Delta College Corporate Services Dow Branch Site Payroll ... · Delta College Corporate Services...
Transcript of Delta College Corporate Services Dow Branch Site Payroll ... · Delta College Corporate Services...
Delta College Corporate Services Dow Branch Site
Payroll/Orientation Information
The following forms must be completed and returned to the Human Resources Office, J101, in order to be placed on
payroll. Questions can be directed to Human Resources staff at (989)686-9107.
Employee Name: _________________________________________________________ Date of Hire: ______________
Home Phone Number: _________________________________________________ ________
Address: _______________________________________________________
ETHNICITY: (please circle one)
(1-Not Hispanic or Latino) (2-Hispanic or Latino)
GENDER: (please circle one)
(1-Female) (2- Male)
RACE: (please circle one or more):
(African American) (American Indian or Alaskan Native) (Asian) (Caucasian)
(Native Hawaiian or Other Pacific Island)
By signing this form, you are verifying that you have completed the payroll forms and agree to review all of the items listed
below within the first 30 days of employment, including all required training modules
Employee Signature: _________________________________________________________ Date: _______________________
All new employees are required to review each of the items listed below Family Medical Leave Act – Employee Rights and Responsibilities
HIPAA (Health Insurances Portability and Accountability Act)
Notice Regarding Medicare and Your Prescription Drug Coverage
Injury/Accident Reporting
Regulations and Rules of Conduct
Health Insurance Marketplace Coverage Options
Required Training Modules: Bloodborne Pathogens, Bystander Intervention, Copyright pt1 Provisions, Copyright pt6 Guidelines, Sexual Harassment, Diversity, FERPA, Hazard Communications, Title IX – Higher Ed and SaVE Act.
Additional Information
Delta College's Vision and Mission Statement
Tobacco Free Campus
Delta College Emergency Procedures
Delta College Latex – Safe Product Use Procedure
Electronic Resources – For access to Delta's electronic resources please go through the signup process. You must have completed and returned your payroll paperwork prior to sign up.
Payroll dates - employees are paid biweekly on Fridays for the previous 2 weeks (7 days in arrears)
Employment Application – All employees must submit a completed application
Emergency Information
W-4 Form – Federal
W-4 Form – Michigan SW-4 Form – Saginaw (Residents of the City of Saginaw or Employees working within the City of Saginaw ONLY) Employment Eligibility Verification Form (I-9) (identification required - refer to form for options)
Direct Deposit – (OPTIONAL FORM) Employees not selecting direct deposit must pick up their checks at the Cashier’s
Office. Drug Free Work Place Act Hepatitis B Vaccination Acknowledgement and Release Form – Required for Category A Employees only
Michigan Public School Employees Retirement System (MPSERS): MPSERS website
New employees will receive their Member ID in a personalized Welcome Letter. You should receive your Welcome
Letter approximately two weeks after your first pay period. This letter will direct you to log into your miAccount where
you can nominate a beneficiary.
Health / Dental Enrollment Forms (Employee self-pay option available) – Health/Dental rates.
Center for Organizational Success (COS) Review of Human Resources/Benefits Portal
Review of MyDelta and Web Time Entry
Review of Procedure Manual and Corporate Services Handbook within Portal
Emergency Procedures
☐ N-O-R-A: Need Officer Right Away ☐ Emergency Text Notification/Nixle ☐ Adverse Weather
Human Resources staff will provide overview of the Benefits Summary
Rev. 1/10/17
Delta College Emergency Information
Employee Name: __________________________________
Position: _________________________________________
Faculty
Staff
Full-time
Part-time
IN CASE OF AN EMERGENCY NOTIFY:
First choice:
Name
Address
Day Phone
Evening Phone
Relationship
Second choice:
Name
Address
Day Phone
Evening Phone
Relationship
1. Do you have any health and/or medication information you want the College to know in
the event of emergency situations:
2. Additional Comments:
-- This page is left blank intentionally --
5. Are you a new employee?
9. Employee's Signature
Home Address (No., Street, P.O. Box or Rural Route)
3. Type or Print Your First Name, Middle Initial and Last Name
EMPLOYEE'S MICHIGAN WITHHOLDING EXEMPTION CERTIFICATESTATE OF MICHIGAN - DEPARTMENT OF TREASURY
MI-W4(Rev. 11-19)
This certificate is for Michigan income tax withholding purposes only. You must file a revised form within 10 days if your exemptions decrease or your residency status changes from nonresident to resident. Read instructions below before completing this form.
Issued under P.A. 281 of 1967.
Under penalty of perjury, I certify that the number of withholding exemptions claimed on this certificate does not exceed the number to which I am entitled. If claiming exemption from withholding, I certify that I anticipate that I will not incur a Michigan income tax liability for this year.
Date
11. Federal Employer Identification Number
Enter the number of personal and dependent exemptions you are claimingAdditional amount you want deducted from each pay(if employer agrees)
6.7.
8.
a.b.c.
EMPLOYEE:If you fail or refuse to file this form, youremployer must withhold Michigan income taxfrom your wages without allowance for anyexemptions. Keep a copy of this form for yourrecords.
INSTRUCTIONS TO EMPLOYER:Employers must report all new hires to the Stateof Michigan. Keep a copy of this certificate withyour records. If the employee claims 10 or morepersonal and dependent exemptions or claims astatus exempting the employee from withholding,you must file their original MI-W4 form with theMichigan Department of Treasury. Mail to: NewHire Operations Center, P.O. Box 85010;Lansing, MI 48908-5010.
$ .00
Employer: Complete lines 10 and 11 before sending to the Michigan Department of Treasury.10. Employer's Name, Address, Phone No. and Name of Contact Person
4. Driver's License Number or State ID
6.
7.
A Michigan income tax liability is not expected this year.Wages are exempt from withholding. Explain: _______________________________________________________Permanent home (domicile) is located in the following Renaissance Zone: _________________________________
Yes
No
If Yes, enter date of hire . . . .
If you hold more than one job, you may not claim the sameexemptions with more than one employer. If you claim thesame exemptions at more than one job, your tax will be underwithheld.
Line 7: You may designate additional withholding if you expect to owe more than the amount withheld.
Line 8: You may claim exemption from Michigan income tax withholding ONLY if you do not anticipate a Michigan incometax liability for the current year because all of the followingexist: a) your employment is less than full time, b) yourpersonal and dependent exemption allowance exceeds yourannual compensation, c) you claimed exemption from federalwithholding, d) you did not incur a Michigan income tax liabilityfor the previous year. You may also claim exemption if yourpermanent home (domicile) is located in a Renaissance Zone,you are a non-resident spouse of military personnel stationed inMichigan, or you are a member of a Native American tribe thathas a tax agreement with the State of Michigan and whoseprincipal place of residence is within the designated agreementarea. Members of flow-through entities may not claim exemptionfrom nonresident flow-through withholding. For more informationon Renaissance Zones call (517) 636-4486. Full-time studentsthat do not satisfy all of the above requirements cannot claimexempt status.
INSTRUCTIONS TO EMPLOYEEYou must submit a Michigan withholding exemption
certificate (form MI-W4) to your employer on or before the datethat employment begins. If you fail or refuse to submit thiscertificate, your employer must withhold tax from yourcompensation without allowance for any exemptions. Youremployer is required to notify the Michigan Department ofTreasury if you have claimed 10 or more personal anddependent exemptions or claimed a status which exempts youfrom withholding.
You MUST file a new MI-W4 within 10 days if your residencystatus changes or if your exemptions decrease because: a)your spouse, for whom you have been claiming an exemption,is divorced or legally separated from you or claims his/her ownexemption(s) on a separate certificate, or b) a dependent mustbe dropped for federal purposes.
Line 5: If you check "Yes," enter your date of hire (mo/day/year).
Line 6: Personal and dependent exemptions. The total number of exemptions you claim on the MI-W4 may not exceed thenumber of exemptions you are entitled to claim when you fileyour Michigan individual income tax return.
If you are married and you and your spouse are bothemployed, you both may not claim the same exemptions witheach of your employers.
1. Social Security Number
2. Date of Birth
City or Town State ZIP Code
I claim exemption from withholding because (does not apply to nonresident members of flow-through entities - see instructions):
-- This page is left blank intentionally --
City of Saginaw Withholding Information
Rev 07/2019
In accordance with the City of Saginaw Income Tax Ordinance, all Delta College employees who are
residents of the City of Saginaw or work within the City of Saginaw are required to have city income tax
withholdings from their payroll and must complete a Form SW-4 Withholding Certificate.
