-0-” may help you avoid having too little tax withheld.) . . . . . . . . . . . . . . C

D Enter number of dependents (other than your spouse or yourself) you will claim on your tax return . . . . . . . . DE Enter “1” if you will file as head of household on your tax return (see conditions under Head of household above) . . EF Enter “1” if you have at least $2,000 of child or dependent care expenses for which you plan to claim a credit . . . F

(Note: Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for details.) G Child Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information.

• If your total income will be less than $70,000 ($100,000 if married), enter “2” for each eligible child; then less “1” if you have two to four eligible children or less “2” if you have five or more eligible children. • If your total income will be between $70,000 and $84,000 ($100,000 and $119,000 if married), enter “1” for each eligible child . . G

H Add lines A through G and enter total here. (Note: This may be different from the number of exemptions you claim on your tax return.) ▶ H

For accuracy, complete all worksheets that apply. {

• If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions and Adjustments Worksheet on page 2.

• If you are single and have more than one job or are married and you and your spouse both work and the combined earnings from all jobs exceed $50,000 ($20,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2 to avoid having too little tax withheld.• If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W-4 below.

Separate here and give Form W-4 to your employer. Keep the top part for your records.

Form W-4Department of the Treasury Internal Revenue Service

Employee's Withholding Allowance Certificate▶ Whether you are entitled to claim a certain number of allowances or exemption from withholding is

subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.

OMB No. 1545-0074

20161 Your first name and middle initial Last name

Home address (number and street or rural route)

City or town, state, and ZIP code

2 Your social security number

3 Single Married Married, but withhold at higher Single rate.

Note: If married, but legally separated, or spouse is a nonresident alien, check the “Single” box.

4 If your last name differs from that shown on your social security card,

check here. You must call 1-800-772-1213 for a replacement card. ▶

5 Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2) 56 Additional amount, if any, you want withheld from each paycheck . . . . . . . . . . . . . . 6 $

7 I claim exemption from withholding for 2016, and I certify that I meet both of the following conditions for exemption.• Last year I had a right to a refund of all federal income tax withheld because I had no tax liability, and• This year I expect a refund of all federal income tax withheld because I expect to have no tax liability.If you meet both conditions, write “Exempt” here . . . . . . . . . . . . . . . ▶ 7

Under penalties of perjury, I declare that I have examined this certificate and, to the best of my knowledge and belief, it is true, correct, and complete.

Employee’s signature (This form is not valid unless you sign it.) ▶ Date ▶

8 Employer’s name and address (Employer: Complete lines 8 and 10 only if sending to the IRS.) 9 Office code (optional) 10 Employer identification number (EIN)

For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No. 10220Q Form W-4 (2016)

Form W-4 (2016) Page 2 Deductions and Adjustments Worksheet

Note: Use this worksheet only if you plan to itemize deductions or claim certain credits or adjustments to income.1 Enter an estimate of your 2016 itemized deductions. These include qualifying home mortgage interest, charitable contributions, state

and local taxes, medical expenses in excess of 10% (7.5% if either you or your spouse was born before January 2, 1952) of your income, and miscellaneous deductions. For 2016, you may have to reduce your itemized deductions if your income is over $311,300 and you are married filing jointly or are a qualifying widow(er); $285,350 if you are head of household; $259,400 if you are single and not head of household or a qualifying widow(er); or $155,650 if you are married filing separately. See Pub. 505 for details . . . 1 $

2 Enter: { $12,600 if married filing jointly or qualifying widow(er)$9,300 if head of household . . . . . . . . . . .$6,300 if single or married filing separately

} 2 $

3 Subtract line 2 from line 1. If zero or less, enter “-0-” . . . . . . . . . . . . . . . . 3 $4 Enter an estimate of your 2016 adjustments to income and any additional standard deduction (see Pub. 505) 4 $5 Add lines 3 and 4 and enter the total. (Include any amount for credits from the Converting Credits to

Withholding Allowances for 2016 Form W-4 worksheet in Pub. 505.) . . . . . . . . . . . . 5 $6 Enter an estimate of your 2016 nonwage income (such as dividends or interest) . . . . . . . . 6 $7 Subtract line 6 from line 5. If zero or less, enter “-0-” . . . . . . . . . . . . . . . . 7 $8 Divide the amount on line 7 by $4,050 and enter the result here. Drop any fraction . . . . . . . 89 Enter the number from the Personal Allowances Worksheet, line H, page 1 . . . . . . . . . 9

10 Add lines 8 and 9 and enter the total here. If you plan to use the Two-Earners/Multiple Jobs Worksheet, also enter this total on line 1 below. Otherwise, stop here and enter this total on Form W-4, line 5, page 1 10

Two-Earners/Multiple Jobs Worksheet (See Two earners or multiple jobs on page 1.)Note: Use this worksheet only if the instructions under line H on page 1 direct you here.1 Enter the number from line H, page 1 (or from line 10 above if you used the Deductions and Adjustments Worksheet) 12 Find the number in Table 1 below that applies to the LOWEST paying job and enter it here. However, if

you are married filing jointly and wages from the highest paying job are $65,000 or less, do not enter more than “3” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

3 If line 1 is more than or equal to line 2, subtract line 2 from line 1. Enter the result here (if zero, enter “-0-”) and on Form W-4, line 5, page 1. Do not use the rest of this worksheet . . . . . . . . . 3

Note: If line 1 is less than line 2, enter “-0-” on Form W-4, line 5, page 1. Complete lines 4 through 9 below to figure the additional withholding amount necessary to avoid a year-end tax bill.

