b"Introducing the Next Generation of Forms:Fill-and-Save HR Form LibrariesForms that Can be Routed, Completed and Stored Electronically Fill-and-Save Form Librariesare collections of forms that come as fillable PDFs foreasy (and Printed to Paper if Necessary) electronic routing, completion and storage. Beyond convenience, HR Form Libraries provide the peace of mind that comes from guaranteed compliance.Labor law attorneys review each The targeted collections of HR forms in each library are : document and provide updates every time federal or state labor law requirements change.Always in compliance HR experts round out the content with valuable tips and best practices on each topic. Accessible 24/7 online Library Membership Is as Easy as 1-2-3: Affordable way to accomplish specific HR tasks (less than $100/year) 1. Choose a library focused on a particular HR function (minimum of 10 forms in each library)Available for multiple users/admins on platform 2. 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Enjoy 12 months of unlimited access to best-selling, up-to-date forms and tip sheets related to that function $ 99 for 12 months ($129 value).Type directly Learn More About These HR Form Librariesinto fillable fields for easy electronic 2021 Attendance Calendar Na ____________________________________________________BSENCE CODES Dempaer:t _________________completionEmployee Policy Acknowledgment L F irst Form Midle(a)First name and middle initialEmployees Withholding Certicate (b) atOMB No. 1545-0074 get toF D A B E GH ICA S103 F Aedreitaiovenmale HnotB H I In l 1 4 Turs 5 W136 SN P LJ LO K T14 7 M L L T Jueerarymv Dei nuoatf tyAiobnsence F8 f a S9 Total Ab _ _ U Y VZX TI Tared _ _ __ _ S14_ _ th 7 _ _ olei dFaaymily _ 1 8 rmatio T2 9 WEmp T11 F/Payrol S13 6 e plLastT y al ee Inf or S17 m 4 MFirst15 nHire Date: T23 __________________ ( T1 48/ F) 1 M59 id le / S6Todays Date _______________________ S P Separation Notice _ __ E E a m _ t __ ___________ oy __ __ _ _ __ e_ _ e_ _ o _ _W _ _ _ _ _ _ _ _ _ a_ _ _ _ r_ _ n_ _ _i _ _n _ _ _ _g D _ _ eN __ o _ ti _ e _N Pn Employee Performance Review _ l __ o _____________ _____ r ie ew /Supervisor ___________________________________________ /ment: _______________________________Doctors Apointment UncaxytciuonedsFo Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. Pxacrtuisael Hd ours Worked LE Leafyto Ef rly Va ______ __________Positloioyne:e _____________________________________ __________________ Employee Information Employee InformationFllonaetsisn ignH#: __________________________________ Phone #____________________:A rni pplication forEmploym W-4 AddressSingle or # _________________ b Last name name 2021 go24 EMojuLlidrAya yon Job 2 1220 M21 Noili tCaarlyl/ NLeoa Svheow 2 2 Em Last Day Worked e y 15l # 1610 n 1812 Overtime Request & Approval 3 i 0 l s 2 7DTotal // Noasmiteio _n_ __________________________________________________________ __ m ______pl r_k oy ___ ________ _____ / /__ n__________E partmc _ota______________________________________________________ n Conducting R Cuevr Salary/Hourly Rate ____________________________________________ n Employee/Payr__________________________________________________________________________________________________________________________Position____________________________________________________________________ (Rev. December 2020) Give Form W-4 to your employer. credit your name security JANUARY Personal sence Report Nam______________________________________________________________________________________________________ / / ____ ee rmatio a_a m__e_o_ __________________ol ID # ______________________ Department_____________________________ Employees Name _______________________________________________________________________________________ Employee/Payrol FEBRUARY Vacation Time: ________________________MARC HSick Time: _______________________ _l_ _#_ ___________________________________of forms. s ast Department of the Treasury Your withholding is subject to review by the IRS. card? Social security number the nes M - Self Suspension 1 162= Legal Public Holidays 173 4 195 Emo ot atio 16 W10 11 1213 Position ______________________________________________________________ Huirpe Dervaitse or _ _ ______________ __________________________La __s_t D ____e W _ed Inf _____________ __f_f_e_c_t_iv_e_ S_D_ep esiti _a n _____________________________________ e of P _e _s_o______________ nt __________________________________________________________________Internal Revenue Service entStep 1:______________________________________________________ MDepartment EnterCity or town, state, and ZIP code Does forIfonyournot, yourtosocial contact Employee Info plo E_m_r oyee/_vP_iea_yw_r_ __________________ _______ N _a_m_Personalensure matchyou tp _n_ Date _____________________for the application and/or interview proces Information (c)Married ling jointlyor Qualifying widow(er)easonable acommoonds ationswww.ssa.gov.earnings,1715 819 27 28 292 330 Shipftl o(iyf eap/p 212223 24 25 26 Dep 202118 2317 25 2620epartment_____________________________ TyRpees oigfn Saetipoanr atio nL:ayofTerminPaotsioitnion Job abandonment 1.e of Rti_oe ing// dGoodH / / Unsatisfactory/ /Eeqxuuaal al occeriesns ttao ption arognrd gamesn, sdeerr ividcees antintyd e), ramcep, cloyomloer, rnt oeligpipoonr, ntuantiitoiens ial os arvigainila, cblie ttizeo anslhl pipe, arsgoen, ds wisiatbhoilituyt r, geegnaerd ttic io snfoex (rminatciolund, oinr ag pnry oegntahner bcy, asisSSA 800-772-1213or15Employee/Payrol# ___________________________________ 9 __________________ Details of Separation Performance Ratings# _____________________ Date of Notice _________________protected by federal, state, and/or local law. Married ling separatelyName_________________________________________________________________________________________________________________________________________ Name_____________________________________________________________ Employee/Payrol d neat.