b"Manage HR Tasks for On-Site,Remote and Hybrid WorkforcesSmart Apps are easy-to-use, affordable web-based apps that focus on a particular Fill-and-Save HR Form Librariesare collections of HR-management function. Similar to HR Form Libraries to the right, Smart Apps are: forms that come as fillable PDFs for easy electronic routing, Always in compliance completion and storage. Accessible 24/7 online The targeted collections of HR forms in each library are :Affordable ways to accomplish specific HR tasks (less than $100/year) Always in compliance (theyre updated as compliance laws change)Form Libraries provide Fill-and-Save PDFs that you route electronically and store. Any information entered into Accessible 24/7 onlineSmart Apps is stored in a highly secure database where it is backed up, and seamlessly integrated so data enteredAffordable way to accomplish specific HR tasksautomatically populates other Smart Apps you purchase now and in the future. Both options are ideally suited tomanaging on-site, remote and hybrid workforces.Available for multiple users/admins on the platformChoose a library focused on a particular HR function (minimum ofTime & Attendance 10 forms in each library) and enjoy 12 months of unlimited access to best-selling, up-to-date forms and tip sheets related to that function.$ 90Attendance Calendar Time Off Request Schedule Publisher A YEAR Learn More About These HR Form LibrariesLog absences usingSimplify and standardize Plan and publish PER APPstraightforward the process of requesting,weekly schedules andEmployee Policy Acknowledgment L F irstDepar Form MidleEmployee/Payrol #Employees Withholding Certificate OMB No. 1545-0074 A FB E G CIHD 2022 Attendance Calendar SF H Il B In TK L P SN LE J TM T L L Ff S1__ X ZVT Y U I s S_ MT1WName: _________________ 2T3F4S5____________________________________________________ST1 2 :( T3 / F) M 4id d l e / S5Separation Notice S __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ E _ _ _ _ _m_ __ _ _ _ _p _ _ _ l_o _ _ _ _ _ _ y_ _ _e _ _e __W __ _ _ _a_ _ _r _ _n _ _ _ _i_ _ n_ _ _g _D_ eN __ o __ ti _ ecP N_ not Employee Performance Review a e ______________ ____Cur Supervisor ___________________________________________LastFirst ABSENCE CODES Department: _______________________________ Hire Date: __________________Aedreitaiovenmale Hnot urs Jueerarymv Dei nuoatf tyAiobnsence Tared axytciuonedth Position: _____________________________________ __________________ Employee Information Employee InformationDoctors Apours Workedointment UncPospitloioyne____________________________________________________________________ Department of the Treasury _________________ Last name (b) Social security number Pxacrtuisael Hd- Self Noili tCaarlyl/ NLeoa Svheow Va ___________________Vacation Time: ________________________ RCH nPhone #____________________ Position _ eEmployee/Payr__________________________________________________________________________________________________________________________codes and easily spot granting and tracking notify employees ofEm Application forEmploym W-4Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. 2022 EMojuLlidrAya yon Job WLOLeafyto Ef arly Total __ Fllonaetsisn ignHolei dFaaymily Employee/Payrol #: __________________________________ Total Name _ _____ ____ partm _m__ __________________ol ID # ______________________ ent Salary/Hourly Rate ________________________________________________________________________________________________Give Form W-4 to your employer. nes MPersonal Last Day Worked Overtime Request & Approval _____________________________________________________Internal Revenue Service Your withholding is subject to review by the IRS. JANUARY Suspension_____________________ Employee Infor MA M Sick Time: _______________________ sition _____________________________________ Department_____________________________(a) First name and middle initial= Legal Public Holidays es Name ___________________________________ Step 1:FEBRUARY __ # _________________________________________________ast ent ______________________________________________________ Does your name match the2361 9 M1 10 4 2 14 15 2 136 2 14872 158Absen p2 13 P 7ce Reporty2 2 14 8 2 5 241 111 8 Em N121 9lo eTotalositi 20 2 m 7 6 atio 2 7 2 158 W2 169 3 10 1111 8 2 126D epartment_____________________________ Todays Date _______________________ Huirpe Dervaitse or _ _ ______________ ______________________________ L_ ___s_t DaEm _e W n o y r_k _edI _ __ _nf_o ____ r__ _ ____ _atio_______________ _E_f_f_e_c_t_i_v_e_ S_D_e_a_p_tae o_r_a_Employee/Payrol_ f R _e_v_i_e_a_wt_e __________________ t e s _______ N _a_m_ e of P _e_r_s_on Conducting Review __________________________________________________________________ cN r /a nd n/ / tment Information card? If not, to ensure you get___________ / /EnterCity or town, state, and ZIP code credit for your earnings, contact______ / / ti_on D //troubling patternstime off their shifts via email I ue d th n rni s protected by federal, state, and/or local law. us o hu PersonalAddressSingle or Married filing separately easonable ac b ommoonds ations, and privacy. name on your social security 302 27 3 15 81920 21 29Emplo N yee I 6 nformation s 917 0 25amp 26 __________________ n t t e e i s c ____________________________________________________________________________________ //O / /atploee m n 1.sfac_____________________# _____________________ Date of Notice _________________ Unsatisfactory _______________In ac (c) DMarried filing jointly or Qualifying widow(er) e, llea arcge pcomrimnt oodr aatiudiowww.ssa.gov. 31 26 27 Shi 20 liacarbo 17 18 16 Dep yee/Payrol# _____________________________________________________Position ______________________________________________________________TerminPaotsioitniof VJob abandonment Performance R ployeemploye e Gso woodr k i s auraeirtee, dD stha Itomero p_________________13 1417 19Eeqxuuaal al occeriesns ttao ption arognrd gamesn, sdeerr ividcees antintyd e), ramcep, cloyomloer, rnt oeligpipoonr, ntuantiitoiens ial os arvigainila, cblie ttizeo anslhl pipe, arsgoen, ds wisiathboilituyt r, geegnaerd ttic io snfoex (rminatciolund, oinr ag pnry oegntahner bcy, asisSSA at 800-772-1213 or go toName_________________________________________________________________________________________________________________________________________ Details of Separation Name_____________________________________________________________ Em ating /Payrol / // 23artmen tP_____________________________________________________________Supervisor ___________________________________________________________for the application and/or interview proces should notify the Human Resources Department. Examples of res basorai www.irs.gov/W4App See page 2 for more information on each step, who canOvertime Requst Deta 29330 2425Type o__________________________________________________________________ dHead 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.) 