4 Enter the number from line 2 of this worksheet . . . . . . . . . . 45 Enter the number from line 1 of this worksheet . . . . . . . . . . 56 Subtract line 5 from line 4 . . . . . . . . . . . . . . . . . . . . . . . . . 67 Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here . . . . 7 $8 Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed . . 8 $9 Divide line 8 by the number of pay periods remaining in 2016. For example, divide by 25 if you are paid every two

weeks and you complete this form on a date in January when there are 25 pay periods remaining in 2016. Enter the result here and on Form W-4, line 6, page 1. This is the additional amount to be withheld from each paycheck 9 $

Table 1Married Filing Jointly

If wages from LOWEST paying job are—

Enter on line 2 above

$0 - $6,000 06,001 - 14,000 1

14,001 - 25,000 225,001 - 27,000 327,001 - 35,000 435,001 - 44,000 544,001 - 55,000 655,001 - 65,000 765,001 - 75,000 875,001 - 80,000 980,001 - 100,000 10

100,001 - 115,000 11115,001 - 130,000 12130,001 - 140,000 13140,001 - 150,000 14 150,001 and over 15

All Others

If wages from LOWEST paying job are—

Enter on line 2 above

$0 - $9,000 09,001 - 17,000 1

17,001 - 26,000 226,001 - 34,000 334,001 - 44,000 444,001 - 75,000 575,001 - 85,000 685,001 - 110,000 7

110,001 - 125,000 8125,001 - 140,000 9140,001 and over 10

Table 2Married Filing Jointly

If wages from HIGHEST paying job are—

Enter on line 7 above

$0 - $75,000 $61075,001 - 135,000 1,010

135,001 - 205,000 1,130205,001 - 360,000 1,340360,001 - 405,000 1,420405,001 and over 1,600

All Others

If wages from HIGHEST paying job are—

Enter on line 7 above

$0 - $38,000 $61038,001 - 85,000 1,01085,001 - 185,000 1,130

185,001 - 400,000 1,340400,001 and over 1,600

Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this form to carry out the Internal Revenue laws of the United States. Internal Revenue Code sections 3402(f)(2) and 6109 and their regulations require you to provide this information; your employer uses it to determine your federal income tax withholding. Failure to provide a properly completed form will result in your being treated as a single person who claims no withholding allowances; providing fraudulent information may subject you to penalties. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation; to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their tax laws; and to the Department of Health and Human Services for use in the National Directory of New Hires. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism.

You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by Code section 6103.

The average time and expenses required to complete and file this form will vary depending on individual circumstances. For estimated averages, see the instructions for your income tax return.

If you have suggestions for making this form simpler, we would be happy to hear from you. See the instructions for your income tax return.

USCIS Form I-9

OMB No. 1615-0047 Expires 08/31/2019

Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

Form I-9 11/14/2016 N Page 1 of 3

►START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically, during completion of this form. Employers are liable for errors in the completion of this form.

ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the documentation presented has a future expiration date may also constitute illegal discrimination.

Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form I-9 no later than the first day of employment, but not before accepting a job offer.)Last Name (Family Name) First Name (Given Name) Middle Initial Other Last Names Used (if any)

Address (Street Number and Name) Apt. Number City or Town State ZIP Code

Date of Birth (mm/dd/yyyy) U.S. Social Security Number

- -

Employee's E-mail Address Employee's Telephone Number

I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form.

I attest, under penalty of perjury, that I am (check one of the following boxes):

1. A citizen of the United States

2. A noncitizen national of the United States (See instructions)

3. A lawful permanent resident

4. An alien authorized to work until (See instructions)

(expiration date, if applicable, mm/dd/yyyy):

(Alien Registration Number/USCIS Number):

Some aliens may write "N/A" in the expiration date field.

Aliens authorized to work must provide only one of the following document numbers to complete Form I-9: An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.

1. Alien Registration Number/USCIS Number:

2. Form I-94 Admission Number:

3. Foreign Passport Number:

Country of Issuance:

OR

OR

QR Code - Section 1 Do Not Write In This Space

Signature of Employee Today's Date (mm/dd/yyyy)

Preparer and/or Translator Certification (check one): I did not use a preparer or translator. A preparer(s) and/or translator(s) assisted the employee in completing Section 1.(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct.Signature of Preparer or Translator Today's Date (mm/dd/yyyy)

Last Name (Family Name) First Name (Given Name)

Address (Street Number and Name) City or Town State ZIP Code

Employer Completes Next Page

Form I-9 11/14/2016 N Page 2 of 3

USCIS Form I-9

OMB No. 1615-0047 Expires 08/31/2019

Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

Section 2. Employer or Authorized Representative Review and Verification (Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You must physically examine one document from List A OR a combination of one document from List B and one document from List C as listed on the "Lists of Acceptable Documents.")

Last Name (Family Name) M.I.First Name (Given Name)Employee Info from Section 1 Citizenship/Immigration Status

List AIdentity and Employment Authorization Identity Employment Authorization

OR List B AND List C

Additional Information QR Code - Sections 2 & 3 Do Not Write In This Space

Document Title

Issuing Authority

Document Number

Expiration Date (if any)(mm/dd/yyyy)

Document Title

Issuing Authority

Document Number

Expiration Date (if any)(mm/dd/yyyy)

Document Title

Issuing Authority

Document Number

Expiration Date (if any)(mm/dd/yyyy)

Document Title

Issuing Authority

Document Number

Expiration Date (if any)(mm/dd/yyyy)

Document Title

Issuing Authority

Document Number

Expiration Date (if any)(mm/dd/yyyy)

Certification: I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee, (2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the employee is authorized to work in the United States. The employee's first day of employment (mm/dd/yyyy): (See instructions for exemptions)

Signature of Employer or Authorized Representative Today's Date(mm/dd/yyyy) Title of Employer or Authorized Representative

Last Name of Employer or Authorized Representative First Name of Employer or Authorized Representative Employer's Business or Organization Name

Employer's Business or Organization Address (Street Number and Name) City or Town State ZIP Code

Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.)A. New Name (if applicable)Last Name (Family Name) First Name (Given Name) Middle Initial

B. Date of Rehire (if applicable)Date (mm/dd/yyyy)

Document Title Document Number Expiration Date (if any) (mm/dd/yyyy)

C. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes continuing employment authorization in the space provided below.

I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual. Signature of Employer or Authorized Representative Today's Date (mm/dd/yyyy) Name of Employer or Authorized Representative

LISTS OF ACCEPTABLE DOCUMENTSAll documents must be UNEXPIRED

Employees may present one selection from List A or a combination of one selection from List B and one selection from List C.