Delta College is located within University Center, Delta College is not located within the City of Saginaw.
Except for the following site locations, which are within the City of Saginaw:
The Downtown Saginaw Center
Saginaw MiWorks!
St. Mary’s of Michigan clinical site
Covenant Healthcare clinical sites
For detailed requirements of the City of Saginaw Income Tax Ordinance, please review the City of
Saginaw Withholding Tax Guide.
Please complete the following Form SW-4 Withholding Certificate, SW-4, if either of below
apply:
You work within the City of Saginaw (see above listing of Delta College site locations within the
City of Saginaw)
o If you split your time at a City of Saginaw location and non City of Saginaw location,
there is a section on the form where you can note you work X% amount of time in the
City of Saginaw and X% amount of time at another Delta College location
You reside within the City of Saginaw
OR
_____Check here if you do not live nor work in the City of Saginaw, and do not want City of Saginaw
taxes withheld (If you check this, you do not need to compete the following SW-4 form)
Employee Name: ______________________________________
Date: ________________________________
Form SW-4 Instructions - revised 1/05/10
Purpose: Complete form SW-4 so your employer can withhold the correct amount of city income taxes from your pay. Dependents: To qualify as your dependent (line 4 below), a person
(a) Must receive more than one-half of his or her support from you for the year, and (b) Must have less than $750.00 gross income during the year (except your child who is a student or who is under 19 years of
age, and (c) Must not be claimed as an exemption by such person’s husband or wife, and (d) Must be a citizen or resident of the United States, and (e) Must have your home as his/her principal residence and be a member of your household for the entire year, or Must be related
to you as follows: Your son or daughter, grandchild, step-son/daughter, son/daughter-in-law, father, mother, grandparent, step-father/mother, father/mother-in-law, brother, sister, stepbrother/sister, half brother/sister, brother/sister-in-law, uncle, aunt, nephew, or niece (but only if related by blood).
Changes in exemptions: You must file a new certificate within 10 days if the number of exemptions previously claimed by you decreases for any of the following reasons:
(a) Your wife/husband for whom you have been claiming exemption is divorced or legally separated, or claims her/his own exemption on a separate certificate.
(b) The support of a dependent for whom you claimed exemption is taken over by someone else. (c) You find that a dependent for whom you claimed exemption will receive $750.00 or more income of his/her own during the
year (except your child who is a student and who is under 19 years of age). Other Decreases: Such as the death of a wife, husband, or a dependent, do not affect your withholding until the next year, but require the filing of a new certificate by December 1 of the year in which they occur. Change of Residence: You must file a new certificate within 10 days after you change your residence from or to a taxing city.
Employee: File this form with your employer. Otherwise your employer must withhold City of Saginaw income tax from your earnings without exemptions. Employer: Keep this certificate with your record. If the information submitted by the employee is not believed to be true, correct and complete the City of Saginaw must be advised.
FORM SW-4 EMPLOYEE’S WITHHOLDING CERTIFICATE FOR
CITY OF SAGINAW INCOME TAX
City Resident or Non-City Resident
Your Social Security Number:
Full Name: (First, Middle and Last Name)
Home Address: (Number & Street)
State: Zip Code:
City: Under 25%
40%
60%
80%
100%
City: Main place of employment: Print name of each city where you work for this employer and circle closest % of total earnings in each. This is for withholding purposes only.
City: Under 25%
40%
60%
80%
100%
1. Exemptions for yourself: Yourself age 65 or over Blind
2. Exemptions for your spouse:
Yourself age 65 or over Blind
3. Enter Total number of boxes checked in 1& 2:
4. Other Exemptions: Number of exemptions Number of exemptions for your children for your other dependents
5. Enter total number of Other Exemptions in box 4 below:
6. Add the number of exemptions which you have claimed in box 3 & 5 and write the total below:
7. Write the additional amounts you want withheld from each paycheck, if any:
Employer’s Name and Address:
I certify that the information submitted on this certificate is true, correct and complete to the best of my knowledge and belief. SIGNATURE: DATE:
USCIS Form I-9
OMB No. 1615-0047 Expires 08/31/2019
Employment Eligibility Verification Department of Homeland Security
U.S. Citizenship and Immigration Services
Form I-9 11/14/2016 N Page 1 of 3
►START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically,
during completion of this form. Employers are liable for errors in the completion of this form.
ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the documentation presented has a future expiration date may also constitute illegal discrimination.
Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form I-9 no later than the first day of employment, but not before accepting a job offer.)Last Name (Family Name) First Name (Given Name) Middle Initial Other Last Names Used (if any)
Address (Street Number and Name) Apt. Number City or Town State ZIP Code
Date of Birth (mm/dd/yyyy) U.S. Social Security Number
- -
Employee's E-mail Address Employee's Telephone Number
I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in
connection with the completion of this form.
I attest, under penalty of perjury, that I am (check one of the following boxes):
1. A citizen of the United States
2. A noncitizen national of the United States (See instructions)
3. A lawful permanent resident
4. An alien authorized to work until (See instructions)
(expiration date, if applicable, mm/dd/yyyy):
(Alien Registration Number/USCIS Number):
Some aliens may write "N/A" in the expiration date field.
Aliens authorized to work must provide only one of the following document numbers to complete Form I-9: An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.
1. Alien Registration Number/USCIS Number:
2. Form I-94 Admission Number:
3. Foreign Passport Number:
Country of Issuance:
OR
OR
QR Code - Section 1 Do Not Write In This Space
Signature of Employee Today's Date (mm/dd/yyyy)
Preparer and/or Translator Certification (check one): I did not use a preparer or translator. A preparer(s) and/or translator(s) assisted the employee in completing Section 1.(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my
knowledge the information is true and correct.
Signature of Preparer or Translator Today's Date (mm/dd/yyyy)
Last Name (Family Name) First Name (Given Name)
Address (Street Number and Name) City or Town State ZIP Code
Employer Completes Next Page
Form I-9 11/14/2016 N Page 2 of 3
USCIS Form I-9
OMB No. 1615-0047 Expires 08/31/2019
Employment Eligibility Verification Department of Homeland Security
U.S. Citizenship and Immigration Services
Section 2. Employer or Authorized Representative Review and Verification (Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You must physically examine one document from List A OR a combination of one document from List B and one document from List C as listed on the "Lists of Acceptable Documents.")
Last Name (Family Name) M.I.First Name (Given Name)Employee Info from Section 1
Citizenship/Immigration Status
List AIdentity and Employment Authorization Identity Employment Authorization
OR List B AND List C
Additional Information QR Code - Sections 2 & 3 Do Not Write In This Space
Document Title
Issuing Authority
Document Number
Expiration Date (if any)(mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any)(mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any)(mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any)(mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any)(mm/dd/yyyy)
Certification: I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee,
(2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the
employee is authorized to work in the United States.
The employee's first day of employment (mm/dd/yyyy): (See instructions for exemptions)
Signature of Employer or Authorized Representative Today's Date(mm/dd/yyyy) Title of Employer or Authorized Representative
Last Name of Employer or Authorized Representative First Name of Employer or Authorized Representative Employer's Business or Organization Name
Employer's Business or Organization Address (Street Number and Name) City or Town State ZIP Code
Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.)A. New Name (if applicable)Last Name (Family Name) First Name (Given Name) Middle Initial
B. Date of Rehire (if applicable)Date (mm/dd/yyyy)
Document Title Document Number Expiration Date (if any) (mm/dd/yyyy)
C. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes continuing employment authorization in the space provided below.
I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if
the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual.
Signature of Employer or Authorized Representative Today's Date (mm/dd/yyyy) Name of Employer or Authorized Representative
LISTS OF ACCEPTABLE DOCUMENTS
All documents must be UNEXPIRED
Employees may present one selection from List A or a combination of one selection from List B and one selection from List C.