// 27artmen tP_____________________________________________________________Supervisor _____________________________________________________________________________________________________________________________DepVaretrmy Genot o___________________________urate, thorough aHead of household (Check only if youre unmarried and pay more than half the costs of keeping up a home for yourself and a qualifying individual.)osition____________________________________2224should notify the Human Resources Department. Examples of res basorai carbolle) _____________________________________________________________________ ________________________________________________________________________________________________________________Name of Policy/Document______________________________________________________________________________ Date Provided:_____________________ e, llea arcge pcomrimnt oodr aatiudio31 26 Plia __________________________________ 28 es 29 eta 31 ________________________________________________________Other Type of Violation CommeThe extent to which an employees work is ac Neiree dDs aImtep _________________ _______________In acordance with the Americans with Disabilities Act and/or applicable state and local laws, applicants requiring rnal 28Overtime Requt D Q u Oaulittys tnatns:d__________________ rovement ecclourdde minga; uksining a cg a hsigann gle tano tguhage ae ipnptelircparteiotn per; ruosceings ss; ppercoivaildiziendg w eqriutitpemn menat;t eorria mls ion adifyn aingl tteersntainte fg coornmdaitt siouncsh a.By signing below, I acknowledugee tsthioant I hs abaovue rt thee pceiovelid tcy, I she whoourld ckpolancte pact:oliclaim exemption from withholding, when to use the estimator at Completecy listed a Stepsbove.24 ONLY if they apply to you; otherwise, skipwww.irs.gov/W4App to Step 5. See page, and privacy. 2 for more information on each step, who can_ _ ______ __ _ __s _ __ t__ _ __S_t_r___t_ ________ _ F__ _ i__rs _ t_ _______ _ __e __ t _ M _ _i__ dd C le_ _it _ y _ p _ .Notes ______________________________________________________ S1 8 45T67T1 18F1 29S3Al ReasoNotes ______________________________________________________ l h eS2 30 329 M t 1 d 30 d yT 2 1 a 5412 1 v io 6 52 d c T 2 1 h y73 6F7S2s9 1e T :Nl Notes ______________________________________________________ S3 4 T15 6 2T3F1 8 4S5 __________________tto __________________ Re ARe ___________________________________________________________________________________________________________________________________ y AA gb t t o o n un a e dInsubordination GeeNseseesd sth Ime pprroacvetimcaeln/tet ch ni c al kUnnoswalteisfactorydge required on the job. Absence Details Please enter the anticipated date(s) and time(s) when overtime will be required: AtendanceUnsat i_______________________________________________________________________________________________________________________________sfactory Performance I understand that if I have any q __ __ __ ____ __________ __ T dd __ __________________________________________ _ La eeCel ______ Step 2:() Complete _this___ _ __ __ __ _ ___ _ _step ___ A you _ __ __________________________more than one job at a time, or (2) are married jointly and your spouse _____________________________________________________________ _____________________________________________________________ 8 _________________________________________________________________________________________ on for Separation: me nO t thURnelxpocrcuoaspteirodinaAt e bB see nhRceaevti iroerment Condu ctD 2a. oe t ne O Kd Colp n Oemthope_______________________________________ ow-up._________N_______a___m______e_______________________ Multiple Jobs__________only one __if ___p_l_i_c _(1)_a_n_t I _hold_D #___________________________________ or APRILMWTota List Date(sM pAobYrstet__________________________________Dathter(s : ) ota _____________________________________________________________Time(s): Time ________________ to __________________ Re Paesrdsuocntaiol n/Re oOrgthaenri zEamtiopnlo y er In _________________________________________________________________________________________________Oe posWorks ___________________________________________also works. The correct amount of withholding depends on income earned from all of these jobs. Was notificat end b bse Weceive __________________________________________________________ Viomlaa itJof tCsotonwammce npadiannggyyePR P rue oT lr hepf e /oePrr eVmotyxl aticeenryny G cte too owdhich a thelorrod::y________________________________________________________________________________________________________________ ) A ame____________________________________________________________a a wil ting a pr H It u f n a g o ece I i i o ss.es Ii e a n fru u y, b sivt b m x p eh it se a t t (e.g., Walk-in, Job Posting, Companys Website, etc.) e r t (s__ n rs o e y rsi a s t a e an _ s(s _ ,_ t ______ _ ___ _YsSteps_N _ a o o _ _ s _c _ y H d is o p o (a) o is a r u i ti _ a e bc oni I il ati a yt Form o P r lr p l c p a lyi i eW-4 dr d d a g oe t( t v h s w isIffor l x e e a tit pi r h oroe eonly v r isN h tenjobs). g r fu. Ifn you enter tb x te by $500 d b . . ZIP Code . . w .No . . . . . . other. . . . income$ $ . . . . . . you . . . . . . expect . . . . 4(a) 3 $ $ $ lete. 0.00 SS251 34M261 45TT2756 21 67 TT2971 8 FF30 1829SS24 293Total If so, did t A E o N i d n o e S Ste 1 161 4718 5d s o t *o of m M Ml 171 1829sU T TR 1 e 293 7,nce r 3id xe t TT1 1 12 i 459th d in a t FFJ Il 1 u 36e sSS2 1 15 1 u t p 3 67 14 YesNo t y N mot D SS YesNo e 1 5 5 2 :P M 6 6 is TT222 P 7 1 7 a ROV 232 2 E 1 8 9 185 D TT2 17 9 6 29FF252 7 3SS19 1 1 4 TotalVa __________________ __________________ __________________ Acccrruueed Sd Vaicck PatiaoynPayCYTotnNoab sle A e 401AG Am e kE o lT t Pro u u 0 a n H3O k t(e ISb$ s n n m t pstio es c c roG ces a edon4.______________________________________________________________________________________________________________________________________________ ru ii o N T E/____________________ ______________________________________________________________________A Peolseiptiohnon(se)a#p() ____________________________________________________________________________ ________________ _____________ Do__________________ _ of the following. State for most accurate withholding for this step (and Steps 34); 11 1920 14 252 236 10bsence r y tion of a , w Emplo 20O eeO im ys ely fashion?JUNE M17 18 W1910 1112Total __________________ to o__________________ Fingaull aPra Pya:Yesaep / / Time 3.Comments:__________________________________________________________________________________________________________________________________or Spouse ____________________ ular/Other Phone # ____________________(c) __________________________www.irs.gov/W4App // 2817 Abseednicceae e r ePaaie oye 18s a d 19 t r 22 ertificat 16 2129 30 2426__________________ to __________________ Amount$_____________________________________________ V______________________________________________________________ Unsatisfactory_(b)_Use the estimator at_______________________________________________________________________________________________________r_e_s_s_ _____________________________________________________________________________________________________________________________________ npa 14 __________________________________________________________ __________________ Description of Violation _____________________________Use the Multiple Jobs Worksheet on page 3 and enter the result in Step 4(c) below for roughly accurate withholding; or __________________________________________________________M Refer i l e e al Sourceo g n e o r c t t a u t im b h e t e e w o c ork al ? l you i l______________________________ if yt satgem Or a m oE-mail Addres Ds__________________________________________ rrJULY M12 13 W10If m Accccid csaetf nt24 e pro W14 or seeen? as p ssi cia Nn co 20 e h quested?YesNo Suspension __________________ Other/ /___ Ye ess Date of Incident ____________________ / / ReliabilityThe extent to which an employee can be relied upon regarding task completion and fol _______________If there are only two jobs total, you may check this box. Do the same on Form W-4 for the other job. This optionplied for _________________________________________________________________________is accurate for jobs with similar pay; otherwise, more tax than necessary may be withheld ate of application _____________________ 21__________________________________________________________ Amount$_____________________________________________Outstandingery GoodGoodNeeds Improvement TIP: To be accurate, submit a 2021 Form W-4________________ for all other jobs. If you (or your spouse) have self-employmentplYeh ion re 28omments:__________________________________________________________________________________________________________________________________I understand that the fo_____________________________________________________________________ If the absence exceeded three dayiss?, w 28 __________________________________________________________ _________________________________________________________________________________________________________________________________________________po o ay wcHometa rrt Cel mun r a po lo ic qu ndtlh ain Complete h ioN a o-wil income, including as an independent contractor, use the estimator. _____________________________________________________________Edxcuu en r Absence: FamRielya sLeona vfeor overti 27Leaovue ors rf Aeqbuseesntceed:____________________Tardy/Leave Early __________________ Date Payable__________________YesDes NNoocori ption: _____________________________________________________________________Oem nng OV oodGoodignments and asumes additional duties when necesary.mationd ientt hae poicaytsthupee irsfed annypi riourr rwrnitte onn loy a ot ta hle ONE of these jobs. Leave those steps blank for the other jobs. (Your withholding will31 _______________________________________________________________________________________________________________________________ormesa t34(b)be most accurate if you complete Steps 34(b) on the Form W-4 for the highest paying job.)______________________________________________________ _____________________________________________________________ Action _____________________________________________ C_________________________________________________________________________________________________________________________________________________timleic ipesro ovnid edthi,sanpdw s subject to ular/Other est time to call: n oidthinmae ther tehdaicn tal cimoe ondfitf fioonr r, aere tasohnes rre aelnay dted tayo ys oor tur rimeels wigiohne, a dn yoisu aabrie lity,Notes ______________________________________________________n the Job Illn Estimated total overtim _________________________________________________________________________________________________________________________ WN to b m moouunntt$ $ _____________________________________________ theerry G________________________________________________________________________________________________________________discretion. I ackno If y ed k ntchangey a dtoe ansyntoimt em w Ye unavailable to work? ________________________________________________ _____________________________________________________________ es ______________________________________________________ al Pay M _____________________________________________ : __________________________________________________________ Unsatisfactory cs, w hyou atnd b . e n enmtps lsooymle ent the Job Holiday Family SEP TEMMedBiEcRal Leave InitiativeThe extent to which an employee seeks out new asot yhmn Step 3:______________________________________________________________________GUSTry D TotalMedical Appointment 10 Other:_____________________________ At Yeaser q n u i negn Nc eo sho lde beinatctiniidogen D n at to e____________________ Needs Improvement om () s r ired ClaimWill yMultiply the number of qualifying children under age 17 by $2,000 ne_______________________________________________________________________________________________________________________________ urtmestniantans:dt__________________relationship (if applicable) and that pn er ineg c on N/An the policy may be construed: ___________________________________ DeathA iiUno nFaamily 10Self Mtaorny WUnceaxtciounsed* Seaps tarhaetrie a son Meepeatriantgio:n meeting? Co WsuSru asgpeinns: i_________________________________________________________________________________________________thse c porealicy conflicts with applicable fedal, s or tfutuedreibel lanwe,f tithse. nIftah f n, p matio n win12 13 14 15 16 17*Reason for abenc as e18planed 20 _______________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________ ney ou work overtipme if required? .Yes______________________________________________________________________________________________________________________________________ Co LmTocation______________________________________se for future em Dependents Multiply the number of other dependentsMeilr l Day______________________________________________________________________________________________________________________________________________ govern. can you furnish a work permit?.tate or loca nfpic lease elain by emloyee _________________________________________________________________________________________ ended by____________________________________________________________________________________________________________________________________ ing and demonstrates the