LIST A

2. Permanent Resident Card or Alien Registration Receipt Card (Form I-551)

1. U.S. Passport or U.S. Passport Card

3. Foreign passport that contains a temporary I-551 stamp or temporary I-551 printed notation on a machine-readable immigrant visa

4. Employment Authorization Document that contains a photograph (Form I-766)

5. For a nonimmigrant alien authorized to work for a specific employer because of his or her status:

Documents that Establish Both Identity and

Employment Authorization

6. Passport from the Federated States of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with Form I-94 or Form I-94A indicating nonimmigrant admission under the Compact of Free Association Between the United States and the FSM or RMI

b. Form I-94 or Form I-94A that has the following:(1) The same name as the passport;

and(2) An endorsement of the alien's

nonimmigrant status as long as that period of endorsement has not yet expired and the proposed employment is not in conflict with any restrictions or limitations identified on the form.

a. Foreign passport; and

For persons under age 18 who are unable to present a document

listed above:

1. Driver's license or ID card issued by a State or outlying possession of the United States provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address

9. Driver's license issued by a Canadian government authority

3. School ID card with a photograph

6. Military dependent's ID card

7. U.S. Coast Guard Merchant Mariner Card

8. Native American tribal document

10. School record or report card

11. Clinic, doctor, or hospital record

12. Day-care or nursery school record

2. ID card issued by federal, state or local government agencies or entities, provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address

4. Voter's registration card

5. U.S. Military card or draft record

Documents that Establish Identity

LIST B

OR AND

LIST C

8. Employment authorization document issued by the Department of Homeland Security

1. A Social Security Account Number card, unless the card includes one of the following restrictions:

2. Certification of Birth Abroad issued by the Department of State (Form FS-545)

3. Certification of Report of Birth issued by the Department of State (Form DS-1350)

4. Original or certified copy of birth certificate issued by a State, county, municipal authority, or territory of the United States bearing an official seal

5. Native American tribal document

7. Identification Card for Use of Resident Citizen in the United States (Form I-179)

Documents that Establish Employment Authorization

6. U.S. Citizen ID Card (Form I-197)

(2) VALID FOR WORK ONLY WITH INS AUTHORIZATION

(3) VALID FOR WORK ONLY WITH DHS AUTHORIZATION

(1) NOT VALID FOR EMPLOYMENT

Page 3 of 3Form I-9 11/14/2016 N

Examples of many of these documents appear in Part 8 of the Handbook for Employers (M-274).

Refer to the instructions for more information about acceptable receipts.

Direct Deposit Form The College has the capability to provide direct deposit services to all banks that are members of the automated clearing house (ACH) system. Most financial institutions are members. Benefits of direct deposit include:

• Availability of funds at 8AM on pay day • Eliminates problems of picking up checks during vacation • Eliminates possibility o being delayed in US Mail • Many banks offer reduced banking charges for direct deposit customers

If you would like to have your pay deposited directly to your bank, please complete the bottom portion of this form and return it to the Controller’s office. The process requires a test period of one pay prior to activation. This will assure the accuracy of all activity through the national transfer system. In order to begin your direct deposit, you must provide the information no later than 10 days before your usual payday. Receipt of information after this time will be processed with the next subsequent payroll. There will always be a one payroll lead time (including any changes of information.) If you are not sure of your account number and your bank’s ACH number, please contact your bank for the information you need. Direct deposit cannot be processed without these numbers. Do not attach a voided check or deposit slip. If you have any questions or concerns, please contact Rosemary Gallagher, x3153. 1/2016 ================================================================================================ EMPLOYEE NAME______________________________________________ Dept _______________________ Check one: ____New Payroll Deposit ____Change Deposit Information ____Revoke Authorization

□ Checking Account or

□ Savings Account

Account Number ____________________________________ Bank Transit/ACH Number ___ ___ ___ ___ ___ ___ ___ ___ ___ (Required) I wish to deposit: ______Entire Net Pay or $___________

□ Checking Account or

□ Savings Account

Account Number ____________________________________ Bank Transit/ACH Number ___ ___ ___ ___ ___ ___ ___ ___ ___ (Required) I wish to deposit: ______Entire Net Pay or $___________

I authorize Muhlenberg College to direct deposit my pay to the above named account beginning the next available pay date and continuing until I revoke this authorization.

EMPLOYEE SIGNATURE_______________________________________ DATE__________________

LST Exemption 10-07

LOCAL SERVICES TAX – EXEMPTION CERTIFICATE ___________________________________________

Tax Year

APPLICATION FOR EXEMPTION FROM LOCAL SERVICES TAX

A copy of this application for exemption from the Local Services Tax (LST), and all necessary supporting documents, must be completed and presented to your employer AND to the political subdivision levying the Local Services Tax where you are principally employed.

This application for exemption from the Local Services Tax must be signed and dated. No exemption will be approved until proper documentation has been received.

Name: _____________________________________ Soc Sec #: ____________________________________ Address: ___________________________________ Phone #: _____________________________________ City/State: _________________________________ Zip: _________________________________________

REASON FOR EXEMPTION

1. __________ MULTIPLE EMPLOYERS: Attach a copy of a current pay statement from your principal employer that shows the name of the employer, the length of the payroll period and the amount of Local Services Tax withheld. List all employers on the reverse side of this form. You must notify your other employers of a change in principal place of employment within two weeks of the change.

2. __________ EXPECTED TOTAL EARNED INCOME AND NET PROFITS FROM ALL SOURCES

WITHIN _____________________________________________ (municipality or school district) WILL BE LESS THAN $___________: Attach copies of your last pay statements or your W-2 for the year prior. If you are self-employed, please attach a copy of your PA Schedule C, F, or RK-1 for the prior year.

3. __________ ACTIVE DUTY MILITARY EXEMPTION: Please attach a copy of your orders directing you to

active duty status. Annual training is not eligible for exemption. You are required to advise the tax office when you are discharged from active duty status.

4. __________ MILITARY DISABILITY EXEMPTION: Please attach copy of your discharge orders and a

statement from the United States Veterans Administrator documenting your disability. Only 100% permanent disabilities are recognized for this exemption.