LIST A
2. Permanent Resident Card or Alien Registration Receipt Card (Form I-551)
1. U.S. Passport or U.S. Passport Card
3. Foreign passport that contains a temporary I-551 stamp or temporary I-551 printed notation on a machine-readable immigrant visa
4. Employment Authorization Document that contains a photograph (Form I-766)
5. For a nonimmigrant alien authorized to work for a specific employer because of his or her status:
Documents that Establish
Both Identity and
Employment Authorization
6. Passport from the Federated States of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with Form I-94 or Form I-94A indicating nonimmigrant admission under the Compact of Free Association Between the United States and the FSM or RMI
b. Form I-94 or Form I-94A that has the following:(1) The same name as the passport;
and(2) An endorsement of the alien's
nonimmigrant status as long as that period of endorsement has not yet expired and the proposed employment is not in conflict with any restrictions or limitations identified on the form.
a. Foreign passport; and
For persons under age 18 who are
unable to present a document
listed above:
1. Driver's license or ID card issued by a State or outlying possession of the United States provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address
9. Driver's license issued by a Canadian government authority
3. School ID card with a photograph
6. Military dependent's ID card
7. U.S. Coast Guard Merchant Mariner Card
8. Native American tribal document
10. School record or report card
11. Clinic, doctor, or hospital record
12. Day-care or nursery school record
2. ID card issued by federal, state or local government agencies or entities, provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address
4. Voter's registration card
5. U.S. Military card or draft record
Documents that Establish
Identity
LIST B
OR AND
LIST C
8. Employment authorization document issued by the Department of Homeland Security
1. A Social Security Account Number card, unless the card includes one of the following restrictions:
2. Certification of Birth Abroad issued by the Department of State (Form FS-545)
3. Certification of Report of Birth issued by the Department of State (Form DS-1350)
4. Original or certified copy of birth certificate issued by a State, county, municipal authority, or territory of the United States bearing an official seal
5. Native American tribal document
7. Identification Card for Use of Resident Citizen in the United States (Form I-179)
Documents that Establish
Employment Authorization
6. U.S. Citizen ID Card (Form I-197)
(2) VALID FOR WORK ONLY WITH INS AUTHORIZATION
(3) VALID FOR WORK ONLY WITH DHS AUTHORIZATION
(1) NOT VALID FOR EMPLOYMENT
Page 3 of 3Form I-9 11/14/2016 N
Examples of many of these documents appear in Part 8 of the Handbook for Employers (M-274).
Refer to the instructions for more information about acceptable receipts.
Rev. 4/5/2017
DELTA COLLEGE
NEW HIRE DIRECT DEPOSIT
Direct deposit advices are delivered to employees online via WebAdvisor.
For questions about direct deposits contact payroll at 989-686-9388
Employee ID or SSN: ______________________________
Employee Name ______________________________________________________________________
Employee Phone Number: _________________________
MAY TAKE UP TO ONE MONTH TO GO INTO EFFECT
Bank/Credit Union Name __________________________________________________________________
Address ___________________________________________________ City, State ________________________________________
Bank Routing Number ________________________________________ (Contact your Institution for this number)
Type of account for Deposit _____ Checking ______ Savings
Account Number _______________________________ Dollar Amount $ _________________________________
Enter ‘Total Check’ to have your entire check deposited or enter a specific dollar amount to have a portion of you check deposited
ADDITIONAL DEPOSIT (Optional)
Bank/Credit Union Name __________________________________________________________________
Address ___________________________________________________ City, State ________________________________________
Bank Routing Number ________________________________________ (Contact your Institution for this number)
Type of account for Deposit _____ Checking ______ Savings
Account Number _______________________________ Dollar Amount $ _________________________________
AUTHORIZATION
* I authorize Delta College and the financial institution listed to deposit my pay automatically to my account each payday. Adjusting entries to
correct errors are also authorized. This authority will remain in effect until I have cancelled it in writing.
* I understand that if I am setting up a new direct deposit or changing account numbers or banking institutions, that I will receive a printed
paycheck in the interim until my direct deposit is officially established. Paychecks are available for pickup at the Cashier’s Office.
SIGNATURE __________________________________________ DATE _____________________
Rev. 12/2016
DELTA COLLEGE POSITION STATEMENT
ON DRUG-FREE WORK PLACE ACT OF 1988
By signing below, this indicates that I acknowledge receipt of the Delta College Position
Statement on the Drug-Free Workplace Act of 1988.
________________________
Print Name Human Resources Office
________________________ ______________________
Employee Signature Received by
______________________ __________________________
Date Date
INTRODUCTION
Under the Drug-Free Work Place Act of 1988 effective March 18, 1989, all Federal grant
recipients are required to publish a statement, notifying employees that the unlawful
manufacture, distributions, dispensation, possession, or use of a controlled substance is
prohibited in the work place, specifying the sanctions that will take place against violators of
their policy. The following is the position statement of Delta College pursuant to the
requirements of such act.
DRUG-FREE WORK PLACE ACT OF 1988 STATEMENT
No member of the college community shall manufacture, possess, distribute or use any
prohibited drug in either the refines or crude form, except:
(1) Controlled substance for personal usage must be under a current prescription of a
licensed physician.
(2) Those specifically authorized to Delta College by federal or state authorizing agencies for
educational purposes, nor shall any member of the college community possess property,
which is used, or intended for use, as a container for any controlled substances.
Such policy is specifically applicable to college employees during the course of their
employment or at their work place. Employees who admit to violating such policy or are found
to be in violation by a judicial process of the state or Delta College shall be suspended from
employment.
Employees who are certified to medically dependent (hereafter dependent employees) by a
licensed physician will be considered to have a health problem and eligible for medical leave
Rev. 12/2016
provided they participate in a recognized medically supervised program of treatment for
chemical dependency under the following conditions:
(a) Dependent employees will first obtain Delta’s written consent to participate in a specified
treatment program.
(b) Dependent employees who voluntarily enroll in such a recognized program may use
personal and/or vacation time, if medical leave is not available, or may apply to borrow
sick leave. Otherwise, such employees will be considered to be on an approved leave of
absence (without pay) for the period of the rehabilitation program.
(c) During the period of enrollment in the program, such employees will comply with all
medical decisions made by the treating or supervising physician of the program under the
above conditions after being given the opportunity to participate, will be subject to
disciplinary action including suspension for a stated period of time, or termination of
employment
(d) A dependent employee will be given only one opportunity for rehabilitation. If after
returning to work it is determined by Delta that such employee has again violated any of
Delta's rules and regulations related to possession or use of illegal drugs, or that such
employee has been convicted of a drug related violation in the workplace, such employee
will be subject to immediate discharge.
(e) Dependent employees who do not participate in a rehabilitation program under the above
conditions after being given the opportunity to participate, will be subject to disciplinary
action including suspension for a stated period of time, or termination of employment.
All employees are notified that as a condition of employment each employee shall abide by the
terms of this statement and must further notify Delta College of any criminal drug statute
conviction for a violation occurring in the workplace no later than five (5) days after receiving
such conviction.
Upon such notification, if funded under a Federal Grant, The Human Resources Office of the
college must notify the granting agency within (10) days.
Delta College has established and is making a good faith effort to maintain a drug-free
workplace through the implementation of a drug-free awareness program to inform and educate
employees about:
(1) The dangers of drug abuse in the workplace,
(2) The policy of maintaining a drug-free workplace;
(3) Any available drug counseling, rehabilitation, and employee assistance program; and
(4) The penalties that may be imposed upon employees from drug violations occurring in the
workplace.
Employees should make a copy of this policy for their own records.
Rev. 1/10/17
DELTA COLLEGE EMPLOYEES
ACKNOWLEDGEMENT AND RELEASE FORM
HEPATITIS B VACCINATION
Only complete if you are a Category A Employee
Please check with your supervisor for clarification if you are unsure whether or not your position
is considered Category A.
The following jobs have been identified as requiring procedures or tasks which involve exposure or reasonably anticipated
exposure to blood or other potentially hazardous material:
Public Safety Coaches
Dental Assisting - Faculty, Staff & Students Dental Hygiene - Faculty, Staff & Students
Exploratory Teaching - Faculty, Staff & Students Facilities Management Staff
Fire Science Technology – Faculty, Staff & Students Multimedia Learning Lab (MLL) Technicians
Nursing LPN - Faculty, Staff & Students Nursing RN - Faculty, Staff & Students
Phlebotomy - Faculty, Staff & Students Designated Ctr Personnel -Planetarium, Saginaw & Midland
Respiratory Care - Faculty, Staff & Students Surgical Technology - Faculty, Staff & Students
Lifeguards Operations Assistants
Science courses with microbiology components and/or involving human specimen collection - Faculty, Staff & Students
involved in BIO 102 and BIO 203
I understand that due to my occupational exposure to blood or other potentially infectious materials I
may be at risk of acquiring hepatitis B virus (HBV) infection. I have been given the opportunity to be
vaccinated with hepatitis B vaccine, at no charge to me.