218Name of Policy/Document______________________________________________________________________________ate Provided:_____________________ Empftl (oiyf ea e/p lle l )#__________________________________ on____________________________________ Ty Rpees oigfn Saetpioanr a t io nL:ayof Q u Oaulittys ta nTdhien ge xe nD tetpoVa wrehtrmiy Gcehn oatn o___________________________ H uogvhementeat.ordance with the Americans with Disabilities Act and/or applicable state and local laws, applicants requiring rnal _____________________________________________________________________________________________________________________________ iolation omments:__________________________________________________________________________________________________________________________________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 tetersntainte fg coornmdaitt siouncsh a.igning below, I acknowledge that I have received the workplace poliComplete Steps 24 ONLY if they apply to you; otherwise, skip to Step 5. ilscy listed above. By sn_d_____r_s_t_a_n_____a_t i__f I h ___a_v_e a____y q ____e__t_i_o_n_ _s abou _____t t __h_e p _ ____li_c_y_, I s_ _S__ _t_r_ee_t___ _ __o__l_d c __ on ___t_a_c_t_:__ claim exemption from withholding, when to use the estimator at_ __ _________________ _ _ _ _ _ __ __ _ Ci__ _ t__ y _ _______ _ _ _______ZIP Code Notes ______________________________________________________3 1 4 5 6 7 2 8 9ce Detail l 89d , w ___________________________________________ 1 a 7 1 1 8o 19 NoS 125 ___________ 6___________________________________________ T72 81T29 F2 4 N 3o S1 4 __________________ to __________________ Reatshoenrf o___________________________________________________________________________________________________________________________________ D rR o C t Rul ef e / O G re dein patoios nes es the practical/technical knowledge required on the job. yStep 2:Complete this step if you (1) hold more than one job at a time, or (2) are married filing jointly and your spouse_____________________________________________________________ ) Absent__________________________________D se enter the a _____________________________________________________________ Unexcused AbsenceUnsatC i_______________________________________________________________________________________________________________________________Page 12 Page 12 Page 12 ___ ___________________________________________________________________________ Name _________________________________________________________________________________________ sLa__ _s__t _ _F_t _ ___Mid_d_leApplicant ID # _____________________________ APRIL SMTWTF1 S2TotalA Absen b otes ___________ S1M 2 yT 3 EmW 4 pce T 12y5 e e F 136 O Plaeate(s):S7r:l T Nl ipated date(s) and time(s) when overtime wTimill be(e rs):equired:to__________________P r Separation: AttendanceBe hReavtiio rerment D2a.m aJgoeb t oKt noCoroywm Plpeeardfngoyer Pm r oaTnhpceer e txy tent to which a n IOenmtshupeblroo: y_______________________________________ UnsatisfactoryMultiple Jobsalso works. The correct amount of withholding depends on income earned from all of these jobs. List Date _____________________________________________________________ _________________________________________________________________________________________Reedrsuocntaiol n/Re oOrtghaenri zEamtipolno yIn_____________________________________________________________________ PeroPrV oodthoeor:d _____________________________________________________________________________________________________ or SpouseDo _only one __ of the following. Statefor most accurate withholding for this step (and Steps 34); orenoce rt (sM pAoYrted b 10lo __________________________________________________________TotalTime ________________ Final Pay: me nO ttheaeploprcoaptiroiant e ConductV iola tiAooOm om daoncem Needs Improvement JUNE olaiecnryy G ceirs __ ota M No W10__________________ t n enuft Cstamndpiangy____________________________tim agovern. __________________________A______d_____d_______r___e______s__ I c I f H t c r a a a t g _ y eo l e o s es e o ____________________________________ e g n u n e e taa ib o vt is _ r e t __ o u _ t u ._ llue tl ( ts e a _ b h I) a ta _ d i e e w _ ro c n o _ __________ n _ li _ c lic l e _ y r a q _a e sit y u h st t _ i _Cel _ e ge _ e t _ o c _ s efo a a l: u _ re _ e ? Works s __ a _i __ n _e t es _ s h () e _N _ o o _ t _ -wil __ o d T p D _ o n hsie r i _ r r n y u s q te _ m i g c Use the estimator atiu u li a ty l t a e t tio r lr le cs o a o ot v d n i e a ois s t igo p r n r e . o ei .is s ______________________________ . . t u If youwant tax. withheld . . . a o . . . other $ $ . . . . . . income. . . . . . . you. . . 4(a) 3$ $ $ $ lete. 0.00 SS10329M181 43TT1 1254W1365TT1476FF2 15187SS162981Total Wass n* E Ac N it ifiecation of absence re ot h SS 2 1 1e f 34679so F M 3 1 b p 1 875 0 s i TT1 e 18269239cto TT1 1 r s 7 4 3 en FF Ill I 20 1 1 1 b l 9 5 24?y n e tih p SS1 1 m s t 9 56 2 eeio F T y fash a o aimoe n? ____________________________________________________________ N v o e SSt 1 r e 44t s 2T655ed T T2P a 7 66lR W 2 2 v E 4 787e D TT2 5 8181FF1 2929SS2 7 33to __________________ __________________ Regular PayA C / /Y edDescription of Violation 4 P 0A1G rt e k a o lt o u W tt p es cc u Timea on3.6ReIO O Temram O Iu O ents:__________________________________________________________________________________________________________________________________ esp a s() ______________________________________________________________________________________________________________________________ AbsencePaidUnpaidOther _____________________________________________________________________________________________________urce______________________________________________________________(b) (a)_________If there are only two jobs total, you may check this box. Do the same on Form W-4 for the other job. Thisy t 2326 27__________________________________________________________ __________________ enAAtmm ____________________ liaubtsilittayn d Tinghe enVery Ghicoh aodn emplo yGeoe coda n be re l iNed ueedpso n rImpergoavredming tenta sk com p Ulentisoan atisnfad fctoorlTelephone # ______________________ ___ Use the Multiple Jobs Worksheet on page 3 and enter the result in Step 4(c) below for roughly accurate1719 20 2123If t 1516 24s a d 25ived in a t__________________________________________________________ 18 __________________to __________________ //______________________________________________________________________________________________________________________________________________f npceH am ryo ____________________ ular/Other Phone # ____________________ E ___ -mail Adordr es__________________________________________ 24 25 26 27 28 29 30 If so, did t n e emlo31 1426 Yes13 14 15 16 1725 __________________to __________________ Other YNooAm ouunntt$ $ _____________________________________________ xt o w __________________ ow-up. __________________ _____________________________________www.irs.gov/W4App withholding;21_____________________________Position(s) applied for _________________________________________________________________________option is accurate for jobs with similar pay; otherwise, more tax than necessary may be withheldDate of application _____________________(c)// If mhe aedibca 22reax teceeded three days e, w __________________________________________________________ Ye ess_____________________________________________ t t______________________________________________________________(e.g., Walk-in, Job Posting, Companys Website, etc.) TIP: To be accurate, submit a 2022 Form W-4 for all other jobs. If you (or your spouse) have self-employmentsence e 28 Yse 19 20 212923Dae t sNNec ooroi p f tIinocnid: _____________________________________________________________________Oincome, including as an independent contractor, use the estimator.________________ as phyicsi an c Neortification requested?YesthisReferrasl S , best tCeim /Oahll yerou is _____________________________________________________________________ Notes ______________________________________________________ yee provide this? __________________________________________________________ To Acccrruueed Sd Viacck PatiaoynPay___ _________________________________________________________________________________________________________________________________________________ umes additional duties when necesary.Hiring I understand that the information in the policy supe Complete Steps 34(b) on Form W-4 for only ONE of these jobs. Leave those steps blank for the other jobs. (Your withholding will_____________________________________________________________ Reaso dhen int d* r Absence: W1018 26 e AYesNo ily 11 M 27 28Lea 11 30 236 10tal Suspension ____________________ __________________ Date Payable__________________YeessN uen Nc mTake$ n / / 4.cn omments:__________________________________________________________________________________________________________________________________rsedes any prior writen or oralEstimated total o ime hours requested:____________________ _____________________________________________C _____________________________________________________________________________________________________________________________________________________________ Or a m ob FamRielya Lseoanv feor overtTELeMaBve oERf Absence Amouunntt$ $ _____________________________________________Step 3:ther tehdaicn tal cimoe ondfitf fioonr r, aere tasohnes rre aelany dted tayo ys oor tur rimeels wigiohne, a dn yoisu aabrie lity,ideAnUt GoUn StThe Job tal imSeE: P _________________________________________________________________________________________________________________________polere s ovni.d Ied ac,k a M od w ic. I further understand that the ibe most accurate if you complete Steps 34(b) on the Form W-4 for the highest paying job.) _____________________________________________________________Ac _____________________________________________________________ _____________________________________________________________ _______________________________________________________________________________________________________________________________ ignments and as Unsatisfactorydisc ic ieptrioon o nn o n yIw f y ed ur , g nd)f p c t ypl te m th er a n po d b ic m in im cont nformationna isge cmu isais (a)ab ent only at then d t daeh i fromram jobs).licant'ssb e ility,enter4(b) JULY1812 13 14 15 16 Dea on fo______________________________________________________ 18______________________________________________________ _______________ __________________ Separation Meeting: Total Payable A ER ) 4 unt IS _____________________________________________ OV oodGoodi n Needs Improvementd demonstrates the ability to cooperate, work and iscso, wk n d at rtk?.in the policyIf your total income will be $200,000 or less ($400,000 or less if married filing jointly):17Edxcuuse 21oaff th lye J 231725Holida y uty m Medical Appointment Tardxyc/Luesaedve* Early Was there a separation meeting? Co Yneses q5.Outstan:d__________________________________________________________________________________________________________________________________Compliance resl actrieoantsinhgip apram(ifs is subject to changey a dtoe ansyntoimt em with fiyY di ma a unavailable to work? la________________________________________________ . and. 4(c) 10M2519 20 212923TotalReas _____________________________________________________________ _____________________________________________________________ _______________ __________________ Administrative Checklist Actions to b (o PMlrdoe bienatctiniidogen D n a tt oe____________________ InitiativeThe extent to which an employee seeks out new as s wil DATE/ c t.Unsatisfactory _______________the policy confli w u ffolre u ha crae t is r oe ired,t oterfourt ul Claim No enmtps lsooylme entlain: ___________________________________ cational _______________________________________________________________________________________________________________________________ Com tn iio tn tiionng theerry G: ______________________________________________________________________________________________ od ______________________________________________________________________ m sSelf MVa Loc() pl DependentsMultiply the number of qualifying children under age 17 by $2,000ln_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ppliecab atnuinot ral, nsta inedYesmay be construed N esss 13Militaicry Unceation Warningeo sho Sru asgpeinn:s i_________________________________________________________________________________________________f you are u r 18 an blem fed rea bel lanwe,f tithse. nIftah ou work overtipme if required? by $500. Ye.s_______ . Jury D_______________________________________________________________________________________________________________________________ na_______________________________________________________________ Will yMultiply the number of other dependents N/AIf n matio n win12 Attended by____________________________________________________________________________________________________________________________________Step 4infpo icable (not eap o, please exwil ve y ith vie h a work permit?. oc _______ Add the amounts above and enter the total here standard deduction 2426 27 283028r a 22enc 30, as explainedm 20 proval Status 25NO Personal Day 12 30 14 Other:_____________________________ _________________________________________________________________________________________________________________________________________________Other income auIf y u s rs mitated an app deos n n h to raeq Other ional ilnyfAre you able to perform t he eos foe etn rteiaals fuonnacbtiloen asc ocof mthme joodba ftoior nw)?hich .for . 