EMPLOYER: Once you receive this Exemption Certificate, you shall not withhold the Local Services Tax for the portion of the calendar year for which this certificate applies, unless you are otherwise notified or instructed by the tax collector to withhold the tax. Tax Office: _________________________________ Address: ___________________________________ Phone #: _____________________________________ City/State: _________________________________ Zip: _________________________________________

IMPORTANT NOTE TO EMPLOYERS 1. The municipality is required by law to exempt from the LST employees whose earned income from all sources (employers

and self-employment) in their municipality is less than $12,000 when the levied rate exceeds $10.00. 2. The school district for the municipality in which your worksite(s) is located may or may not levy an LST. If it does, the

income exemption provided may differ from the municipality and can be anywhere from $0 to $11,999. 3. Contact the tax office where your business worksites are located to obtain this information.

LST Exemption 10-07

Employment Information: List all places of employment for the applicable tax year. Please list your PRIMARY EMPLOYER under #1 below and your secondary employers under the other columns. If self employed, write SELF under Employer Name column.

1. PRIMARY EMPLOYER 2. 3. Employer Name Address Address 2 City, State Zip Municipality Phone Start Date End Date Status (FT or PT) Gross Earnings 4. 5. 6. Employer Name Address Address 2 City, State Zip Municipality Phone Start Date End Date Status (FT or PT) Gross Earnings PLEASE NOTE: All information received by the Tax Collector is considered to be CONFIDENTIAL and is only used for official purposes relating to the collection, administration and enforcement of the LOCAL SERVICES TAX. I DECLARE UNDER PENALTY OF LAW THAT THE INFORMATION STATED ON AND ATTACHED TO THIS FORM IS TRUE AND CORRECT: SIGNATURE: _________________________________________________ DATE: ____________________

Human Resources Office

POST EMPLOYMENT FORM

Date of Employment: ___________________________

The information requested is for internal confidential use and is used for administration of benefits and emergency contact.

Name:______________________________________________________________________________ Last First Middle Initial Phone Number: ___________________________________ Address: ____________________________________________________________________________ Street City State Zip Date of Birth:___________________ Social Security No.:___________________________________ Marital Status: __________________________ Family Member Information: (Please list spouse/partner and all children) Name Date of Birth Social Security No. __________________________ _____________________ ____________________________ (Spouse) Children: Date of Birth Social Security No. ___________________________ _____________________ ____________________________ ___________________________ _____________________ ____________________________ ___________________________ _____________________ ____________________________ ___________________________ _____________________ ____________________________ Please list the name(s) and phone number(s) of the person(s) to be contacted in case of an emergency: Do you have any physical condition or particular problems the College should be aware of so that reasonable accommodations can be made or assistance provided appropriately in case of emergency? No _________ Yes _________ Describe: _________________________________________

If there are any changes to the above information, please advise the Human Resources Office as soon as possible. For HR Office Use Only:

Self-Identification Questionnaire Equal Opportunity Data Sheet

The information requested is solely for statistical reporting purposes in the implementation of non discrimination provisions of Federal and State law and our College equal opportunity in employment policy. The Federal government requires colleges and universities to collect and report information concerning their students, faculty and staff each year (numbers of students and faculty, status, age, majors, graduation statistics, etc.) We do this each year through a system known as IPEDS (Integrated Postsecondary Education Data Systems). Part of the required data is the race and ethnicity of students, faculty, and staff. There has been a discussion for a number of years concerning the way we record race/ethnicity, and it has finally been decided to change the format. The change in format requires that we resurvey all current students, faculty and staff concerning their race/ethnicity. Newly hired employees will also be asked to complete the questionnaire. This information will be maintained in a confidential file separate from your personnel record.

Please review the following 2 items and answer accordingly: 1) Are you of Hispanic or Latino ethnicity? (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.) YES NO 2) Are you from one or more of the following racial groups?

American Indian or Alaska Native - A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.

Asian - A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

Black or African American - A person having origins in any of the black racial groups of Africa.

Native Hawaiian or Other Pacific Islander - A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

White - A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

Signature: ____________________________________ Date: ___________________ Name: ____________________________________ 9-Digit Berg ID:__________________

Please Print (Located on your Muhlenberg ID card)

Date of Birth: _____ _____ _____ Please return this form to the Human Resources Office.

Revised 12/2009

COLLEGE IDENTIFICATION CARD

A College ID card may be secured at the desk in the J. Conrad Seegers Union Building from 10 a.m. - 4 p.m. An appointment is recommended (call Ext. 3493) but not essential. Authorization must be provided by the Human Resources Office or the Dean of the Wescoe School for employee, retiree and family member ID cards. Campus Safety will activate the card. Campus Safety will activate the card. A College ID card is required for access to the Life Sports Center and entitles the holder to library privileges and a discount on College Bookstore purchases. The spouse (or same sex domestic partner) and dependent children of full-time employees may secure personal cards as well. Employee/Retiree Name (Please Print) Classification Faculty Staff Retiree Family Member Berg ID #: Family Member’s Name: Department: Date of Birth: Expiration Date: (Age 23 for dependent children) Status: FT PT TEMP Expiration Date (Required for TEMP: Authorization (Manager, Employment & Benefits or Dean, Wescoe School) Date :

Faculty and Staff Parking Permits Faculty and staff parking lot assignments are generally allocated in relation to the building where the employee’s major function occurs. The fact that an individual is assigned a space in a certain lot one year does not necessarily guarantee a space in the same lot for the following year. Each registered vehicle will be assigned a window decal when registered with the Department of Campus Safety. Faculty and staff assigned locations are as follows:

• Back Drive Parking Lot (Rear of Academic Buildings) - Silver # 0001 - 0500 • Library Lot and North side of CFA West Lot - Purple # 0501 - 1000 • Berks & Liberty Street Lot – Dark Blue # 1001 - 1500 • Back Drive Entrance Parking Lot (Walz/Brown North Lot) – Maroon # 1501 – 2000 • 23rd & Gordon Lot (3 rows on the East side of lot) - Brown # 2001 - 2500 • Prosser Lot – Dark Green # 2501 - 3000

Employees can register their vehicle by utilizing the on-line form available through a campus network computer or by stopping at Campus Safety.

http://arms/parking/

A. Transaction Information1. Enrollment

Basic Life

Supplemental LifeSupplemental AD&PL/AD&D

AD&PL/AD&D

Requested Employee CoverageBasic Dependent Life

Supplemental Dependent LifeSupplemental Dependent AD&PL/AD&D

Basic Dependent AD&PL/AD&D

Requested Dependent CoverageEmployee *

2. Termination (Cancel)

Add Dependent(s) Plan Change

Increase/Decrease Benefit Amount*

Remove Dependent(s)