ability to cooperate, work and If you are under 18 and it i p ablI agree to thoro ve yu s , g view t te h d a e po pp lic licio n n here before?st aYes_______ No l inf (a) m hou able to perform the esen rteiaal sfuonncatbiolen sac ocof mthme joodba ftoior nw)?hich . withheld .income here. This .may. 18 19 20 21 22 23 24t fol 22 236 24 25 26 27Approval Status 19 13 1412 13 14 18 _______________ Administrative Checklist _______________________________________________________________________________________________________________________________ /DA Unsatisfactory _______________nd e dd) and ptiond Step 4w re y_________________________________________________________________ 29 30 31 28EDNO 20 T AP 2830 25 _______________________________________________________________________________________________________________________________ u If no, plebase explan ain: ___________________________________ n AAdd the amounts above and enter the total heretax amount . of . forother.25 26 27 28 29 30 31_______________________________________________________________________________________________________________________________ _______________ Company Materials/Equipment ReturnedFacility/Systems AcTerminated5. Interpersonal RelationshipsThe extent to which an employee is wilhlyre d to requeYes (b) Other o income no ois (nothavefrom withholding, ioo ou want then aplicant'sthanthe standard deduction 4(b) Notes ______________________________________________________ Notes ______________________________________________________ 26ECE 27BER WTotal __________________ __________________ EO SUPERVISOR/M Fina (l P ) 4 ay Proces D W edn P iption of viola edcommunicate with coworkers, supervisors, subordinates and/or o____________________________________utside contacts. Uyns osaf dtisofaincg ttorhyings.(optional): are a n that wont o d t iswithout OutstandingVery GoodGoodNeeds Improvementf y ):___________________________ this yearosm n info reon. n o ndae o elicit inforoomnma hame e n abihooen iu t aees nxrim setietcnetecsse aory lfy . Taa dhiseasbe ility,_____________________________________________________________ w-up action and date scheduledN, i of A taePnsPy: ,R________ wOitVh th__________________________e employee ______________________________________________________________________________________________________________________________________________________________________________ Life Insurance Conversion_______________________________________________________________ SIGNATUREotified: ____________________ofn tyhthisin pog Il icdyo,In mo y be su ipltinarya dditio sruatg include interest, dividends, and retirement incomeotheron page 3 and . 4(c)$ WTotal Lis _______________________________________________________________________________________________________________________________ __________________ mBplRoAy eNeo Rtieficcoartdiosn A PrrcohciveesdsedANR WAeme ) O e P ARNIN 6t.i onC.eO InH ce Companies N________________________________________________________________________________________________________________Other This question is not design Commseunrtasn:___________________________________________________________________________________ D and he p your l e incf.otirom .usenas.t i totheon a. re Deductionsbs. Comment NOVEMBE W_______________________________________________________________________________________________________________________________ OL ifeea _______________________________________________________ta ru ajnec .tIo dis dce thcattio ifnI udpotnoo at ncdo minpclluy din uiltte r a ece a modatid ao yout a l r wier stofhtreamr aactcio t dat ttnt p out the job Worksheetspay period_____________________________________________________________ _____________________________________________________________ Notes ______________________________________________________ Date_______________________ __________________ EmployePa Syirta SUE nta FycohremcskProces_______________________________________________________________________________________________________________________________Is thiIs af yepsp, gliciave dtion a r Adjustments t(c) s ma . y bm toNreduce expecttoe tclaim deductions po.nd. OCTOBER _______________________________________________________________________________________________________________________________ // Mal/oPickdujpu Ltast O lthMajor Medical & Medical po ses ideeaesd, fsi nImdps nroevw aemend bntet t e r waDeductions._____________________________________________________________ _____________________________________________________________ a T OF SUPERVISOR/MANAGER Have you ever been employed here before? YesNoYe wants_____________________________________________________________// // enter the result here ees.esd m ewithholding,ntioa __________________________________________________________________________________________________________________ dilnhge extenVt to wates:Fequerost fm ________________ iveExtra withholding.e a eqpupilryeid ingf d: riving may be required ins __________________________________ Total M ati tvsDhtietearynnt________________________________________or reemployme nt T o ________________ s loicer wnhse nich yumou aber rrEnter any additional tax you want withheld each1012 _______________________________________________________________________________________________________________________________ I d ree Commthenetrsery Ghicoh aodn emplo y Gee poodr o _______________________________________________________________________________________________________________________________hre jorb f State _____________ _______________________________________________________________________________________________________________________________ :__________________________________________________________________________________________________________________________________Employees Signature_ _____ frfo m _ _d m _i_li_t_a_r_y l___a_ ve of a_bse_nce_Step 5: _ _ ___N ________________________________________________ YesNo 1012 13 14 15 161516 17 1819 5 Op ____________________________________________________________________________________________________________________ 2 3 I agisrag ee wit hfo re mthpelsoey erersa sdoenssc:r _____________________________________________________________________________________________________________ iciently in a specified period of time.14 ___________________________________________o_l_lm__w_ _t_ih_n_ig as_ _c_n eo___t_ae_n_n_y_d_?