IF YOU CHOOSE TO DECLINE….
If I decline the vaccination at this time, I understand that I continue to be at risk of acquiring hepatitis B,
a serious disease. If in the future I still have occupational exposure risk and want to be vaccinated, I can
receive the vaccine series at no charge to me.
MAKE YOUR DECISION, CHECK ONE OF THE FOLLOWING:
_____ I have ALREADY RECEIVED the hepatitis B vaccine and decline the vaccination provided by
Delta College.
_____ I WOULD LIKE TO RECEIVE the hepatitis B vaccine series provided by Delta College.
_____ I DECLINE the vaccine and release Delta College from liability should I become
infected.
EMPLOYEE’S NAME (print): _______________________________________________________
EMPLOYEE’S SIGNATURE: __________________________________ DATE:______________
DEPARTMENT/DIVISION: ___________________________ PHONE: ______________________
-- This page is left blank intentionally --
CORPORATE SERVICES – EMPLOYEES ON ASSIGNMENT AT DOW BENEFITS ENROLLMENT FORM
PLAN YEAR: 2020
Section A - Employee Information
Employee Name: Social Security No:
Address: City/State/Zip:
Email Address: Employee ID#:
Phone: Sex: Date of Hire: Date of Birth:
Section B – Select Action (circle one)
Effective Date of Qualifying Event:
Open Enrollment
New Hire/Full-time Position
Resignation/Retirement
Birth of Child
Marriage
Divorce
Other:
Qualifying events must be communicated within 30 days to Human Resources. Failure to notify Human Resources within 30 days may cause the employee to be liable for insurance claims and college paid health, vision and dental premiums. Documentation is required for qualifying events to be processed. (Additions - marriage licenses and birth certificates. Removal - divorce decree)
Section C – Benefit Elections
Health Insurance (circle election below)
1) Decline health insurance
Decline
2) PPO #15 Plan
Single
2 Person
Family
20% cost share of premium
$100 / month
$240 / month
$300 / month
Dental Insurance (circle election below)
Decline
Single
2 Person
Family
$23.24 / month
$43.43 / month
$80.27 / month
Flexible Spending Accounts
Health Care
Cannot participate if you & your spouse have an HSA. maximum $2,750 annually
$ Annual Amount
Dependent Care
Complete Dependent Care Certification Statement. maximum $5,000 annually
$ Annual Amount
Section D – Dependent Information
Name (First, MI, Last)
Social Security #
Birth Date
M/F
Check One Add Remove
Spouse
Dep. 1
Dep. 2
Dep. 3
Dep. 4
COBRA NOTIFICATION ADDRESS: _________________________________________________________________
Complete only if you are discontinuing coverage for a covered member
Section E - Authorization
I acknowledge that:
I have reviewed Delta College’s benefit plan documents for which I am enrolling.
By signing this form, I make a binding election concerning my benefits for the plan year of January 1 – December 31, 2020.
I understand that I will not be able to change my elections unless I have a qualifying event. (marriage, divorce, death, birth or adoption of a child, termination of employment of a spouse, or other such qualifying events allowed by the plans)
I authorize Delta College to reduce my annual salary in accordance with my elections.
Eligible deductions will be taken on a pre-tax basis and my social security benefits may be reduced.
Delta College may reduce or cancel my compensation reduction or otherwise modify this agreement in the event that it is advisable in order to satisfy certain provisions of the IRS.
I will be offered the opportunity to change my benefit elections for the following plan year during open enrollment.
If I do not complete and return a new election form during open enrollment, these elections will remain in place for future plan years except for Flexible Spending.
Any Flex Spending payroll contribution not collected must be paid to Delta College within 30 days of the payroll date it was due. Failure to pay within this timeframe will terminate participation in the Flex Spending Plan for the remainder of the year.
The Flex Spending debit card is to be used exclusively for qualified expenses incurred during the Plan Year. If used for an unqualified expense or if substantiation is not provided, I authorize Delta College to take an after-tax deduction from my paycheck to cover the expense.
I understand that I could forfeit Flex Spending Plan contributions if I fail to incur eligible expenses during the Plan Year or fail to submit payment requests with in the timeframe specified by the Plan Document.
Employees on a sick or FMLA leave continue to be responsible for paying their share of premiums for benefit plans. If the employee fails to pay their share of the premiums, the coverage will be terminated with prior notice.
I affirm that the information provided is correct. I understand that if I submit false information, I may be held financially responsible for all claims filed and be required to reimburse the College for any payments made on behalf of or for the benefit of an ineligible dependent.
Employee Signature: Date:
HUMAN RESOURCES OFFICE USE ONLY
Transfer
Benefit
Benefit Effective/Separation Date
Colleague Processed
From:
PPO #15
COBRA
To:
Dental
PREL / PBEN
Flexible Spending
Notify Arcadia / Payroll
1095C
Rev. 12/20/2016
REQUIRED TRAINING MODULES
All employees are required to view the: Bloodborne Pathogens, Bystander
Intervention, Copyright pt1 Provisions, Copyright pt6 Guidelines, Sexual
Harassment, Diversity, FERPA, Hazard Communications, Title IX – Higher Ed and
SaVE Act modules
Delta College employees have access to training modules at the following link: http://www.gcntraining.com/site.cfm
Username: delta
You can create a UID (Personal ID) by clicking Create New Account. Your User ID
should simply be your First Name, Middle Initial and Last Name.
Additional instructions for accessing the Global Compliance Network are available on
the FAQ tab at the following link: http://www.gcntraining.com/site.cfm?faq
After you review each module, click the submit button at the bottom and this will register
you on the completion report that Human Resources will run to verify all modules were
reviewed.
If you have any questions or difficulties accessing these resources, please the Human
Resources Office at 686-9107.
EMPLOYEE RIGHTSUNDER THE FAMILY AND MEDICAL LEAVE ACT
Eligible employees who work for a covered employer can take up to 12 weeks of unpaid, job-protected leave in a 12-month period for the following reasons:
• The birth of a child or placement of a child for adoption or foster care;• To bond with a child (leave must be taken within 1 year of the child’s birth or placement);• To care for the employee’s spouse, child, or parent who has a qualifying serious health condition;• For the employee’s own qualifying serious health condition that makes the employee unable to perform the employee’s job;• For qualifying exigencies related to the foreign deployment of a military member who is the employee’s spouse,
child, or parent.
An eligible employee who is a covered servicemember’s spouse, child, parent, or next of kin may also take up to 26 weeks of FMLA leave in a single 12-month period to care for the servicemember with a serious injury or illness.
An employee does not need to use leave in one block. When it is medically necessary or otherwise permitted, employees may take leave intermittently or on a reduced schedule.
Employees may choose, or an employer may require, use of accrued paid leave while taking FMLA leave. If an employee substitutes accrued paid leave for FMLA leave, the employee must comply with the employer’s normal paid leave policies.
While employees are on FMLA leave, employers must continue health insurance coverage as if the employees were not on leave.
Upon return from FMLA leave, most employees must be restored to the same job or one nearly identical to it with equivalent pay, benefits, and other employment terms and conditions.
An employer may not interfere with an individual’s FMLA rights or retaliate against someone for using or trying to use FMLA leave, opposing any practice made unlawful by the FMLA, or being involved in any proceeding under or related to the FMLA.
An employee who works for a covered employer must meet three criteria in order to be eligible for FMLA leave. The employee must:
• Have worked for the employer for at least 12 months; • Have at least 1,250 hours of service in the 12 months before taking leave;* and • Work at a location where the employer has at least 50 employees within 75 miles of the employee’s worksite.
*Special “hours of service” requirements apply to airline flight crew employees.
Generally, employees must give 30-days’ advance notice of the need for FMLA leave. If it is not possible to give 30-days’ notice, an employee must notify the employer as soon as possible and, generally, follow the employer’s usual procedures.