3. Change (*Provide explanation in Section D, Special Remarks.)

Other*

9. Employee Coverage Amounts (Based on the requirements of your Plan, you may have to submit evidence of good health.)Basic Life Amount Supplemental Life Amount Basic AD&PL/AD&D Amount Supplemental AD&PL/AD&D Amount

$

$ $ $ $

D. Covered Dependents (Complete only if Dependent Coverage is offered under your Plan.)(A)dd/New(C)hange(R)emove Dependent Name (First, Middle Initial, Last)

Social Security Number(If dependent has no SSN, write "None")

Basic Dependent AD&PL/AD&D Amount

/ /

/ /

/ /

- -

- -- -

- -

Supplemental Dependent AD&PL/AD&D Amount

Yes No

Supplemental Dependent Amount

Basic Dependent Amount

$

$

$

$

$

$

$

$

$

$

$

$

$ $ $ $

Check this box if you are refusing coverage for your dependents.

SpecialRemarks

Full Beneficiary Name (First, Middle, Last)

10. Beneficiary Designation - If more than one beneficiary, use Special Remarks. Dependent coverage Beneficiary is always the Employee. Social Security Number of Beneficiary

- -Relationship to Employee

E. Certification - Signatures Required

My signature below signifies my agreement with the statements and authorization under Certification and Authorization on the back of this form.

1. Employee Social Security Number

C. Employee Information - Please Print all Information

6. Employee Home Address (Number, Street, Apt. No., City, State, ZIP Code)

1. Employer Name - Full Name of Business or Organization 2. Control No.

5. Employer Address (Street, City, State, ZIP Code) - Primary Location of Business or Organization

B. Employer Information Account 3. Plan Number 4. SFOSuffix

6. Claim Office Code 7. Customer Code (Optional)

X 1. Employee Signatures (Required) Date

X 2. Employer Signature (Required) Date

/ /

Life Enrollment/Change RequestAetna Life Insurance Company

GR-67269-97 (12-01)

Employee's E-mail Address:

V2 R-POD C

2. Employee Name (Last, First, M.I.)

- -

Employee must be enrolled for dependent(s) to have coverage.

*

Effective Date (MM/DD/YYYY) Effective Date (MM/DD/YYYY)

New Employee RetireeRehire/Reinstatement

Date of Hire (MM/DD/YYYY)

Effective Date (MM/DD/YYYY)

5. Telephone Numbers3. Birthdate (MM/DD/YYYY) 4. Sex

( ) -Home/ / ( ) -Work7. Employee Annual Earnings 8. Occupation/Title

Please make a copy for your records. visit us at www.aetna.com

Student Age19 or Older

Relation. Code

Birthdate

MM / DD / YYYY

Instructions - Instructions are provided only for those fields which are not self-explanatory or for which you may need additional information.

A. Transaction Information

B. Employer InformationThe Servicing Field Office (B4) and Claim Office Code (B6) are assigned by Aetna.

C. Employee InformationTo be completed by the Enrollee.

D. Covered Dependents

Make sure you complete the Effective Date in Section A - Transaction Information.

Make sure you read Section E. Sign name and date.

To be completed by Enrollee.

List only those individuals for whom you are electing/ changing coverage and complete ALL items for each individual listed.

• Add/Change/Remove - Use "A", "C", or "R" to indicate whether you are adding, changing or removing coverage for an individual.

• Name - This must be completed for all individuals for whom you are electing or changing coverage. Please complete ALL items in Section D for each individual listed. Attach another form if you are requesting coverage for additional dependents.

• RelationshipCode - Use ONLY: H=Husband, W=Wife, N=Divorced Spouse, S=Son, D=Daughter, Y=Sponsored Male, X=Sponsored Female. If the dependent is NOT a biological or legally adopted child, please indicate relationship to employee in Special Remarks.

• Birthdate - Date of birth should include four digit year of birth.

• StudentAge19orOlder- Defined as: Unmarried dependent child age 19 or older (refer to your Summary of Coverage), regularly attends school and depends solely on the enrollee for support. Member Services may request that you provide proof from the educational institution.

• InsuranceAmounts - Consult your Benefits Administrator to identify which insurance amounts need to be reported. Complete the appropriate box(es).

Birthdate - Date of birth should include four digit year of birth.

Employee Coverage Amounts - Consult your Benefits Administrator to identify which earnings/insurance amounts need to be reported. Complete the appropriate box and enter the rounded dollar amount.

Beneficiary Designation - Full Beneficiary Name (First, Middle and Last), Social Security Number and relationship of the person to whom benefits will be paid in the event of your death.

C3.

C9.

C10.

Control, Suffix and Account - If this information is not preprinted, provide the complete Control, Suffix and Account numbers.

Plan Number - If this information is not preprinted, refer to the Plan Sheet to determine the correct Plan Number.

Customer Code (Optional) - Provide an identifying Customer Code for the employee only if you had elected to provide this information.

B2.

B3.

B7.

To Change• Complete Effective Date in Section A - Transaction Information, Number 3 and

check appropriate box(es).• CompleteblankfieldsinSectionB - Employer Information (if applicable).• CompleteSectionC - Employee Information.• Indicatechange(s)inappropriateSection(s)(B, C, D) and circle.

• MakesureyoureadSectionE - Certification. Sign name and date.

To Enroll• Complete Effective Date and Date of Hire in Section A - Transaction

Information.

• Check the box(es) applicable to the benefit(s) you wish to enroll for in Section A - Transaction Information, Number 1.

• Complete all blank fields in Section B - Employer Information and Section C - Employee Information.

• Complete Section D - Covered Dependents for all dependents for whom you are electing coverage. Complete ALL items for each individual listed.

• MakesureyoureadSectionE - Certification. Sign name and date.

To Terminate (Cancel)• Complete Effective Date in Section A - Transaction Information, Number 2 and

check appropriate box.

• Complete all blank fields in Section B - Employer Information and Section C - Employee Information.

• MakesureyoureadSectionE - Certification. Sign name and date.