31_______________________________________________________________________________________________________________________________ Employee Records Archived urnedFacility/Systems AcTerminatedotmemrpuenriscoante wal Riteh claotiwoonsrhkeiprstifd: t to which aan etes amnpdlo/oyr oee i____________________________________muptsriodve cemoennIf no, please explain: ___________________________________ _________________________________________________________________ 27 1913(optional):expect this year that wont have withholding, enter the amount of other income here.24ployee _____________________________________________________________________ TI n ut hlyd re e dth u po d p dre b Adjustments (b)This may include interest, dividends, and retirement incomeList fol 2931 APPROVED AP 20 OV 29SUPERVISOR/M Final Pay Processedntssutaranndcie nV s, soioed Needs I /ing antta tioon(s):___________________________ (c) Deductions.t d io n o t a lwithholding, .Deductions .Worksheet on page 3. and. _____________________________________________________________ ow-up action and date scheduledN, iof taens:y ,________ with th__________________________e employee ______________________________________________________________________________________________________________________________________________________________________________ ifeB IRnAs uNroanticfeic aCtoionnve Prrsoiocne s _______________________________________________________________ sl:t__________________ uphee ervixstoerns , s Guoboodr d aygrteehin tgo Itdhoo rnoo n aw nd tand th Yes No you are applying (with or vr w with th ge tother than the. Notes _____________________________________________________________________________________________________________________________________________________________________________________ LO _______________________________________________________________________________________________________________________________n gC o miese Nry Go cal & Medical ____________________ er ways of doing things.t if I dt o dnott comp want r a ion ifo the tid aexpect to .claim. use .deductions the. Notes ______________________________________________________ Notes ______________________________________________________ __________________ Company Materials/Equipment Ret_______________________________________________________________________________________________________________________________the re tosu lreducet hereIfyou your.yed here before? YesNo es . P n is n e mdNoon o elicit information about an ap OCTOBER W_______________________________________________________________________________________________________________________________ // __________________ Employe AN ay A 0d HO3ju(b n UED WARNINGe.d Comm He net a_______________________________________________________ Unsatisfactory_________________________________________________________________ with th m pr es ten er s r aactcio toonmh ame eboodxutate ttnihot pen i ees nxrimseteitctenescd bsea ory lfy . Taa dwhise. OVEMBER W_______________________________________________________________________________________________________________________________ __________________ I agree w e S emes) O metniot n PForrmoces Psrsoecde s CreatiLvDiiefteny ta Tl hMajor Medi________________________________________________________________________________________________________________of this policy, I may be subject to disciplinary action up to and includYesecaom inNeed more information about the jobs_____________________________________________________________ _____________________________________________________________ Date______________________________________________________________________________________________________________________________________________________s may be addresse SIGNATURE OF SUPERVISOR/MANAGER Extra withholding. Enter any additional tax you want withheld each pay periodHaveIf y yoeus , gevieve dr beaetnes e:Fmprloost fm ________________or re //________________ thre j ential f d: funricvtiinog mns aty bo re respeoqnudired in__________________________________________________________________________________________________________________NMitahil /ePmicpkulopye Lrass td Peasycrcihpetciokn of violation. Com utshtearnhe extent to which an employee proposes ideas, finds new and betFREE! A0 Employees Signature_ _ inrrhvooiosvd lviupdecredotd.l ieYnu ac p p T ____ g D Is this applicatxioten a rndeed mqueilitary leave of ab___ l o r e a h is ar t a p ae tn usgrg , n vp a doil ot n d ota u u cc b np o inn y l e o s ce d i ia is rea r tbi our t ratke ot c onand ni u n T gg et vn oot bcl uu e f ra o l _e r sit _n_ce p a y ttiw id e o a e m Sign_ a n i a s a a n // trh yy i e s ?s i p ua _N th rloe ogtrr a N w Hicno an iveorb fs loicer wnhse nich yuomu aber rre aeqpupilryeid ing It ryne e n yo uss rd ctth e l y tsit ieso yu t r h3is c - State _____________ . 1 First date ofDateForm W-4 (2022)2 16102 11812 13 142 15A Commen ts 20o M14 ana 2 15ger A pp 10rova 18l O _______________________________________________________________________________________________________________________________ Ns 2efy dc e th t// 2020 ComplyRight, Inc. inrv T A231 I h u CFL I disagrcdi _____________________________________________________________7.eats tin T p yto ii s d e p tl r at s im i.t n u d v to u gea n pl u eb u f o ir c ots Coy n ey e te hs O d tit enfo p ic a r acinor o rn te ________________________________________ n yo is i itc r ro rs y no t so n oe o oh n a e y e e. . n g n t c n in opanba c le e ti iitreyrnss.Needs Improvement. iciently in a specified period of time.Total DECEMBER WTotal dingVery GoodGood fo _o_l_om win employme nt T o Step 5:_ _ __ Under penalties of perjury, I declare that this certificate, to the best of my knowledge and belief, is true, correct, and comp ____________________________________________________________________________________________________________________________________ ree for these reasons: _____________________________________________________________________________________________________________M ________________________________________________ _______________________________________________________________________________________________________________________________ mthenetr s________________________________________pany? _Y Employees signature // _________________________________________________________________________________________________________________________________________________ :___________________________________________________________________________________________________________________________________ __t_h__ig a_s_ _c_n e_o_md_ _y be reques HereNo Date__________________________No employment Employer identification172519 20 2129_________________________________________________________________________________________________________________________________________________ Completed by__________________________________________________________________________________________________________________________________________________________________________________ted. Opnal: 10_________________________________________________________________________________________________________________________________________________Are yIf you lesa, awfudl iy a EmployersHaavve ye yoouu e envteer brede einn bt (This form is not valid unless you sign it.) number (EIN) Supervisr/M 1624 25Bav26e h ge ___________________________16 17_______________________________________________________________________________________________________________________________ mprovementUnsatisfactorytionutahl ionrifzoerd tmao wtion mork aOnly Employers name and addressment with any former e m Ypelso y erNoor26 27 2827212923ertimouer rly watea1812 13 14 1523 24Productivity ThDe eatex ___________________________ Needs I__________________o aonn daegdre?e 19 20 21ingtent to w/ / Good hich an employee produces a sign__________________ificant volume of work efty (such as a noncompetition agreement) that might, in any28_______________________________ 30 31 _______________________________________________________________________________________________________________________________01CFL W cte agns s y edao r d e f olrt r w d s a d on __________________ rd part f y n o d e eon ase e ork for our company? Yes_______10202 Notes ______________________________________________________ Notes ______________________________________________________ tu ote 25 26 27 28 29Date_____________________Date ____________________ product. You are urged to consult an at ibcu ogrtsherisvinpcreosd. uTcht unr obclue ta arr n aeen is Em qfiu t e W bcile g Ntic Very G________________________________________________________________________________________________________________mumtesntatns:d__________________ ood2020 ComplyRight, Inc. in the United States? Yesrgs otahye, rr epsatrri, pnoabxilpityla itno :w __________________________________ Cat. No. 10220Q 330 34 Supervisor/Manager Name30________________________________________________________________________________________________________ A0373CFL phoiosvl ivpderedo l deinugc catrloiesap dtiiennsigoig, nps roodnned to provide ac acniyn gs poeifsict rfaurate and authorita e ivnefo irn amfiroartioal nt fi oo is np royaov tdwiiH d thd rw iitt shi a st hneo pt euncdsoiasttanu g tshr laeg t al aany pdvei n e oan d tsithn aovt_______________Important note: This is ap n tr sheirsv cprieccrorehs. ase ty isiio urr h y r anu g, eiditt shnot enNo _________________________________________________________________ _____________________________________________________________ p T Approvers Name __________________________________________________________________________________________________h f .oa n d n b sn _______________________________ r laetg aanl ayd pveicrseo ann dor d eonetsi tynoSIGNATURE OFd ad un ei uonse o oy uos redu mtis y /DATE/oudii n eioi eros u opvid ficcfa tourstni nand authoritha e o nefoiprnt malfioraa rim tioalntir ios n. rHoovev dae wr f p //al aaynbd cpilevie icrsts oo a u may have. Supervisor/Manager Signature ________________________________________________________________________ // Important note: This is ap ave r orney concerning sa om eaan,d ryis sing_______________________________________________________________________________________________________________________________ng c dosiufeuictrb s soqttaf iunttuehdsetite niuo gfons es rovede faor usec by etgyhepu For Privacy Act and Paperwork Reduction Act Notice, see page 3. _____________________________________________________________ ______________________________________________________________________________________________ ____________________________________________________________________________________________________________________t i alary r cr only. This form may not be shared publicly or with thi ies. Approvers Signare______________________________________________________ roved for use by the purchaser only. This form may not be shared publicly or with third parties. ____________________$ _______________________________Per_________________________ _____________________________________________________________ EMPLOYEType o Edmucpaf elt oioymnaeln Ct do-eOspir ed:SFeulal-sToimnael PTeamrtp-Toimraer y worTpkE TleorysO R cero tHmo OlpisDetE I naspaSptLilioAcn lNaD Abalew s (PePxCLemhICaAppNttieoTr 2nS: Ts9): 8) uonmlpesas ony its sheruwbijsee nct too tted bhe setlaotw esRouting: Human Resources_____________________________________________________________________ p n fa f oirnmfoarmtioanti oisn p. rHoovwideevde wr, iitth i st hneo ut an dsuerbssttaitnudtein gfo (eOm Throisv pidreo dleugcatloisp dineisoigns eodn t oa npyr ospveidceiicc fcaucrtast oe ra snedr aviuctehso. rTihtaet iivnWill you relocate if job requires it? .Yes______________________________________________________________________ orrmi involved in creating, producing or distributing this product is not liable for any damages arising out of the use or inability to use this AN EQUAL OPPORTUNITY EMPLOYER PAGElerhgoisadlpuorcpoinidngui oocntr i sds o idsnet rasibniguyn tsienpdge t ctoihf ipiAcsr0po2fa90vrcoi72dtds50e uCo CcarFctoLsicmseu rpnrvaloicytteR e lisaiga. bnhTdlthe, e aIfoun incrt werev eu rehur, is nugit esdi disees raotnospotr a pctinaoisug t htanuat uas tetn too rrpn ilseeerhsoy racl on adon ocv eeir.e naY isitnaotneuygr d iyonaodvrneooul relyuv.serpg Tdanheo ritdinsti cftpcuorrroel amrvati sd mineitg ua, ya ntioontbane sdh aanrey dsp peucbifliicc lqyu oers wtioitnh st hoirrd c opnacretrienss. you may have. inhrvoiosvl vipdereod dl einugc catrleiosa pdtinienisgoi, ngpnsr eoodndroved for use bor sd. rTciht at iv uinnef iptnramfloriaartibtcmileuoa lnatfio rior ssnpai.t nurHoyaov tdwiidaoemnev daear, d a dseubrssttaitudtien gfo trh laetg aanl ayd ripcvce stoaoyn nu oodsu er dmeotnheaitssyit hyno avte Importantanyt aadtativiomena i ginsfeIp ompsr omapordviarsuidtiitconaet.dngn .Yotw H ounuitooth ote fth :t heT roaveiulbdlit