Employees do not have to share a medical diagnosis, but must provide enough information to the employer so it can determine if the leave qualifies for FMLA protection. Sufficient information could include informing an employer that the employee is or will be unable to perform his or her job functions, that a family member cannot perform daily activities, or that hospitalization or continuing medical treatment is necessary. Employees must inform the employer if the need for leave is for a reason for which FMLA leave was previously taken or certified.
Employers can require a certification or periodic recertification supporting the need for leave. If the employer determines that the certification is incomplete, it must provide a written notice indicating what additional information is required.
Once an employer becomes aware that an employee’s need for leave is for a reason that may qualify under the FMLA, the employer must notify the employee if he or she is eligible for FMLA leave and, if eligible, must also provide a notice of rights and responsibilities under the FMLA. If the employee is not eligible, the employer must provide a reason for ineligibility.
Employers must notify its employees if leave will be designated as FMLA leave, and if so, how much leave will be designated as FMLA leave.
Employees may file a complaint with the U.S. Department of Labor, Wage and Hour Division, or may bring a private lawsuit against an employer.
The FMLA does not affect any federal or state law prohibiting discrimination or supersede any state or local law or collective bargaining agreement that provides greater family or medical leave rights.
LEAVE ENTITLEMENTS
BENEFITS &PROTECTIONS
ELIGIBILITY REQUIREMENTS
1-866-4-USWAGE
www.dol.gov/whd
For additional information or to file a complaint:
(1-866-487-9243) TTY: 1-877-889-5627
U.S. Department of Labor Wage and Hour Division
THE UNITED STATES DEPARTMENT OF LABOR WAGE AND HOUR DIVISION
WH1420 REV 04/16
REQUESTING LEAVE
EMPLOYER RESPONSIBILITIES
ENFORCEMENT
Rev 12/2016
HIPAA NOTICE
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT
CAREFULLY.
If you have any questions about this Notice, please contact:
Delta College
HIPAA Privacy Officer
1961 Delta Road
University Center, MI 48710
(989) 686-9106
Notice Effective Date: April 14, 2004
THIS NOTICE GIVES YOU INFORMATION REQUIRED BY LAW about the duties and privacy practices of
the Delta College Group Health Plans (the “Plans”) to protect the privacy of your medical information. The Delta
College Group Health Plans consist of the following components:
· Blue Cross/Blue Shield Medical Plans
· Delta Dental Plan
· Blue Cross/Blue Shield Vision Plans
· Flexible Spending Plan Health Care Expense Reimbursement Account
The Plans provide health and/or dental benefits to you as described in your summary plan descriptions. The Plans
receive and maintain your medical information in the course of providing these health benefits to you. The Plans
may hire business associates to help provide these benefits to you. These business associates also receive and
maintain your medical information in the course of assisting the Plans. The Plans are sponsored by Delta College
(the “Plan Sponsor”). The Plans are all subject to the same federal privacy law, and are part of an Organized
Health Care Arrangement (“OCHA”) that follows the same privacy policies and procedures.
This notice applies to the Flexible Spending Plan Health Care Expense Reimbursement Account. Blue Cross and
Blue Shield of Michigan and Delta Dental each issued a Notice of Privacy Practices for their plans, which
describes how they may use and disclose health information in connection with the coverage they provide for the
Delta College Group Health Plans.
Our purpose for providing you with this notice is to tell you how the Plans and the third parties that assist in plan
administration will use and disclose health information about you. The description of the uses and disclosures of
medical information applies to the Plans and to the entities that perform services for the Plans or perform the
functions of the Plans.
The Plans are required to follow the terms of this notice until it is replaced. The Plans reserve the right to change
the terms of this notice at any time. If the Plans make changes to this notice, the Plans will revise it and send a
new notice to all subscribers covered by the Plans at that time. The Plans reserve the right to make the new
changes apply to all of your medical information maintained by the Plans before and after the effective date of the
new notice.
For ease of reference, this Notice will use the word “Plan” to mean each of the Plans identified above.
Rev 12/2016
Purposes for Which the Plan May Use or Disclose Your Medical Information
The Plan may use and disclose your medical information without your consent or authorization for the
following purposes:
Health Care Providers’ Treatment Purposes. The Plan may disclose your medical information to your health
care providers, at their request, for your treatment by them. For example, the Plan may disclose to your primary
care physician the name of a specialist who is treating you so that they may coordinate your care.
Payment. The Plan may use or disclose your medical information to determine eligibility for plan benefits, to
facilitate payment for the treatment and services you receive from health care providers, to determine benefit
responsibility under the Plan, or to coordinate plan coverage. For example, the Plan may tell your health care
provider about your medical history to determine whether a particular treatment is experimental, investigational,
or medically necessary or to determine whether the Plan will cover the treatment.
Health Care Operations. The Plan may use or disclose your medical information as necessary to operate the
Plan, including plan management and administrative activities. For example, the Plan may (i) conduct quality
assessment and improvement activities, (ii) underwriting, premium rating, or other activities relating to the
creation, renewal or replacement of a contract of health insurance, (iii) authorize business associates to perform
data aggregation services, (iv) engage in care coordination or case management, and (v) manage, plan or develop
the Plan’s business.
As required by law. The Plan must allow the U.S. Department of Health and Human Services to audit the
Plan’s records. The Plan may also disclose your medical information as authorized by and to the extent necessary
as required by federal, state or local law, including compliance with workers’ compensation or other similar laws.
To Business Associates. The Plan may disclose your medical information to business associates the Plan hires to
assist the Plan. Each business associate of the Plan must agree in writing to ensure the continuing confidentiality
and security of your medical information.
To Plan Sponsor. The Plan may disclose to the Plan Sponsor, in summary form, claims history and other similar
information. Such summary information does not disclose your name or other distinguishing characteristics. The
Plan may also disclose to the Plan Sponsor the fact that you are enrolled in, or disenrolled from the Plan. The
Plan may disclose your medical information to the Plan Sponsor for plan administrative functions that the Plan
Sponsor provides to the Plan if the Plan Sponsor agrees in writing to ensure the continuing confidentiality and
security of your medical information. The Plan Sponsor must also agree not to use or disclose your medical
information for employment-related activities.
To Plans in the OHCA. Your medical information may be shared, used and disclosed among the Plans sponsored
by Delta College and their business associates for purposes of facilitating and coordinating health care treatment,
payments and operations, including the health care operations of the Organized Health Care Arrangement
(“OHCA”).
The Plan may also use and disclose your medical information as follows:
To comply with legal proceedings, such as a court or administrative order or subpoena;
To law enforcement officials for limited law enforcement purposes;
To a family member, friend or other person, for the purpose of helping you with your health care or with
payment for your health care, if you are in a situation such as a medical emergency and you cannot give
your agreement to the Plan;
To your personal representatives appointed by you or designated by applicable law;
For research purposes in limited circumstances;
To a coroner, medical examiner, or funeral director about a deceased person;
Rev 12/2016
To an organ procurement organization in limited circumstances;
To avert a serious threat to your health or safety or the health or safety of others;
To a governmental agency authorized to oversee the health care system or government programs;
To federal officials for lawful intelligence, counterintelligence and other national security purposes;
To public health authorities for public health purposes;
To appropriate military authorities, if you are a member of the armed forces.
Uses and Disclosures with Your Permission
The Plan will not use or disclose your medical information for any other purposes unless you give the Plan your
written authorization to do so. If you give the Plan written authorization to use or disclose your medical
information for a purpose that is not described in this notice, then, in most cases, you may revoke it in writing at
any time. Your revocation will be effective for all your medical information the Plan maintains, unless the Plan
has taken action in reliance on your authorization.
Your Rights
You have certain rights with respect to your health information. To exercise these rights, you or your personal
representative must make your request, in writing, directed to the Delta College HIPAA Privacy Officer. The
HIPAA Privacy Officer will give you the necessary information and forms for you to complete and return to the
HIPAA Privacy Officer. In some cases, the Plan may charge you a nominal, cost-based fee to carry out your
request.
You have the right to:
· Request restrictions on certain uses and disclosures of your health information; however the Plan is not required
to agree to a requested restriction;
· Receive confidential communications of your health information. You may request that the Plan communicates
with you about your health information by alternative means or at an alternative location;
· Inspect and obtain a copy of your health information, except with regard to psychotherapy notes or information
compiled in reasonable anticipation of certain civil, criminal or administrative proceedings;
· Request an amendment to your health information that the Plan has created, except with regard to those portions
of your health information that you are precluded from inspecting and copying as set forth above.