E. CertificationSignatures Required

• ReadtheinformationcontainedabovethespaceprovidedforyoursignatureinSectionE and the information on the back of the form.

• Signanddatetheform.

Certification I certify that all information on this form is true and complete to the best of my knowledge and belief. I understand that this insurance is subject to all of the terms of the Plan of Insurance contained in the group policy and summarized in the announcement material provided me and the certificate issued to me.

I understand that the effective date of insurance for myself or for any of my dependents is subject to my being actively at work on that date and that the effective date of insurance for any of my dependents is also subject to the dependent health condition requirements of the Plan. Further, I understand that any insurance subject to evidence of good health or medical information will not become effective until Aetna gives its written consent.

I understand that, in the event I fail to sign this form within 31 days of the effective date of eligibility or that for any reason Aetna does not receive notice of the Enrollment/Change Request within a reasonable time following the event, my and my dependents' eligibility may be affected.

I request my employer to arrange for the issuance of Group Life Coverage for which I am or may become eligible and authorize deductions of the required contributions from my earnings.

Misrepresentations: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

Attention California Residents: For your protection, California law requires notice of the following: Any person who knowingly and with intent to defraud or deceive any insurance company files a statement of claim containing any materially false or misleading information is guilty of a crime and may be subject to fines, confinement in a state prison, and substantial civil penalties. Many other states have similar laws.

Attention Colorado Residents: An insurer or agent who knowingly provides false or misleading information to defraud a claimant regarding insurance proceeds must be reported to the Insurance Division.

Attention Florida and Virginia Residents: Any person who knowingly and with intent to defraud or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree.

Attention Pennsylvania Residents: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

(12-01) V2 GR-67269-97

Misrepresentation

To: New Muhlenberg College Faculty/Staff Welcome to Muhlenberg College! As religious/spiritual advisors, we are here to serve all members of the College community. We hope to be of service by helping you connect with religious communities, if you desire, and responding promptly and appropriately to significant life events and other needs. So that we can best serve you, we invite you to fill out the brief form below and return it to the Chaplain’s Office. We appreciate and respect that you may not want to share this information with us. If you do provide it, we will keep it confidential. Please let us know if there are other ways we can support you as you join the Muhlenberg community. Again, welcome! Many thanks, The Rev. Callista Isabelle Rabbi Melissa B. Simon Alexa Doncsecz

College Chaplain Jewish Chaplain & Hillel Director Roman Catholic Campus Minister

Name __________________________________________________________________ Department _____________________________________________________________ Religious Affiliation ______________________________________________________ Congregation ____________________________________________________________ Comments ______________________________________________________________ ________________________________________________________________________

NOTICE: MEDICAL TREATMENT FOR YOUR WORK INJURY OR OCCUPATIONAL ILLNESS

Your employer has selected a list of 6 or more physician and other health care providers who are available to treat your work related injuries and illnesses during the first 90 days of treatment. This list is posted at MEMBER SCHOOL and a copy is attached to this form. If you are injured at work or suffer an occupational illness, you have certain legal RIGHTS and DUTIES under Section 306 (f.1)(1)(i) of the Workers’ Compensation Act regarding your medical treatment. These rights and duties are summarized below: MEDICAL TREATMENT: DURING THE FIRST 90 DAYS

You have the RIGHT to receive reasonable and necessary medical treatment for your work injury or occupational illness. Your employer must pay for the treatment, as long as the treatment is by one of the listed providers

You have the RIGHT to choose which of the listed providers will treat you for your work injury or illness.

You have the RIGHT to switch among any of the listed providers when you receive treatment; and if a listed provider refers you to a provider not on your employer’s list, you have the RIGHT to receive treatment from the referral provider

You have the RIGHT to receive emergency medical treatment from any provider. However, non-emergency treatment must be given by a listed provider.

If a listed provider prescribes surgery for you, you have the RIGHT to receive a second opinion from any provider of your choice. If that opinion is different from the opinion of the listed provider, you have the RIGHT to choose which course of treatment to follow. If you choose the treatment prescribed in the second opinion, you must receive the treatment from a listed provider for a period of 90 days after the date of your visit to the provider of the second opinion.

You have the DUTY to visit one or more of the listed providers for the first 90 days of treatment for your work injury or illness if you expect your employer to pay for the medical treatment you receive.

If you seek treatment for your work injury or illness from a provider who is not on the list, your employer may not have to pay for this medical treatment during the 90-day period. Therefore, you should talk to your employer before seeking treatment from a provider who is not on the list.

Important: The requirements your employer must meet to have a valid list of at least 6 providers are shown on page 2 of this document. If the list does not meet the requirements, it is not a valid list and you have the right to seek medical treatment for your work injury or occupational illness from any health care provider of your choice. MEDICAL TREATMENT AFTER THE FIRST 90 DAYS

You have the RIGHT to receive treatment from any physician or other health care provider of your choice, whether or not they are listed by your employer. Your employer must pay for this treatment, as long as it is reasonable and necessary for your work injury or occupational illness and has been properly documented by the physician or other health care provider.

You have the DUTY to notify your employer if you receive treatment from a physician or other

health care provider who is not listed by your employer. You must notify your employer within five days of the first visit to any provider who is not on your employer’s list. The employer may not be required to pay for treatment received until you have given this notice.

Your signature on this form indicates that you have been informed of and you understand theses rights and duties. If you have questions, be sure you have your rights and duties explained to you before you sign. I HAVE BEEN INFORMED OF MY MEDICAL TREATMENT RIGHTS AND DUTIES WTH REGARD TO WORK-RELATED INJURIES AND OCCUPATIONAL ILLNESSES. THIS NOTICE WAS PRESENTED TO ME AT (check one)

Time of hire When I was injured Other:____________________________________________ _______________________________________ ____________ Employee Signature Date _______________________________________ ____________ Employer Representative Date

Page 2

REQUIREMENTS FOR EMPLOYER’S LIST OF HEALTH CARE PROVIDERS

1. There must be at least 6 health care providers on the list, but there may be more than 6 listed

2. At least 3 of the health care providers on the list must be physicians.

3. No more than 4 of the health care providers on the list may be coordinated care organizations (CCOs)

4. The names, addresses, phone numbers and areas of medical specialties of all health care providers must be included on the list.