_ e _ _. _e_ __a_ Date__________________________ Ba20 ional: ___________________________ 10 18__________________ _____________________________________________________________7. _______________________________________________________________________________________________________________________________________________u_e _s ___ // _______________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________v_e you ever been bonded?se hourly wagetent to w/ /Here 19 20 21 22 23Outstandinghich an employee produces a sign____________________________________ificant volume of work ef2020 ComplyRight, Inc. propdourct invoveedt.eiYn Are yIf you lesa, awfdudl ha ae ti n ugrg ,n vn e s aeoid ot n d u b c n in e iy a s d i i f i r sicte f i d s a at ogr ls a thedirs va puicrteohsdo. ruTichttae it siivn nef ooitrn mflioaarbmtiloean tfoi iosrnpa.n rHoyov dnti a nis opris oticuula rlr a yaid on a ed m Sign anaa a n trhie yy ss? i p neu uo siu uitcb fNooq s yfu te foonii rh o le o airg tr H otahveerypoaur teyn (steurcehd a isn taonaonn acgormeepmeteitniotn w aitghr eaenmy feonrtm) tehra te mmpiglohty, einroarn yN ra i cor vi I er tc e s oe ussed c on th e l y tit ie a a s ve. - First date ofDateForm W-4 (2021)17 18 19 20 21 22 23Supervis or/Mana 23ger 2425va 26l Ov A 2e7r time rate12 13 14 15 16 1725Date_____________________ Date ____________________Completed by __________________________________________________________________________________________________________________________________________________________________ I T p in ma ctrc u lpu se da g v rit e or a tn inpro T cy eto i siivn o er at s ic t a f an i res h t go l uC s o y fo e te e fs or n a r glaan blty o th es is v te e. .mprovementUnsatisfactorytiounathl ionrifzoerd tmao wtion morkay be req ted 21 22 Appro _______________________________24Productivity ThDe eatex ___________________________ Needs I__________________Very GoodGood _______________________________________________________________________________________________________________________________A001CFL Trhoisvl pidrodu lp D in the United States? Yesa ais o t ,d dersttaitnuding t Employees signatureour abi (This form is not valid unless you sign it.)No employment number (EIN) 24 25 26 27 28 29 30Supervisor/Manager Name________________________________________________________________________________________________________ // A02307230 CCFoLmplyRight, Inc. prhoisv ipdreo ldeugon sr d nio srgn I hprovi e r urate d an authorgihtta nd e pinformantiroris n . rH d th wiith tais ant n mp a sub o itumments:_________________________________________________________________________________________________________________________________________________Im gct e a s y la o tua o prgso uvide acrcurtrate a cn ry ranegr ge or h y ritau weve arw f piitt sh is not a cbliclotehrs wet uses al a ydp tie ry s f y eto an tri, p s ynote e lity to work for our company? .Yes_______ 31 28 29 3026 27 28 29 30 31// rvopodoluvrectdatn.itnYatiiengig,n pro n oany s poecifictc arfcta bcu ts eo grya sntchdoeir nsvices. nformatio lao nsiptuoyaov dtwiidoaemenvd aaen g,d s E riesi n un cdiersttandi n ug esth olaeot r ciaano rn dvieiceanentticanto not de nsioig on le for work __________________ th th way, r n dorets h xplain: __________________________________ Supervisor/Manager Signature ________________________________________________________________________ oieaote:e This is ap cindiasd u urt alir blue y osp efitc que thstio ny cipe inrson dooy sp oer c lt anatbto cutnsi n Employers Employers name and addressonsuldt ean cerndi un e W rns g N$ _______________________________ ot be // _________________________________________________________________ Cat. No. 10220Q _____________________________________________________________ Notes ______________________________________________________ re ______________________________________________________________________________________________ edo tdotu croved for use by the purchaser only. This form may not be shared publicly or with third parties. toy ous u re dmayit hnyao____________________Wculr eerap t i prdocroved for use by ehye opnucrecrhnyonulyr . Tah form sm te oOnly ared pgn dnnpa anbcilei nss. you may Notes ______________________________________________________ ApppprroovveerrssSNiagnmaet u_________________________________________________________________________________________________________________________________________________________________________________________________________________________________W : iThis is ap r d g esh 8) uonmlpesas ony its sheruwbijsee nct too tted bhe setlaotw es1_____________________________________________________________ p Notes ______________________________________________________ ot _______________________________r oaa oi r n i aw t nhdei nugs teh oartainnaybp ilietyrston u osreethntisit y o A231 ____________________________________________________________________________________________________________________ T p inh r is o p rta a ha o or ann stos ony u os er etonhaetsyiistnh yo avte d m . /DATE/Per_________________________ Routing:_____________________________________________________________pr SIGNATURE OF EMPLOYEType o f eEdmucpaltoioymnaeln Ct do-eOspir ed:SFeual-Toinmael s PTeamrt-pToimraer y (eOm h3is c PAGEA02800280 CCFoLmplyRight, Inc.Human Resources_____________________________________________________________________ r d e s ot rn d stu ooa ctc n o i a dh a tiuo or rne lfm visr tdimanoy v da otd nbane g eidst shh aaa ntrhreyise sdiupnpnegu codbiuefliictrc s olqytfuaor with third parties. 2020 ComplyRight, Inc. prvooduct. Young yo unroitnu tedseteti niuo fgnso tresh lertg aa y dpveirce and ouworTpkE TleorysO R cero tHmo OlpisDetE I naspaSptLiloAicn lNaD Abalew s (PePxCLemhICaAppNttieoTr 2nS: Ts9): This product is designed to provide acurate and authoritative information. However, it is not a substitute for legal advice and does not For Privacy Act and Paperwork Reduction Act Notice, see page 3.Wiilll yl yoou ru teralovecl iatf je iof jb rob requeqireus iiret?s i .t? . YYeess NNoo ______________________________________________________________________ T provide legal opinions on any specific facts or sep iasnr ouvd crvip cecirecrheoensnadt i. sainutTengyhc rt diy ne ooi dsnviuno olnylferv.ooseprtT n madlhio riaistantibc fptcleo i snietg ua,a y tidoem estions or concerns you may have.AN EQUAL OPPORTUNITY EMPLOYER consult annote:ator nThisey c ison approvedcerning yo forurpusearti bycu lthear s ipurchasertuation and only. anyThisspec formific q umayesti onotns o ber c sharedoncern spublicly you ma oryhwithave. thirdse a oprp inroabveiolidt sy Important note: This is aproved for use by the purchaser only. This form may not be shared publicly or with third parties.