ytfso titroe t bhy. t gpe Important note: This is ap te a nd auto weiitt s hai s ant hryni seosdin ppeg ucobiuflii tuthird parties.ac npiynr gos povierd cdeif isaicct rcfaibucrutastnyi the purchaser only. This form may not be shareoncererhniungApplicantWill you travel if job requires it? . YesNo ______________________________________________________________________ 02082008C CFoLmplyRight, Inc. consult annote:ator nThisey c ison approvedcerning yo forurpusearti bycul thear s ipurchasertuation and only. anyThisspec formific q umayesti onotnsober c sharedoncerns publicly you m aoryhwithave puurccth 2020 ComplyRight, Inc. product. You are urged to consult an at ogr c stheirsvcloqyfu o terh sweti ioutnshe sthooirrrdI-9 & W-4 Company Policies Employee RecordsSimplify onboarding Customize and Manage employee Tracking Hiring & Onboarding Time & Attendance Performance Managementand ensure USCIS deliver mandatory contact information, Streamline your hiring process Page 19 Page 11 Page 23and IRS compliance and recommended payroll details, healthcare workplace policies coverage and more so you canPage 18 FMLA Employee Leave Request W ness move quickly Emoprklopylaecee R Ienpjuorryt/IlPage 20 Page 80 l u Eligible employees are entitled under the Family and Medical Leave Act (FMLA) to take umceph e eier i l s u f ti rr ist gts i o m n12 poar 2s6 v at n o g s fia b weeks of job-protqeefuctrmsed leavet l a ubt 3 l 0 i t t s e btp o e e Employee Information N Safety Violation Noticefor certainb sfaesmgibilinlen, d.w O/ohuerr ns C tpaoot dicaiabw l r le C mafunyo esou oat e o io no equ He sto a m ice d h hyea C la er re iaP ed rodviitdioenr forPoasmiteio____________________________________________________________________________________ ol #________________________________seonaodvneerai sfs e todpo eral a y and memes spla n.ye.raWesshoeenrnsv.e3Ss0utbdhmeay irsti gt hhaidts vt oraen qdceeun esysu to bfrom rpimsoss ittoopn oy onoufetrlheEau v ert o d fo c ese ad er lte us H tah nh et tthts on n __________________________________ Department ____________________________________ Em pSulopyeerev/iPsoayr r_____________________________________re q p yno Se e,e sanwe reC Employee Informationm rioPage 18 Employee Information T/ Hire Date: _____________________ y/ EmpTlhoey eFaem/Pialy aronldl #M: ______________________________________________ e . tifDic H e m is nvasidr bee e ptcrhaoeuv side er.Incident Information Ed ns /Tim___________________________________________________________________________________________________ h rol # _____________________ Date of Notice _________________/Performance & Training Interested in Name: ____________________________________________________________________a nf.:iS eco__________________________________________________________ puloeyde eby s etheek ienmg pFlMoLyeAe psr oheteacltthio osct may beDate of in ___________________________________ e _______________ Time of incident caPNnoansmioteito __________________bne __________________________________________________________________Improper Use of PPE / / Sotadtauyss: Da tFeu: l_______________________ Temporar ad ofno io s u.Ftoa.R tpi.o rno8vai2db5eo.3 uc0to 5tmh. peTl hFM Lx cident _______________________ (Rev. 04/2004)determined___________________________________________ Employ Deee/pPaarytment ________________________________________________________Department: _____________________________________________________________SPuopso2cietef9 iror vtUnis .C edical Leave Act (FMLA) provides thatmsapunbl oemymeirtpamlo ymuesert d mgicivaaeyl ctreehqretu iefimricea ptailono ny aweteieo bans,tihtleeis aa sott r w 1hw5e crwa F.ldMeonLld.Aga rloe dva/avayegs re etnoq cpuieres/whd/fmla. ocpalatioinn what ayouewtheermedaonigp jeucsitf yb wefoart ey othu ew ienrceid deonintg o wc ituhr trheedm. B (ee .ags.,cspleimcibfinic ga sa p laodsdseibrl ew. hIfi lyeo cua rwreyirne gu psainign ttinogol sm, aetqeuriiaplms;e nt, l-Time/Part-Time/denied. 29 C.F.R.825.313. In earilr s health conditioeneteteo LaAn md sauyf bfiec ifeonutn md eodnic tahl ec eWr or materials, nm Type(s) of Violation _________________ .r2Il6fe 1ta3hv,e e2e6dm1u4pe( lctoo)(y 3ae)e ; s 2ff9 o Cm daily computer entry).r:t i _______________________________________________________ Reason for Requesting Leave Q R R P G i r M ie o 3 H 5 P F p m r h Ws .lc o e t le Te M e ie E w Bb a hig h a nf s T e rt it e io l r e od d t at LA nis c u h b o o s e le to u e ta h fo nLeave Tracker e b t s a le r tl a y e1 b rec h l c o e o w n n e t e d o ,o n r i t e t fe e nr t i n n E o 2 E p A 1 f ne r t yts ori 9 e o n t m r ih r te tt e o it h a rt. on ic . e s n . la h he k n ic einp te . ea r a a il a t d b leci d f c h l o a sab a 1 y f e t r lr e i r , y n m es e e w c n . en. o s e a mt h i u b y,t hc a ei p e eon n emusd nth o if sy a outar n e e: d e1ine e ce2 ac -m k o G tt o s c w o tth r e o lu son a n a e cr me d1 tr e r h qn y ou t 2sF -mv f u M e o ild l I q s ro oyer oma L tnte Aa lel h e r c ,it o uh Fi a e r r ri r 3 t ey pp sto m e l idn er complete Section I. While use ofiec trah tiitosh _____________nfeo,rFwmMh LiicsAh oirpset sgioeu nt l_____________________________ aaotl,u iott hnaists,29f2o9r Cm C FFaRsRk. .s t8h2 e85 2.h35e0.a36lt0.h 6Y.nio . f d oFst r M n .a L dr A tsi ss . AcF h Mi ir s a d t leM Id dc le h L a st c8aur2 e5m .p3ar0yo 8vi. der o -M Last 0 0 U TH R LY S CUM U 0 0 U LA R TIV S E Enxpdl naainm he objehcetsow t D a OSHAs Form 300Aw (H) s For T joobt aLockout/Tagout Violationr T r / dh t_________________ 1 a U StreetViolation of Safety Rules/Policies Form approved OMB no. 1218-0176_______________________________________________________________________________________________________________________________Unsafe Material Handling Summary of Work-Related Injuries Fill-and-Save ConvenienceI am requesting family/medical leave for t 2.Us ollowing reasons: (check al r f SECTION I - Employer m pe mte a mo tu roFnM tL Employee Informationaild placed fo ______________________________ _______________________________________________________________________________________________________________________________Unsafe Fire Prevention Other: ______________________________________Meyl aotwionn ssheirpio ouf sf ahmeaillyt hm ceomnbdietrio tno you:1.elow the employe ar y aFML e. r dd A- ghthat apply)Td y nl cg rp av i fficiheNntmee _________________healthy newborn child or Hire Date _______________________________ I developed sho and Illnesses Obstruction of Acces/Exit Poin_________________ _____________________________________________________________________________________________________________________________________________________________________ Lleaacevem teon cta orefafo crh ail