· Obtain an accounting of certain disclosures of your health information; and
· Receive a paper copy of this notice in addition to any electronic copy you may receive.
Complaints
If you believe your privacy rights have been violated by the Plan, you have the right to complain to the Plan or to
the Secretary of the U.S. Department of Health and Human Services. You may file a complaint to the Plan, in
writing, directed to the Delta College HIPAA Privacy Officer. You will not be penalized or retaliated against if
you choose to file a complaint.
Delta College
HIPAA Privacy Officer
1961 Delta Road
University Center, MI 48710
(989) 686-9106
Important Notice from Delta College
About Your Prescription Drug Coverage and Medicare
Please read this notice carefully and keep it where you can find it. This notice has information about
your current prescription drug coverage with Delta College and about your options under Medicare’s
prescription drug coverage. This information can help you decide whether or not you want to join a
Medicare drug plan. If you are considering joining, you should compare your current coverage,
including which drugs are covered at what cost, with the coverage and costs of the plans offering
Medicare prescription drug coverage in your area. Information about where you can get help to make
decisions about your prescription drug coverage is at the end of this notice.
There are two important things you need to know about your current coverage and Medicare’s
prescription drug coverage:
1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare.
You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare
Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare
drug plans provide at least a standard level of coverage set by Medicare. Some plans may
also offer more coverage for a higher monthly premium.
2. Delta College has determined that the prescription drug coverage offered by the Delta
College Health Plan is, on average for all plan participants, expected to pay out as much as
standard Medicare prescription drug coverage pays and is therefore considered Creditable
Coverage. Because your existing coverage is Creditable Coverage, you can keep this
coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare
drug plan.
When Can You Join A Medicare Drug Plan? You can join a Medicare drug plan when you first become eligible for Medicare and each year from
October 15th through December 7th.
However, if you lose your current creditable prescription drug coverage, through no fault of your
own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a
Medicare drug plan.
What Happens to Your Current Coverage If You Decide to Join A Medicare Drug Plan? If you do decide to enroll in a Medicare prescription drug plan and drop your Delta College
prescription drug coverage, be aware that you and your dependents may not be able to get the
coverage back.
When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan? You should also know that if you drop or lose your current coverage with Delta College and don’t
join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a
higher premium (a penalty) to join a Medicare drug plan later.
If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly
premium may go up by at least 1% of the Medicare base beneficiary premium per month for every
month that you did not have that coverage. For example, if you go nineteen months without
creditable coverage, your premium may consistently be at least 19% higher than the Medicare base
beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have
Medicare prescription drug coverage. In addition, you may have to wait until the following October
to join.
For More Information About This Notice Or Your Current Prescription Drug Coverage… Contact the person listed below for further information. NOTE: You’ll get this notice each year. You
will also get it before the next period you can join a Medicare drug plan, and if this coverage through
Delta College changes. You also may request a copy of this notice at any time.
For More Information About Your Options Under Medicare Prescription Drug Coverage… More detailed information about Medicare plans that offer prescription drug coverage is in the
“Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from
Medicare. You may also be contacted directly by Medicare drug plans.
For more information about Medicare prescription drug coverage:
• Visit www.medicare.gov
• Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the
“Medicare & You” handbook for their telephone number) for personalized help
• Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
If you have limited income and resources, extra help paying for Medicare prescription drug
coverage is available. For information about this extra help, visit Social Security on the web at
www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778).
Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare
drug plans, you may be required to provide a copy of this notice when you join to show
whether or not you have maintained creditable coverage and, therefore, whether or not you are
required to pay a higher premium (a penalty)
Date: October 8, 2019
Entity: Delta College
Contact: Shannon Mehl
Address: 1961 Delta Road
University Center, MI 48710
Phone: (989) 686-9106
INJURY/ACCIDENT REPORTING PROCEDURE
If an employee sustains a personal injury or occupational disease, which arises out of and in the course of employment, the employee must file a work-related claim of injury or illness.
1. All injuries/illnesses must be reported to Public Safety (Ext. 9111) within 24 hours of the injury/illness.
2. Injuries/illnesses requiring treatment must be done within ten days at Covenant Occupational Health Services located at 600 Irving Avenue, Saginaw, MI 48602. If treatment requires first aid only, the officer on duty shall administer first aid. If the employee needs to be transported to Covenant, Public Safety will make any decisions regarding transportation.
3. If at the time of the injury/illness you need to seek treatment, authorization must be given by Public Safety or the Human Resources Office (Ext. 9106) prior to receiving treatment. Employees electing to seek their own treatment will be responsible for all payments incurred.
4. If treatment is needed other than at the time of the injury, the employee must contact the Human Resources Office (9106 or 9107) for authorization to seek treatment at Covenant Occupational Health Services.
5. All employees seeking treatment due to a work related injury or illness will be drug and alcohol tested at the time of the visit.
6. The employee will be responsible for providing the Human Resources Office and their immediate supervisor with a copy of their physician's statement.
Human Resources will complete the appropriate forms to be forwarded to our Workers' Compensation Company, if necessary.
Any bills the employee receives as a result of the work-related injury/illness must be sent to the Human Resources Office.
Any lost time as a result of a work-related injury or illness will be reported as sick leave, if available.
Injuries/illnesses occurring off campus, which are work-related (i.e., at a College off campus facility or center, College sponsored trip, or approved off campus work assignment) shall be reported by phone as per instructions mentioned above.
Regulations and Rules of Conduct Delta College has adopted rules consistent with its goals and operations & enforces them with appropriate due process.
I. General Responsibility: Delta College has the responsibility to adopt and enforce rules which are consistent with Delta College goals and operations and to establish due process procedures in disciplinary cases.
II. Authority to Establish Standards of Conduct: Standards of conduct are established by rules of the College, as adopted by the Board of Trustees, and made known through College publications or by notices distributed or prominently posted on College bulletin boards and by law of the United States, State of Michigan, and County of Bay (public laws). Except in the case of interim or emergency-type rules as granted by Michigan Public Act No. 26 of 1970, such regulations will be established and amended with the advice of the College Senate, but final authority is through either the Delta College Board of Trustees or the laws of the United States, State of Michigan, or County of Bay.
III. Individual Responsibility: An individual having an institutional relationship to Delta College (member of College Community) is automatically placed under the rules of the College. "Institutional relationship to the College" means any connection of employment, enrollment, or service existing between any person and Delta College. As used herein, this phraseology is intended to prevent the application of these rules to purely personal or social relationships between or among students, Faculty members, Administration, or staff members outside of the College proper. Therefore, it is important for all members of the College Community to familiarize themselves with the rules and regulations affecting them.
IV. Effect of Violating Rules: A member of the College Community violating any of the rules of the College, or a public law, on campus or off campus at a Delta College sponsored activity is subject to disciplinary action by Delta College that is appropriate to the nature of the offense. Disciplinary action will be taken in accordance with applicable law, regulation, policies and procedures governing cases of violation.
V. Reports of Violations: Reporting of violations will be within the province of all members of the College Community because they have a common responsibility to maintain an orderly and efficient community for their mutual benefit. Violations may fall in one of several categories: (1) Minor offenses which are dealt with by reprimand; (2) Violations by students which are to be reported to the Vice President of Student and Educational Services; (3) Violations by Faculty or staff members which are to be reported to the President; (4) Civil or criminal violations which are to be reported to the Campus Police Department.
VI. Severance Provision: If any of the foregoing rules or any part of any such rule will be adjudged invalid by a court of competent jurisdiction, then such adjudication will not affect the validity of these rules as a whole or any provision or part of any such rule not so adjudged invalid.
Rules and Regulations:
A. Physical Force: No member of the College community shall use physical force, threaten physical force, or use
intimidation against any person engaged in an activity properly undertaken as part of an institutional relationship of the
College except as permitted under normal law enforcement procedures.
B. Disruption: No member of the College community shall interfere with a College function by depriving any person of
needed safety, quiet, or other physical conditions of work or study.
C. Interference: No member of the College community shall interfere with the free movement of any person engaged in an
activity properly undertaken as part of an institutional relationship to the College.
D. Compliance: In keeping with the system of voluntary compliance that underlies the College Regulations and Rules of
Conduct, no member of the College community shall fail to follow the reasonable instructions given by an appropriate
College official to cease specified conduct, if such conduct threatens disruption or interference with the rights of others,
College discipline, College functions, and/or order in the College community.