______________________________________________________________________ lehrgoiasdlupocrpoinidngui ocontr si sd o isdnte raisbniguynt isenpdgetctohif ipiscAr0f2opa90rvco2i7dtd5s0e uoC CacFrot cL scmiseu rpnrvalioctytReeliisaag. nbThdlthe ,a e If unoinctrhf. aoonrrmiyt aadttaiviomenaiignsefIpio mpnsrvr roapmoodrovaliuvirstedcitinaodetgn.n diY tn.owHon ucuioottr h aetowe rfetah:te vt ehi Tenuhre rug,i s gu, ni eptsd i n gs usugblr tft tdioiatrnsutututa raesitsnebe toyf o u btrhtpyni ei nletesrghy gpsoaetrcnlh ood parties.uct. You are urged CFL v livdreeod l dienugc catrlioaes rapdetiine nuisgroigg, nepns redoo dntd o tuoa cc nopinynr gossp uvoelirtdcaedifin aisc act rfcitabtucorutrastnti neoe grya tscnhdoei nrsav cipuceretrohsndoi. Tiuchte ti isivenfoipntrm aflroiartaibtcmileoua nlfatoi rois r n sipa.t rnHuoyaov tdiwidoaeenmvd eaa rwng,de iitsth a i sa ntr hynies osi ptnu agencsdoifueuibcrts os qttfuicnlnoabcielityrninImportantHiring & Onboarding Time & Attendance Performance ManagementPage 21 Page 13 Page 25FMLA Employee Leave Request W ness Emoprklopylaecee R Ienpjuorryt/IlEligible employees are entitled under the Family and Medsicta flo Lrema vtoeyAoctu r( Fheuf s r m ) nto r etaskoeu rucep sto m 1a2n aogr e2r6awt eleeakssto3f0 j odba-ypsr obteefoctreed t hleea ves fl l sEmployee Information Safety Violation NoticeMLAalo l reasons. 3S0u bdmayist t haidsv arendceen Ce eques if t form ision o ib Hea mit the reques e t aProvider forName____________________________________________________________________________________ Employee/Payrol #________________________________earv cee irst ationbfaemgiinly,wahnedn m peodsiscaibnley . rWesheernv es the right toque syu obrm pisossitopno noeftlheE rticat not po e, sub thCar ed ndition Position __________________________________ Department ____________________________________ Supervisor _____________________________________mployees Serious Health Couonodne ra fse dpoesrasli balen.d O/our rs Ctaotme plaaw. ave if you do not give adequate notice when permit Employee InformationIncident InformationEmployee Information Temporary.:Se.C / 9noC. .FIf. Rth. ee8m25p.l3o1y3e. eIn ffaoilrsm toa tpioron vaibdoe ucot mthpel eFMteL aAn md sauyf bfiec ifeonut nmd eodnic tahl ec eWr tifDic awtieobns,i thei sa ot rw hwerw F.dMoLl.Agov/agencies/whd/fmla. leave request may beH r.D dra milya cteom o cident _______________________ / e _______________ ing a laddetermined#_____________________ Date of Notice _________________/ment: _____________________________________________________________ oUee__________________________________________________________ / Tim___________________________________________________________________________________________________ / Todays Date: _______________________ /Hire Date: _____________________ aynnePd. a fyor ro2 l6le 1#a3v:, ______________________________________________ Loacteat oiofn in ___________________________________ Time of incident cNPanoansmoiteito __________________bne __________________________________________________________________ nt___________________________________________________________________________________________________ Employ Deeep/PaarytrmoelD Neampaer:t ____________________________________________________________________PEomspo2itl9fo iThe Family and Medical Leave Act (FMLA) provides that an employer may require an employeey s etheek ienmg pFlMoLyeAe psr oheteaclttiho ncas rbee pcraouvsidee/ Explain what you were doing just before the incident oc ed. Be as specific as posdsiebrl ew. hIfi lyeo cua rwreyrine gu psianingt tiongol ms, aetqeuriiaplmse; nt, e2 6d1u4e( cto)( 3a) ;s 2e9ri oCu.Fs. Rh. ea 8lt2h5 c.3on05di. tTiohneteom spulbomyeirtam musetd gicivaelctheret iefimcaptliooyne ies saut eleda bst 15 calendar days to provide the enet rthye)m.and specify what you were doing with them (e.g., climbur Type(s) of Violation _________________Improper Use of PPEStatus: Ful-Time/Part-Time/Supdceernvtiiiefsicodar. :2t i_______________________________________________________ riaplsu, tnearm (Rev. 04/2004)Reason for Requesting Leave FMLA Leave Tracker OSHAs Form 300ALockout/Tagout Violationt_________________ UViolation of Safety Rules/Policies_______________________________________________________________________________________________________________________________Unsafe Material Handling Summary of Work-Related Injuries SECTION I - Employer _______________________________________________________________________________________________________________________________Obstruction of AccesI am requesting family/medical leave for t d L L R y 5. H 1. hc ow sEe h l n T f nHeis i t tl o e od l U o s w e t in e r his a gls le thF re w orc h c a e m o sons: (check al n ne d n it ein n n A E ti d ot L rt r ih d t t Tthat apply) o - e ha ia h E r t s ic is . s t o t la h k r e t p .tle il a t d ld f c h s la o a d laa d y e ls t hc re ,o b 6 i t a e s w s 3 w u a c n . e a m 5 s h n b t i .9 t e vr c i pe e on a i e g e lt h r u s n es o if d d syd nin n e e uo u g ot e de r 1i ore e ln 2- a ne hcg o k c ltc w r p o so a uar e r n pe meq e t1 t r k h ns y t e a o2 u F -m n v u M e is ltip d ro L ne Aw a le,tle hm c it ao u pv h o n eem Fir r r r p ie pl stoedn e i t ri C .ed toe fo F d .Fa R s M nta . L dr A ts.suf 16 Employee Informationle23 nal, this form asks the health care providerF dl R e3 d o - a 2Last CUMULATIVE a I ndde vnealmopee odb sjehco and Illnesses es to the event(s) res For T Descriptio r w / /sEex it Poin_________________StreetOther: ______________________________________ Form approved OMB no. 1218-0176e_______________________________________________________________________________________________________________________________ Birth of my child; to care for my newborn 2.3 p. tU iors n et r the employe h t f a os le t b r e lo a w rinformation a e foen . A geht re rethe employee or the employer may complete Section I. While usernt iodfifce tarht tiisho _____________nfeo,FrwmMh iLicsAh oirpset sgioeu b tl_____________________________ oaotruniotncahts i,29l2d9oC C MId F.R. . il d8 2p 85la2.3ce50. 