dfa wmiitlhymmeem fobrew aitdho a Use this Form informatitoionn a, informear al ostthe eemploylee eor the emp a certification af a an aavledo toae bl dceo unrndti fdwit_________________________________________/All establishments covered by Part 1904 must complete this Summar atl edohcerastrpr erpicpuaelnnal gUye dsae,n ho I wfe itl , npsraofep eLri ftUinseg of Tools/Equipment Birth of my child; to care for my newborn r the employe to rse co rh ny er ret io ow _________________________________iw r adoption / i nancidd/eonr ts oubcsctuarnrceeds.Lanisdt thhoew e vtheenyt(s)e trhea tin rveosluveltde d(e i.ng .t, hFe oiontju srlyip opreDH idlalin sozteranras ds w,ow s /EH 5 pfepeetn;e dIm Establishment informationcteiuoth nladon l em or illnesses occurrfrom typing). y page, even if no work-related injuries th io oting pains in arm ed during the year. Remember to review the Log to verify that the entries are complete 4UtU oss eueptnhdueam tleoe gar auolstno w pmaagtiec 2a l ygoud oe uand Tha s walfic comments. Department________________________________________________________________________________________________________________________________________________and accurate before completing this Summary.Without the Library? thuea Ntio ingn aelxguenarcdyabnedc aRuessee arv feasm) ytoou a:_____________________________________________________________________ cetiup fw m n0 29foerFdFFMorLceA pr3uimr0p.ination Act applies. / / _________________________________________ ON HO If applicable, pro Using the Log, count the individual entries you made for each category. Then write the totals below, makingCity_____________________________________________start in an ata-s ndcain to y maintain records and documenEtms prelolayteineg/P toay mroeldl #ic __________________________________al information, medical certifications, recertifications,entirety. They also have limited access to OSHAsultin Description of Violation _________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________k m sure youve added the entries from every page of the Log. If you had no cases, write 0. _____________________________Your establishment nameenwit hi:n or has been calledo tmro pcolovyeerresd mh me Fd th Rn llliasuctostvr ieegeneral sd uoft ye min pthloey eResg ucrlaear tAerdio ed.R Start of FMLA period:_____________________________ Employees, former employees, and their representatives have the right to review OSHAs Form 300 in its Leave to care for a family member whoveens si n d esig2-m cueraCsomrp tlhosy 635.9, aims nein th out aicn _________________________________ vide the names of any witneses to the event(s) re Date of Incident ____________________ t 1904.35, _____________________________ State_____________ Rela lifaytnisohip of family member toily mf_____________________________________________________________________n o al48 elatC Nond 1c6 s (inc1o4lus(dceis)(n 1ag)s,icf othnefid Aemnetirali cmanesd iwciatlh r eDciosradbsil itinie sse Apcatr aatpep flieiless, /arnedco irnd asc fcroromda tnhcee u wsiutha l _______________________________________________________________________________________________________________________________Time______________________________________________________________ ZIP ___________/ he nedo ntoth period.that 12 standard woreeks ehours. m 301 or its equivalent. See 29 CFR Par _________________teran and who is undergoy noO eHtracking intermittent leave, note6 7(includi 9g _________________________________________ 1 ________________________________________ 2526Da27 28 2/ 930/ 3 1HO tuensncerli bsyen tdhreo mineju)r.yNumber of Cases g in injuDrye socr ilplnteiosns: _____________________________________________________________________ __________________in OSHAs recordkeeping rule, for further details on the access pr _________________________________________ovisions for these forms.________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________is a curiren mberthep Armed EForce eeaep nthe National Guard and Reserves) or /ilnes. Indicate the part of the body that was afected and_______________________________________________________________________________________________________________________________cal tt rmeaet arya coveredr vetei oref dfa lmisti lyfo mr ae msebreior utsoiynojuur: grNmilnes 1 2ment 3 4 5t.i on, Th 8l m patient status or on tempor________________________________________________________ te: ___________________________ Total number of deathsTotal number of cases om workhow it was afected (e.g., Broken leg; carpalIndustry description (e.g., Manufacturer of motor truck trailers)deislaabtioilitnys hip 2.(Must al na ceer 1011121 141516/7 18 1920 21222324isList d ate cer tificatio n requested _________________ with days away fr _________________________________________________________________________________________________________________________________________________Some of our most popularOther (please explain)_____________________________________________________________________ :t _________________________________/Job description is notatached. ________________________________________________________________________________________________________________________________________________ ___________________________________________________________________eedri ca___________________________________________________ otal number of other_______________________________________________________________________________________________________________________________3.Emep mloyi ___________________________________it is not feasible despite the employees diligent, good faith efforts.) (G) _________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________ fication must be returned by ___________________________ tlr annusmferb eorrorfe sctarsiectsi ownithecordable cases __________________ow at least 15 calendar days from the date requested, unles ________________________________________________________________________________________________________________________________________________ North American Industrial Classification (NAICS), if known (e.g., 336212)_________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________Duration of Leave 4. Employees job title:______________________________________________________________________ s / eheld at the time the employe0 0 0 0 Medical Care Information Afreo d a im y c s aa y l employer. w ows: _________________ () _________________ _________________ __________________(I) (J)// / Description of Proper Procedureforms have been modifiedL eintermittentIf ________________________ Leave exp pleaseectedexplainto end ________________________whyEm itployeere gandular work schedule: __________________________________________________________________________________________________________ 0 0 0 0I did not receive medical treatment. To en lt nt f u pr ay YesNo Employee should adhere to the folowing procedure going forward: ______________________________________________________________________ave expecte ord t reduced-leaveo begin: schedule is being requested, Statement of the e themp lproposed leave IIrreececeiivveeddotrnesait te t ta Number of Days Total number of days ofEmployment information__________________is needed oyees es m ream mber of d ovider, as fol __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________entialschedule:job functi ons: ______________________________________________________________________________________ romen atfmroem(If you dont have these figures, see the Worksheet on the back of this page to estimate.)