5. The health care providers on the list must be geographically accessible and must have specialties that are appropriate based on the

anticipated work-related medical problems of the employees.

6. Your employer must specify on the list if any of the health care providers on the list are employed, owned or controlled by your employer or its workers’ compensation insurance company.

NOTE: Your employer’s list of health care providers must meet all of the above requirements. IF the list does not meet all of these requirements, you do not have to choose a provider from the list. Instead, you have the right to seek medical treatment with any health care provider of your choice.

QUESTIONS OR CONCERNS CALL THE FOLLOWNG:

UCIC (c/o SISCO) 1-800-641-6330

BUREAU OF WORKERS’ COMPENSATION HELPLINE INFORMATION CENTER: 1-800-482-2383 (long-distance calls inside PA)

(717) 772-4447 (local and calls outside PA)

NOTICE TO EMPLOYEES

IN ACCORDANCE WITH THE PENNSYLVANIA WORKERS’ COMPENSATION ACT, YOUR EMPLOYER, MUHLENBERG COLLEGE , IS PROVIDING THE FOLLOWING PANEL OF PHYSICIANS TO TREAT INJURED WORKERS. YOUR EMPLOYER’S THIRD PARTY ADMINISTRATOR (TPA) IS

Self-Insured Services Company, Inc.

100 Sterling Parkway Suite 111, Mechanicsburg, PA 17050 1-866-288-9290 IN CASE OF WORK-RELATED INJURY

1. If you suffer a work-related injury, your employer or its insurance company must pay for reasonable surgical and medical services and supplies, hospital treatment, orthopedic appliances and prostheses, including training in their use.

2. In order to insure that your medical treatment will be paid by your employer or the insurance company, you must select from one of the licensed physicians or practitioners of the healing arts listed below:

SPECIALTY PROVIDER NAME & ADDRESS LOCATION PHONE Occupational Patient First

Coordinated Health Systems Or 2775 Schoenersville Road Bethlehem, PA 18017 610 861 8080 Fax 610 861 2989

3178 Tilghman St Allentown PA 18104 1401 N. Cedar Crest Blvd Allentown, PA 18104 Or 2775 Schoenersville Road Bethlehem, PA 18017

610- 844- 9150 fax 610- 844- 9151 610- 861- 8080 fax 610- 433- 4376 610- 861- 8080 Fax 610 861 2989

Primary Care Cedar Crest EmergiCenter 1101 South Cedar Crest Blvd Allentown PA 18103

610 435 3111 Fax 610 432 5953

Ophthamology Lisa Bunin, MD 1611 Pond Rd Suite 403 Allentown PA 18104

610- 435- 5333 Fax 610 435 2253

Physical Therapy Coordinated Health System Sacred Heart Physical Therapy

1401 N. Cedar Crest Blvd Allentown PA 18104 Or 2775 Schoenersville Rd Bethlehem, PA 18017 1227 Liberty St. Allentown PA 18104

610- 433- 8080 Fax 610- 433- 4376 610- 861- 8080 Fax 610- 861- 2989 610-433- 8353

Orthopedic Surgery

Coordinated Health Systems OAA Orthopedic Specialist Work Injury Center

1401 N. Cedar Crest Blvd Allentown, PA 18104 Or 2775 Schoenersville Road Bethlehem, PA 18017 250 South Cetronia Street Allentown 18103

610- 861- 8080 fax 610 433 4376 610- 861- 8080 Fax 610 861 2989 610- 973 -6200 Fax 610 973 6546

Dermatology Advanced Dermatology Assoc. 1259 South Cedar Crest Blvd Allentown PA 18103

610 433 8080 Fax 610-770-0993

Chiropractic Coordinated Health Systems 1401 N. Cedar Crest Blvd Allentown PA 18104 Or 2775 Schoenersville Rd Bethlehem, PA 18017

610- 861- 8080 fax 610 433 4376 610- 861- 8080 Fax 610 861 2989

Podiatry Bruce Ganey, D 5074 Kernsville Road P.O. Box 267 Orefield, PA 18069

610 – 366 – 8637 Fax 610 366 7745

3. You must continue to visit one of these persons listed above, if you need treatment, for ninety (90) days from the date of your first visit.

4. After this ninety (90) day period, if you still need treatment and your employer has provided a list as set forth above, you may choose to go to another licensed physician or practitioner of the healing arts for treatment. Your bills will be paid for IF:

a. You notify your employer in writing of this action or choice within five (5) days of your visit. b. Your licensed physician or practitioner of the healing arts files reports as required. These reports must

be filed within ten (10) days after your first visit and at least once a month for as long as treatment continues.

5. If no list is provided as above (No. 2), you may go to a licensed physician or practitioner of the healing arts of your choice.

6. If one of the persons listed above refers you to another licensed specialist, your employer or his insurer will pay the bill for these services.

7. If you are faced with a medical emergency, you may secure assistance from a hospital or physician or practitioner of the healing arts of your choice

ALL INJURIES, NO MATTER HOW MINOR, SHOULD BE REPORTED IMMEDIATELY TO YOUR SUPERVISOR. REMEMBER, IT IS IMPORTANT TO TELL YOUR EMPLOYER ABOUT YOUR INJURY.

MUHLENBERG COLLEGE

DRUG-FREE WORKPLACE POLICY EMPLOYEE CONSENT FORM

Employee Name (Print):_______________________________________ Date:________________ I understand Muhlenberg College’s Drug-Free Workplace Policy prohibits the use, sale, promotion and distribution of illegal drugs by employees. I understand that if I have an on-the-job injury and seek medical treatment, I will be subject to post-accident drug and alcohol screening. I further understand that if there is reasonable suspicion, circumstance or employee behavior indicating drug use or working while under the influence of drugs and/or alcohol, drug and alcohol testing may be required. Certain medications may be identified in drug testing and I will provide and complete to the best of my knowledge a Medication form at the drug test laboratory. The Medication form will be completed and placed in a sealed envelope by myself for the exclusive use of the above referenced tests. I hereby release and discharge Muhlenberg College and the designated testing laboratory, officers, directors, and employees from any and all claims, potential claims, and actions relating to testing. My release and discharge includes taking of samples, testing process, procedures, analysis, and the disclosure or utilization of the test results in consideration of continuation of employment. Finally, I understand I am required to comply with Muhlenberg College’s Drug-Free Workplace Policy and that any violation of this policy or a positive test finding will result in disciplinary action up to and including termination. I understand this policy does not alter Muhlenberg College’s policy that employment is terminable-at-will at the option of Muhlenberg College or employee. I understand the use or possession of alcohol during the work day or reporting to work under the influence of alcohol is also a violation of Muhlenberg College’s Drug-Free Workplace Policy. My signature below acknowledges that I have read and understand this consent form and agree to the conditions set forth above. I hereby consent to the taking of any required sample/samples for testing by any laboratory designated by Muhlenberg College. ________________________________________ ________________________ Employee Signature Date ________________________________________ ________________________ Witness Signature Date ________________________________________ ________________________ Witness Printed Name Witness Title 06/2008