6 0.f Y6 o ______________________________ Explain how the incident ocured. List the event(s) that resulted in the inju ry octeiot nla/Hddoersre rpulnagy and I fel 1 Imnpsraofep eFrir Ue sPer eovf eTnotoiolsn/ Equipment______________________________________otlep aaavlrelotm wtoe enbdto Firstr a .chHire Date _______________________________ frso amn dtypoinwg t)h. ey were involved (e.g., Foot slip peDdi sotrna rH ilanzeasrds,o wush aEtl ehcatpripcaeln Ued, how it happened,y member to you:Below the employe information,or fd w a u maymtlh t a certif incatiromn afotri oFnM tLhAD a en ical ceun _________________________________________ do.a3p0tyi o8.n All establishments covered by Part 1904 must complete this Summar n of Violation 5 feet ; Unsafe LiftingPleaacevem teo ncta orefafo crh ail dfa wmitilhymmeem fobr e r w iatdho a 4. ba to tenrterg a hlo FuM rsn in r e m yo t.he Tota ce tso fo icieNnta mmeed _________________ r8u 5 m/ /to s tainngd p/oari nssu ibns taarnmce h y page, even if no work-related injuriesEstablishment informationUse nueme and accurate before completing this Summary.ious h io d with a healthy new or illnesses occurred during the year. Remember to review the Log to verify that the entries are complete to update automatical erbcsiefincc ceomments. ________________________________________________________________________________________________________________________________________________ t Reyl aotwionn ssheirpio ouf sf ahmeaillbteh ccaounsdei tai ofanmily me_____________________________________________________________________ P r Te b hen rni b so o le to u i n n :g s tdre r y e _________________________________ ilities Act applies, and in acordance with l________________________________________________________________________________________________________________________________________________ _____________________________________________on page 2 ty as you eno record antery d eata-speh Using the Log, count the individual entries you made for each category. Then write the totals below, makingQ M l e Uaseta chas been calledoE tmro m pcoevdeicraloyernd , dwto ute rdce Gtuuasro29.Nondi1sc6r3im0.i1n4aS(tctio)a(1rnt o) ,A icff F tt haMep pLAA plimese.erriciaodn: sw_____________________________ith Disab // _________________________________________ MONTHLYHOURS If applicable, pro sure youve added the entries from every page of the Log. If you had no cases, write 0. Time _____________________________Your establishment name __________________ ZIP ___________ M huea Nlifaytiinogn aelx Giguenarcdyand Reserves) to a fo m ige se the eloo signed to start in any month an l mato eftrya milnyptmlhoeay eiRneteasg icnurl eraear ctAeordrm dfsoe dra Fn FMdo rLdceAo pcs uu(imrnpceolnuEstmedsis np realgoslay cteioneng/fP itdaoey nmroteilald #l imc __________________________________ael dinicfoalr rmecatoirodns,imn esdeipcaarl aceter ftiilfeicsa/rteiocnosr,d rse fcreormtif icthaetions usua,________________________________________________________________________________________________________________________________________________ ______________________________________________________________ck m s equa ela entiretyes recordkeeping rule, for further details on the access provisions for these for/ ____________________________________________________State_____________ Date of Incident ____________________Employees, former employees, and their representatives have the right to review OSHAs Form 300 in its l W person .Rnel 1files an thGenetinc Informatio in OSHA . They also have limited access to OSHAsultinm 301 or its equivalent. See 29 CFR Part 1904.35, City______________________________________________________________29 C vide thnames of any witnes _________________________________________eahveenstwriatchkinin ga 1 in2t-emrmonth period. ittent leave, note.F that 12 l 480 hours. g in injuDrye oscr ilplntieosns: _________________Reealavteio tnos chaipre o ffo fra am fialym milyem mbeemr btoe ry owuh: o______________________________________________________________________________________________________ ________________________________________ Last Describe the injuryNumber of Caseshow it was af ms. _____________________________ _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________a icsoabveilriteyd r veetitreerda nlis at nfodr w ah soe irsio uunsd ienjrugroinogOrNmi 12 3 4 5 2.n E,F omorp cehsye re(ieanp cnylu,a idmsi en in: __________________________________ 17 181920 Mid 21 2224 252627282/ 9 30/3 1 HOURStunnel syndrome). /ilnes. Indicate the part of the body that was afected and_______________________________________________________________________________________________________________________________ __________________ember to you:is a ceudrcsarenl tt reametmmbenert ,o recf thuep erAram1t.ioe6 m 7 8 9 Naai iotn astl a dr a onndetRemspeor_______verarsy or)it is not feasible despite the employe Date: ___________________________ 0 0 0 0 Total number of deathsTotal number of cases om work joobt a (I) ected (e.g., Broken leg; carpalIndustry description (e.g., Manufacturer of motor truck trailers)lo oyer name:10 11 12 13 14 15List d ate certi ficatio n requested with days away fr _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________ tlr annusmferb oerroref sctarsicesti ownithTotal number of other Oethlaetiro (npslehaips eo fe fxapmlaiilny)m _____________________________________________________________________3. The medical certification must be return__________________ed by ___________________________ s diligent, good faith efforts.) ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________/_______________________________________________________________________________________________________________________________recordable cases _______________________________________________________________________________________________________________________________/_______________________________________________________________________________________________________________________________ _________________ North American Industrial Classification (NAICS), if known (e.g., 336212)(Must alow at least 15 calendar days from the date requested, unles _________________ _________________ _________________ __________________________________Duration of Leave ________________________ /Leave expected to end4 . ________________________ Employees job title:______________________________________________________________________Job description isis notatached. 