E. Identification: No member of the College community shall refuse to provide identification when requested to do so by
an identified employee of the College.
F. Forbidden Occupation: No member of the College community shall, subsequent to reasonable notice to leave given by
the College President, or an authorized designee, continue occupation of any College facility or property which is under
the direct control or responsibility of the College, especially if such occupation interferes with a College function or risks
injury to a person or property.
G. Facility Entry and Usage: No member of the College community shall gain or attempt to gain unauthorized entry to or
make unauthorized use of the College facilities or property.
H. Property: No member of the College community shall damage, deface, destroy, steal, or misappropriate the property of
the College, any member of the College community, or any visitor to the College campus.
I. Unauthorized Use of College Credit, Property, Etc.: No unauthorized member of the College community shall use the
College telephones, postal machines and meters, duplicating machines, motorized vehicles, or other equipment. This
provision shall be deemed to also include College billing, charging, and credit card numbers utilized for communications
or transportation purposes. Further it shall be a violation for any member of the College Community who has not been
issued a key by the College to possess or use College keys for any purpose whatsoever.
J. Counterfeiting, Altering and Copying: No member of the College community, shall falsely make, forge, manufacture,
print, reproduce, copy, tamper with, or alter any writing, document, record, or identification used or maintained by the
College or by members of the College community. No member of the College community shall knowingly possess,
display, or cause or permit to be displayed any writing, record, document, or identification form used or maintained by
the College or by members of the College community, knowing the same to be fictitious, altered, forged, counterfeited,
or made without proper authority.
K. Confidentiality of College Records: No person shall inspect, investigate, or use College files (i.e., Counseling, Financial
Aid, Placement, Records, Registration) without proper College authorization.
L. Firearms and Other Dangerous Material: The possession or use of firearms, firecrackers, explosives, toxic or dangerous
chemicals, or other lethal weapons, equipment or material is not permitted on College property at any time except
when specifically authorized by the College for educational purposes or when firearms used for recreational purposes
and transported through the campus meet the regulations of the Department of Public Safety.
M. Alcoholic Beverages: No member of the College community shall sell, be under the influence of, possess or consume
beer, wine, or other alcoholic beverages on College property, or any property which is under the direct control or
responsibility of the College. This regulation shall not apply to the President's home. This rule may be suspended from
time to time by authorization of the President.
N. Drugs: No member of the College community shall possess, sell, distribute, be under the influence of or use any
controlled substance in either the refined or crude form, except: (1) controlled substances for personal usage, and these
must be under a prescription of a licensed physician, or (2) those specifically authorized to Delta College by Federal or
State authorizing agencies for educational purposes. Nor shall any member of the College community possess property
which is used, or intended for use, as a container for any controlled substance, except where prescribed or authorized as
described in this paragraph.
O. Tobacco Free Policy: Effective August 1, 2007, Delta College became a tobacco free campus. Smoking and use of
tobacco products will not be permitted anywhere on the campus; including centers, campus buildings, sidewalks,
parking lots, building entrances and common areas, and in College-owned vehicles. The Administration shall fully
implement this policy and all applicable laws, regulations, and local ordinances related to smoking and tobacco use.
P. Selling, Soliciting, and Distributing: Any person who wishes to distribute, solicit, or sell information, materials, goods, or
services not within normal College activities and routine, must have the written permission of the Vice President of
Student Services or Vice President of Business and Finance or their designee.
Q. Private Business Ventures: Delta College facilities such as offices, computers, copiers, etc., are not to be used for private
business ventures. Also, Delta College's name is not to be associated in any way (such as use of letterhead, e-mail or
return address) with private business ventures.
R. Animals: People may not bring animals on campus or into College buildings. Leader dogs and animals used for
educational purposes are exceptions; however, all animals must remain under the control of their owners and be
properly licensed and medically treated as required by law.
S. Federal, State, Local Laws: Violations of Federal, State, or local laws, and violations of College policies, procedures, rules
and regulations, including rules of governing bodies such as the Higher Learning Commission or the National Junior
College Athletic Association, and including rules published in the College Catalog and student handbooks and manuals,
shall constitute violations of College rules. Such violations apply both on-Campus, and off-Campus in connection with
college-sponsored activities.
Rev. 2/2017
Notice of Employee Eligibility to Participate in 403(b) Retirement Plan
All employees, excluding student workers, are eligible to participate in the Delta College 403(b) Retirement Plan immediately upon hire. Eligible employees may elect to make pre-tax salary reduction contributions to the 403(b) plan up to the maximum allowed by the IRS each tax year. Each participating employee chooses among the available investment options offered by the approved investment vendors under the plan. Employee contributions and the related investment earnings are tax deferred until withdrawn from the plan.
Please contact Jeanne Doyle at extension 9390 or [email protected] with any questions.
Once you receive your employee login information, feel free to visit the Finance Department’s portal page to view vendor information, enrollment agreements and links to the Plan Document and Adoption Agreement.
Employees may enroll in the 403(b) plan by contacting one or more of the Delta College approved 403(b) vendors at any time throughout the year to speak to a representative.
After establishing a 403(b) account and making investment and beneficiary choices with a vendor representative, a completed Salary Reduction Agreement must be submitted to the Delta College Finance Office to begin making bi-weekly payroll deduction contributions to a 403(b) account. The Salary Reduction Agreement is available. This form may also be used to stop deductions or to make changes to the deduction amount. We ask that employees limit making changes to their salary reduction to 4 times per year.
New Health Insurance Marketplace Coverage Options and Your Health Coverage
PART A: General Information :
What is the Health Insurance Marketplace?
Can I Save Money on my Health Insurance Premiums in the Marketplace?
Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace?
How Can I Get More Information?
Form Approved OMB No. 1210-0149
5 31 2020
PART B: Information About Health Coverage Offered by Your Employer
3. Employer name 4. Employer Identification Number (EIN)
5. Employer address 6. Employer phone number
7. City 8. State 9. ZIP code
10. Who can we contact about employee health coverage at this job?
11. Phone number (if different from above) 12. Email address
13. Is the employee currently eligible for coverage offered by this employer, or will the employee be eligible inthe next 3 months?
Yes (Continue)13a. If the employee is not eligible today, including as a result of a waiting or probationary period, when is the
employee eligible for coverage? (mm/dd/yyyy) (Continue)No (STOP and return this form to employee)
14. Does the employer offer a health plan that meets the minimum value standard*?Yes (Go to question 15) No (STOP and return form to employee)
15. For the lowest-cost plan that meets the minimum value standard* offered only to the employee (don't includefamily plans): If the employer has wellness programs, provide the premium that the employee would pay if he/ shereceived the maximum discount for any tobacco cessation programs, and didn't receive any other discounts based onwellness programs.a. How much would the employee have to pay in premiums for this plan? $b. How often? Weekly Every 2 weeks Twice a month Monthly Quarterly Yearly
16. What change will the employer make for the new plan year?Employer won't offer health coverageEmployer will start offering health coverage to employees or change the premium for the lowest-cost plan available only to the employee that meets the minimum value standard.* (Premium should reflect thediscount for wellness programs. See question 15.)
a. How much would the employee have to pay in premiums for this plan? $b. How often? Weekly Every 2 weeks Twice a month Monthly Quarterly Yearly
DELTA COLLEGE – PPO #15 Note to ASC groups: Before completing this template, please reference the disclaimer on the attached cover page.
Community Blue PPOSM ASC Coverage Period:
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage for: Individual/Family | Plan Type: PPO
Group Number 007000338-0008 SBC000004338790 1 of 8
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.
This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbsm.com or call the number on the back of your BCBSM ID card. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call the number on the back of your BCBSM ID card to request a copy.
Important Questions Answers
Why this Matters: In-Network Out-of-Network
What is the overall deductible? $2,500 Individual/ $5,000 Family
$5,000 Individual/ $10,000 Family
Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.
Are there services covered before you meet your deductible?
Yes. Preventive care services are covered before you meet your deductible.
This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/.
Are there other deductibles for specific services?
No.
You don’t have to meet deductibles for specific services.
What is the out-of-pocket limit for this plan? (May include a coinsurance maximum)
$6,600 Individual/ $13,200 Family
$10,000 Individual/ $20,000 Family
The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.