FERPA at Muhlenberg College Information for Employees concerning the Family Educational Rights and Privacy Act

1. What is FERPA?

“ A Federal law designed to protect the privacy of education records, to establish the right of students to inspect and review their education records, and to provide guidelines for the correction of inaccurate and misleading data through informal and formal hearings.”

2. In a nutshell a. College students must be permitted to inspect their own education records b. School officials may not disclose personally identifiable information about students nor permit inspection of

their records without written permission c. College students must be given the opportunity to challenge the accuracy of their educational record.

3. What are Education Records

a. Maintained by the College b. Directly related to a student c. Includes files, documents, and materials in whatever medium (handwriting, print, tapes, disks, microfilm

microfiche) which contain information directly related to students and from which students can be personally identified.

4. Be careful not to allow others access to student information. a. Don’t post grade information b. Don’t post using an SSN or BergID c. Don’t leave graded material where it is accessible to individuals other than the student.

5. Directory Information: Information not normally considered a violation of a person’s privacy. May be shared

without student approval. Muhlenberg’s Directory Information: Student’s name College mail box and telephone number Permanent home address and telephone number Email address Class Year Major field of study Student status (full-time/part-time) Dates of attendance Degree(s) and or awards received Participation in officially recognized College activities (including but not limited to intercollegiate athletics) Height and weight of student athletes

6. School officials who have a legitimate educational interest may obtain information from education records without obtaining prior written consent.

7. Legitimate Educational Interest is the demonstrated need to know by those officials of an institution who act in the student’s educational interest, including faculty, administration, clerical and professional employees, and other persons who manage student record information. This includes student workers who assist a school official in performing his/her tasks or a student serving on an official committee.

8. Parents: We may disclose information to parents by obtaining the student’s written consent. First year students are

given a form at June Advising that allows them to give parents access to their education records. This data is stored in Capstone and may be viewed online.

9. For questions, contact the Office of the Registrar: 484-664-3190, tamte-horan@muhlenberg.edu

Statement of Understanding of the Family Educational Rights and Privacy Act

I understand that by the virtue of my employment with

the ____________________ Office at Muhlenberg

College, I may have access to records which contain

individually identifiable information, the disclosure of

which is prohibited by the Family Educational Rights

and Privacy Act of 1974. I acknowledge that I fully

understand that the intentional disclosure by me of this

information to any unauthorized person could subject

me to criminal and civil penalties imposed by law. I

further acknowledge that such willful or unauthorized

disclosure also violates Muhlenberg College’s policy and

could constitute just cause for disciplinary action

including termination of my employment regardless of

whether criminal or civil penalties are imposed.

______________ ____________________________________ DATE SIGNATURE ____________________________________ Print Name

Human Resources Office

TRAVEL ACCIDENT INSURANCE

(Provided by Muhlenberg College)

Name of Insured:

I hereby designate as my beneficiary or beneficiaries under the above insurance:

NAME RELATIONSHIP

Signature Date

Human Resources Office

CERTIFICATION OF PREVIOUS COVERAGE

I hereby certify that I was previously employed by:

Name of Previous Employer:

Coverage Insurance/Pension Company Date Coverage Terminated

FULLY VESTED PENSION/ANNUITY

GROUP LONG-TERM DISABILITY

LIFE INSURANCE – WHOLESALE OR GROUP

Name: Date:

CERTIFICATION OF RECEIPT OF LINK TO TRUSTEES' HANDBOOK FOR MANAGERS

I hereby acknowledge receiving information on how to access the electronic Trustees' Handbook for Managers. I understand that I am responsible for familiarizing myself with the information contained in this Handbook. I understand that previously issued policies have been revised and that any prior policies, procedures or benefits of the College, if different from this Handbook, are no longer in effect. I understand that additional operating procedures and work rules apply to me in my particular work area as described by my supervisor. I further understand that the matters discussed in this handbook are subject to change and do not create any contractual commitments by the College or alter the at will employment relationship. Date of Acknowledgment _____________________________ Employee Name Printed _____________________________ Employee Signature _____________________________ Department _____________________________ Signature of Witness _____________________________ Date Witnessed _____________________________

* * RETURN SIGNED CERTIFICATION TO THE HUMAN RESOURCES OFFICE * *

CERTIFICATION OF RECEIPT OF HANDBOOK FOR SUPPORT STAFF

I hereby acknowledge receiving a copy of the Handbook for Support Staff. I understand that I am responsible for familiarizing myself with the information contained in this Handbook. I understand that previously issued policies have been revised and that any prior policies, procedures or benefits of the College if different from this Handbook, are no longer in effect. I understand that additional policies and work rules apply to me in my particular work area as described by my supervisor. I further understand that the matters discussed in the Handbook for Support Staff are subject to change and do not create any contractual commitments by the College. Further, this Handbook is the property of the College and must be returned to the College immediately upon my resignation or termination from employment. Date of Acknowledgement: _________________________________________ Employee Name Printed: _________________________________________ Employee Signature: _________________________________________ Department: _________________________________________ Signature of Witness: _________________________________________ Date Witnessed: _________________________________________

RETURN SIGNED CERTIFICATION TO THE HUMAN RESOURCES OFFICE

Human Resources Office I, ______________________________________________ have viewed the (Print Name) following safety video during orientation:

Pro-Active Safety Attitude (Looking Out for Number One) ______________________________________________ _____________ (Signature) (Date) Cc: Supervisor