0 0 Medical Care Information (H) Employee should adhere to the fol (J) _________________(G) Description of Proper Procedure///Le intermittentIf yees re gandula rthe wo proposedrk schedu lleavee: __________________________________________________________________________________________________________ 0 0IIdreid cenivoet dr eocensiviteemt o or t Number of Days ows: Total number of days of() owing procedure going forward: ______________________________________________________________________ave expecte ord t reduced-leaveo begin: schedule is being requested, please explain whySEmtatement of the employees es itp islo neededschedule: T erm re eadticmael tnrte fartomme nmty. _________________________________________________________________________________________________________________________________________________ential job functions: ______________________________________________________________________________________ nt from a medicalemployer.provider, as fol Employment information __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________n __________________ 0 0 0 0 He Ia rltehcecairvee dP rorviteadtme_____________________________________________________________________f _____ Phoestriction (If you dont have these figures, see the Worksheet on the back of this page to estimate.)alwnourmkber of days away____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Thoeti feisesde tnhtiea el mfupnlcotyioenr so of fth teh en eeemdp floory eleea'sv ep oosri ttihoenlaereav ed esttaerrmitedn, ewd hwicithhe vreerf eis nereceheld at the time the employe 0 0 Adedrere ysosu _________________ (K) tien t? Yes NYeosNo job transfer or rne _______________________________________ Annual average number of employees__________________Employee Certification and Signature arl iteor. the position the employe W _________________ _______________________________________________________________________________________________________________________________ ____________________________________I certify that the above information is true and correct to the best of my knowledge: Wtreated in an e______________________________________________________________________________________________________________________ Total hours worked by all employees last year____________________________________________________________________mergency raono imnp? a_________________________________________________________________________________________________________________________________________________(L)/ / If yeerse,yleonug htoh sopfi tsatlaizye __________________________________ypes _________________________________________________________________________________________________________________________________________________d overnight as_______________________________________________________________________________________________________________________________A Employees Signature ___________________________________________________________________________________________in p Im u h y e d ts o o Date______________________ 0 0 0 0 0 0 0 0 EMPLOYE SIGNATURET l Injury and Illness T i p T n h hi i s s de reS od u uc aet r n ar nd p a o p o g ro e v id u ra tF teg yrao ________________________________________________________________________________________ n raut ry r it 1e at y v at p m ri fo t l io l ud wev f t e h , itt e i sy F Ssi e i en p tr a a co b u fic n f b o s d e l te l u o s tie w n t a P o . hts r i a rhn no gler g i g n at l a o g n h d e ir c e ya . o ea d r on e t is yioty na v .DSign here () __________________ Title wledge the entries are true, Acknowledgment (1)Injuries _______________________________________________________________________________________________________________________________(M)______ sc Wrnings _______________ I certify that I have examined this document and that to the best of my knoesult in a fine.Knowingly falsifying this document may rE ph PLOYER: This form should be treated as a medical record and must be maintained separately from employee personnel files,0 0 I certify that a otal number ofe provided is true, comp ______ (4) H oisonings Date/ ______ accurate, and complete. Reason(s) for WarninginM lootcokceodp yc aobfi ntheets f owrimthtoon ylyo uder esimgnpaltoeyde ep ealrosnogn nweilt hh athvien gC oamccepasn.yARse asnp oenmsep lfooyremr,wyoituh isnh ao urleda rsoetnaainb lteh ipse orrioigdi noaf lt aimnde. provide a information I hav (2)Skin disorders ete, aPnrde vcoiorur (5)earing loss______ By Whom ___________________________________________________________________________________________ATE/(3)Respiratory conditions______ (6)All other illnesses ______roodlipuv cdt. iYno cur aden for this collection of information is estimated to av ay not b guc srt Warnin e not requiry ous eu m tha//12403221C CFoLmplyRight, Inc. Throisv ipdreo dleugcatliosp dineisoi p gns eodntaon pyr ospveidcein fiacc fcaucrtast eo ra snedr vaiucethso. Trihtaet iivnef oirnmfoartmioant iois np. rHoovwideevde wr, iith sha anot a subt s soqttfiuao nttr wi ng etha uosuerme tnhatyiisthy ave. 12-MONTH 2021 ComplyRight, Inc. Post tprvovlegam tl eis m sig y tdo tu ccroved froac meb thd ua ho evie toiprn m fori ation 3 n. H 0 o tidon ed rwi e sharnrisedy nopes oiutq ofiu the u wfgson e o r c inabi arties ndc //by theuctions,form. Company executive//rvopodoluvretcdat. innYt o ncuor taeeare: tTi nuhgrigs, p eisdr oa tdpou pccroionnvgse udolr tfadoinrsarsitbeo ubrtnyi nett gect hopinsu cprcerhronadisnuecgr tyooisnly. This form m t ia sntrhryie sesdi nup pgne ucdobiufeliircclyutie for legal advice and does notN9045CFL Public reporting buropdiienionse oonany gspeceifnict rfca seirvices. Th iinfo A lirable iss proyaovi am aagndesa a h t he understtand W tiit thi at any perstson or e s h ovt e eredw the instr Phone Dateuercvleityn unr opta lriatibcleul afor r siatnuayaytndiooantmbaaegn esd hseti uonsoritrr ciadn onpaynba cirpleiteirteyrnss tso.o ynsearch and gather the data needed, and complete and ronly. This fo cual rmar r miatn erage 58 minutes per response, including time to revieh th Important note: This is ap inns uolrtadis atbitcourstni necons cperrondiungct ois not ersons arrd p ed to respond to the collection of ugr,g pedrfor use by the purchaser w the collection of information. Plicly or TOTAL DC 20210. Do not send the completed forms to this office. Third Warning //information unless it displays a currently valid OMB control number. If you have any comments about these estimates or any other aspects of thisdata collection, contact: US Department of Labor, OSHA Office of Statistical Analysis, Room N-3644, 200 Constitution Avenue, NW, Washington, 1FMLA Administration OSHA & SafetyPage 17 Page 61Visit hrdirect.com/libraries to watch a short video4 WORKPLACE MANAGEMENTHR FORM LIBRARIES HRDIRECT.COM800.999.9111 5"