_________________________________________________________________________________________________________________________________________________ r __________________________________________________________________________ Phoestriction__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Tnhotei feisesde tnhtiea el mfupnlcotyieorn os fo tfh the en eemedp floory leave or the leave sta Headrltehscsa re Providm work job transfer or rne _______________________________________ Annual average number of employees__________________I certify that the above information is true and correct to the best of my knowledge: 's position are deterrmitedn,e wd hwicihthe vreerfe ires neacrel iteor .the position the employe _________________ YesNo __________________________________________________Progressive Discipline Safety Training Harassment Training Job Application Employee Certification and Signature Date______________________ 0 0 0 0 A _______________________________________________________________________________________________________________________________________ Total hours worked by all employees last year ____________________________________Wdere you treated in an emergency room?_______________________________________________________________________________________________________________________________to offer the convenience ofEmployees Signature ___________________________________________________________________________________________/ / s,0 0 Were you hospitalized overnight as an inpatient?ypes _________________________________________________________________________________________________________________________________________________ e(K) _______________________________________________________________________________________________________________________________(L)Injury and Illness T ___________________________________________________________________________________________________________________________________________________________________If yes, length of stay __________________________________________________________________________________________________________________________ Sign hereedgment (1)Injuries _________________________________________________________________________________________________________________________________________________I ccekrntoifwy lthat al Total number ofe provided is true, comp______ (4)Poisonings______ Knowingly falsifying this document may result in a fine.inh lootcokceodp yca obfi ntheetsf owrimthtoon ylyo udre es s sis da tute29040215 CCoFLmplyRight, Inc.information I hav (3)Respiratory conditions pri lete, aPnrde vcoiorur ofsc Wt ion for .arnings ed to r Date/______ accurate, and complete. Reason(s) for Warning TitleDocument and communicateEducate employeesProtect your company andExpand your p EMPLOYER: This form should beimg tnrpaelotaeytdee depeaarslos nao ngm nweeidlt ihhc aathlv erine gCc ooarmcdcep aasnsndy.A mRseu assnptoebnems emp lfaooiynremtra,iwnyoietuhd si nshe aop uraelrdaa tsreoeltnya aifnbro ltemh pi see morripoigdloi noyaef le ta imnpeder. psoronvniedle f ialei p p nr ge n p uotrso e p ati . n r H r g n s ne rhoo 0 0 0 0 0 0 N EMPLOYE SIGNATUREThios p p in hroivl si v dr eeS o d (M)d l u n gm c a m re aig signed tao or , np yna ciyn np g ro (2)g esv p e i f dcae r Skin disorders ifoi acc rta F e e r a btc n r in rua c uh so. duct t oisi e y rih t 1 a in v t urp n ofot a o inf rm A lo iatab r ritciluoe ar fo li s r 3 si.t nua______ 0v dda o w ife mda t n w g hts e s at r yh ne Siotue s eng a a o e n c rd seiiuf u f n r b t o stta d (5) l itn l th u W od tt ee iwn a Hearing lossg usr its e nh nleoa or g i trg iaa n ct no l a n ganb y ci h dpev e liir ere sy sa oen n oa d rretoh mcn a e tsii y s have. o tn yvo te _______________DI certify that I have examined this document and that to the best of my knowledge the entries are true,()electronic routing, completionA12403221C CFoLmplyRight, Inc. This product is designed to provide ac crtate grya cnsthoedirs nva cpiucertrehonsodi. nuTrgcith taye ito siinvu nefr oo iprtna mlfoiraartibmtcilueoan lfatoi roisr n suoyao vdtiwidoaenemv daae n w,e iditt s ha i sant hrnyis esoi nutp aegncosdiuufeibtcr s soqttafu i thdei ougof ts leargrt aicanoln aanyb dpcilveeiitrcyrnse ts oao ynn ou odsuer d metohnaeitsyist ynh oavt e. ___________________________________________________________________________________________ // ______ By Whom// ______ (6)All other illnesses ATE/First Warning tcy to udse eview the instructions,Company executive rvoovlviudetcedatl.ne iYntgonacuorlaoeteapr:i tenTi nuihgroi , pr ood n a butni n estni Post t epor uctl oisa d ptiei nnsr oop d u mfauocu stog sheod s p vie crtreo ni Tng ey maln t ionproya Hoever,e iith i si p co c s quesesponse, including time to r red by the form. Phone Dateodtpou ccnroionynv gssep udolert fcdaoifrniis cu t arfsitae by the purchaser only. This form may not be shared publicly or with third parties. Public r Impo ct.e iYou are : This is ap or disct ribti n ar erage 58 minutes per r e not requir. you espond to the collection of prvodurtant note den for this collection of information is estimated to avtion ad any licly or wit artiesn //ting bururged to consult n attrney only. This form may not be shared pubemployee issues easily and prevent accidentsemployees with low-costrecruiting reach Impor 12T-MOTOANLTH search and gather the data needed, and complete and review the collection of information. Persons arh third p //roved for use by the purchaser Third Warningand storage. 1 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, DC 20210. Do not send the completed forms to this office.and consistently with training anti-harassment training and comply Look for this symbol. FMLA Administration OSHA & SafetyPage 23 Page 58 Page 54 with hiring lawsPage 18 Page 15 Page 61Visit hrdirect.com/libraries to watch a short video4 WORKPLACE MANAGEMENT HRDIRECT.COM800.999.9111 5"