What is not included in the out-of-pocket limit?
Premiums, balance-billing charges, any pharmacy penalty and health care this plan doesn’t cover.
Even though you pay these expenses, they don’t count toward the out–of–pocket limit.
Will you pay less if you use a network provider?
Yes. See www.bcbsm.com or call the number on the back of your BCBSM ID card for a list of network providers.
This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.
Do you need a referral to see a specialist?
No. You can see the specialist you choose without a referral.
2 of 8
All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.
Common Medical Event Services You May Need
What You Will Pay Limitations, Exceptions, & Other Important
Information In-Network Provider (You will pay the least)
Out-of-Network Provider (You will pay the most)
If you visit a health care provider’s office or clinic
Primary care visit to treat an injury or illness
$40 copay/office visit; deductible does not apply
40% coinsurance None
Specialist visit $40 copay/visit; deductible does not apply
40% coinsurance None
Preventive care/ screening/ immunization
No Charge; deductible does not apply
Not covered
You may have to pay for services that aren’t preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for.
If you have a test
Diagnostic test (x-ray, blood work)
20% coinsurance 40% coinsurance None
Imaging (CT/PET scans, MRIs)
20% coinsurance 40% coinsurance May require preauthorization
If you need drugs to treat your illness or condition
More information about prescription drug coverage is available at www.bcbsm.com/druglists
Generic or select prescribed over-the-counter drugs
$10 copay/prescription for retail 30-day supply; $20 copay/prescription for retail or mail order 90-day supply; deductible does not apply
In-Network copay plus an additional 25% of the approved amount; deductible does not apply
Preauthorization, step therapy and quantity limits may apply to select drugs. Preventive drugs covered in full. 90-day supply not covered out of network.
Preferred brand-name drugs
$40 copay/prescription for retail 30-day supply; $80 copay/prescription for retail or mail order 90-day supply; deductible does not apply
In-Network copay plus an additional 25% of the approved amount; deductible does not apply
Non preferred brand-name drugs
Not covered Not Covered
If you have outpatient surgery
Facility fee (e.g., ambulatory surgery center)
20% coinsurance 40% coinsurance None
Physician/surgeon fees 20% coinsurance 40% coinsurance None
If you need immediate medical attention
Emergency room care $100 copay/visit; deductible does not apply
$100 copay/visit; deductible does not apply
Copay waived if admitted or for an accidental injury.
3 of 8
Common Medical Event Services You May Need
What You Will Pay Limitations, Exceptions, & Other Important
Information In-Network Provider (You will pay the least)
Out-of-Network Provider (You will pay the most)
Emergency medical transportation
20% coinsurance 20% coinsurance Mileage limits apply
Urgent care $40 copay/visit; deductible does not apply
40% coinsurance None
If you have a hospital stay
Facility fee (e.g., hospital room)
20% coinsurance 40% coinsurance Preauthorization may be required
Physician/surgeon fee 20% coinsurance 40% coinsurance None
If you need mental health, behavioral health, or substance use disorder services
Outpatient services 20% coinsurance 20% coinsurance Your cost share may be different for services performed in an office setting
Inpatient services 20% coinsurance 40% coinsurance Preauthorization is required.
If you are pregnant
Office visits
Prenatal: No Charge; deductible does not apply
Postnatal: No Charge; deductible does not apply
Prenatal: 40% coinsurance
Postnatal: 40% coinsurance
Maternity care may include services described elsewhere in the SBC (i.e. tests) and cost share may apply. Cost sharing does not apply to certain maternity services considered to be preventive.
Childbirth/delivery professional services
20% coinsurance 40% coinsurance None
Childbirth/delivery facility services
20% coinsurance 40% coinsurance None
If you need help recovering or have other special health needs
Home health care 20% coinsurance 20% coinsurance Preauthorization is required.
Rehabilitation services 20% coinsurance 40% coinsurance Physical, Speech and Occupational Therapy is limited to a combined maximum of 60 visits per member, per calendar year.
Habilitation services
Not covered for Applied Behavioral Analysis; Not covered for Physical, Speech and Occupational Therapy
Not covered for Applied Behavioral Analysis; Not covered for Physical, Speech and Occupational Therapy
None
Skilled nursing care 20% coinsurance 20% coinsurance Preauthorization is required. Limited to 120 days per member per calendar year
Durable medical equipment
20% coinsurance 20% coinsurance Excludes bath, exercise and deluxe equipment and comfort and convenience items. Prescription required.
4 of 8
Common Medical Event Services You May Need
What You Will Pay Limitations, Exceptions, & Other Important
Information In-Network Provider (You will pay the least)
Out-of-Network Provider (You will pay the most)
Hospice services No Charge; deductible does not apply
No Charge; deductible does not apply
Preauthorization is required. Visit limits apply.
If your child needs dental or eye care For more information on pediatric vision or dental, contact your plan administrator
Children’s eye exam Not Covered Not Covered None
Children’s glasses Not Covered Not Covered None
Children’s dental check-up
Not Covered Not Covered None
5 of 8
Excluded Services & Other Covered Services:
Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)
Acupuncture treatment
Cosmetic surgery
Dental care (Adult)
Hearing aids
Infertility treatment
Long term care
Routine eye care (Adult)
Routine foot care
Weight loss programs
Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
Bariatric surgery
Chiropractic care
Coverage provided outside the United States. See http://provider.bcbs.com
If you are also covered by an account-type plan such as an integrated health flexible spending arrangement (FSA), health reimbursement arrangement (HRA), and/or a health savings account (HSA), then you may have access to additional funds to help cover certain out-of-pocket expenses - like the deductible, co-payments, or co-insurance, or benefits not otherwise covered
Non-emergency care when traveling outside the U.S
Private-duty nursing
6 of 8
Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Department of Labor’s Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa/healthreform, or the Department of Health and Human Services, Center for Consumer Information and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov or by calling the number on the back of your BCBSM ID card. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596. Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact Blue Cross® and Blue Shield® of Michigan by calling the number on the back of your BCBSM ID card. Additionally, a consumer assistance program can help you file your appeal. Contact the Michigan Health Insurance Consumer Assistance Program (HICAP) Department of Insurance and Financial Services, P. O. Box 30220, Lansing, MI 48909-7720 or http://www.michigan.gov/difs or [email protected]
Does this plan provide Minimum Essential Coverage? Yes
If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month.
Does this plan meet Minimum Value Standards? Yes
If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. (IMPORTANT: Blue Cross Blue Shield of Michigan is assuming that your coverage provides for all Essential Health Benefit (EHB) categories as defined by the State of Michigan. The minimum value of your plan may be affected if your plan does not cover certain EHB categories, such as prescription drugs, or if your plan provides coverage of specific EHB categories, for example prescription drugs, through another carrier.) Language Access Services: See Addendum
––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section. ––––––––––––––––––––––
The plan would be responsible for the other costs of these EXAMPLE covered services. 7 of 8
About these Coverage Examples:
This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.
Peg is Having a Baby
(9 months of in-network pre-natal care and a hospital delivery)
The plan’s overall deductible $2,500 Specialist copayment $40 Hospital (facility) coinsurance 20% Other coinsurance 20%
This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia)
Total Example Cost $12,700
In this example, Peg would pay:
Cost Sharing
Deductibles $2,500
Copayments $0
Coinsurance $1,100
What isn’t covered
Limits or exclusions $60
The total Peg would pay is $3,660
Managing Joe’s Type 2 Diabetes
(a year of routine in-network care of a well-controlled condition)
The plan’s overall deductible $2,500 Specialist copayment $40 Hospital (facility) coinsurance 20% Other coinsurance 20%
This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter)
Total Example Cost $7,400
In this example, Joe would pay:
Cost Sharing
Deductibles $1,900
Copayments $1,100
Coinsurance $0
What isn’t covered
Limits or exclusions $60
The total Joe would pay is $3,060
Mia’s Simple Fracture
(in-network emergency room visit and follow up care)
The plan’s overall deductible $2,500 Specialist copayment $40 Hospital (facility) coinsurance 20% Other coinsurance 20%
This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic tests (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy)
Total Example Cost $1,900
In this example, Mia would pay:
Cost Sharing
Deductibles $1,100
Copayments $100
Coinsurance $0
What isn’t covered
Limits or exclusions $0
The total Mia would pay is $1,200
. 8 of 8