Employment Service Agreement and Professional Expert New Hire Forms

Submit the following forms for a first-time ESA employee who currently works at Los Rios.

• Academic Employment Service Agreement Form P-132A
• Address/Name Change Form P-113 – Submit if ESA employee has a new address or name. Do not submit address changes through the ESA. If a new address is used on the ESA in the employees "home address" field, then it will not change the address that the district has on file. For name changes, make sure the employee includes a copy of their social security card indicating the new name.
• A signed and dated copy of the Compliance Checklist. Provide the employee with a copy to keep for their records. By signing, the employee acknowledges receipt of the following information:
  1. New Employee Training Checklist P-202
     Ask employee to complete the entire form. Give employee the information attached to the form. Make sure that the person who explains this form to the employee signs and dates the bottom of this form in the "Hiring Representative Signature" field. Make sure to give the employee a copy of the appropriate job safety analysis. See temporary employment job safety analyses.
  2. Workers' Compensation Packet
     Includes information and optional pre-designation form. By signing, employee acknowledges their receipt of the additional Workers' Compensation information. Make sure that the hiring manager/representative also signs this form.
  3. Statement Concerning Your Employment in a Job Not Covered by Social Security Form SSA-1945
  4. Employee FERPA Agreement Form S-1
  5. Hepatitis B Information
     This includes the link to the Vaccination Acceptance/Declination Form GS-178, a list of positions that require the Hepatitis B form/training, and training instructions.
  6. Title IX, Mandatory Training, Sexual Harassment and Sexual Violence, and How to Report It Memo
     Los Rios requires that every new employee complete Title IX and sexual harassment prevention training within 30 days of their initial hire date. See the linked memo for training directions.
  7. Policy P-8631: Conflict of Interest Rules
  8. Computer Use Regulations: R-8811: Purpose and Definitions; R-8831: Statement of Rights and Responsibilities; R-8851: Privacy and Confidentiality; R-8871: Information Security
  9. Rights and Responsibilities Memo
  10. Employee Self-Service Information Form P-195
  11. Health Insurance Marketplace Notice to New Hires
  12. Paid Sick Leave – Notice to Employees
  13. Public Agency Retirement Services (PARS) Information
      The beneficiary form is optional and can be submitted with the intent to employ. The rest of the information should be given to the employee for their records.
  14. Employment Development Department Booklet
      By signing the "Compliance Checklist" form, employee acknowledges they have been informed that the district is in compliance with the Americans with Disabilities Act (ADA) and they have been given the attached brochure from the Employment Development Department (EDD) regarding State Unemployment Insurance. Please note: The district does not participate in State Disability Insurance because the district has its own disability plan.
  15. 403(b) Tax Sheltered Annuity (TSA) Plan information. Call or email Employee Benefits at (916) 568-3070 or benefits@losrios.edu – or visit Envoy Plan Services – for more information.
• Mandated Reporter Statement Form P-155
• Public Service Loan Forgiveness (PSLF) Memo

Submit the following forms for a first-time ESA employee who has never worked at Los Rios (or has worked at Los Rios but is returning after a break in service).

Download all combined First-Time ESA and Non-Employee forms.

• Academic Employment Service Agreement Form P-132A
• Address/Name Change Form P-113 – Submit if ESA employee has a new address or name. Do not submit address changes through the ESA. If a new address is used on the ESA in the employees "home address" field, then it will not change the address that the district has on file. For name changes, make sure the employee includes a copy of their social security card indicating the new name.
• CalSTRS Working After Retirement Fact Sheet – All new or returning employees who have already retired from CalSTRS should be provided this information prior to starting work. The purpose of this fact sheet is to ensure that employees who are CalSTRS retirees are aware of the post-retirement work stipulations and annual earnings limitations as set forth by CalSTRS.
• Emergency Contact Information – Provide updated emergency contact information to Human Resources.
• A signed and dated copy of the Compliance Checklist . Provide the employee with a copy to keep for their records. By signing, the employee acknowledges receipt of the following information:
  1. New Employee Training Checklist P-202
     Ask employee to complete the entire form. Give employee the information attached to the form. Make sure that the person who explains this form to the employee signs and dates the bottom of this form in the "Hiring Representative Signature" field. Make sure to give the employee a copy of the appropriate job safety analysis. See temporary employment job safety analyses.
  2. Workers' Compensation Packet
     Includes information and optional pre-designation form. By signing, employee acknowledges their receipt of the additional Workers' Compensation information. Make sure that the hiring manager/representative also signs this form.
  3. Statement Concerning Your Employment in a Job Not Covered by Social Security Form SSA-1945
  4. Employee FERPA Agreement Form S-1
  5. Hepatitis B Information
     This includes the link to the Vaccination Acceptance/Declination Form GS-178, a list of positions that require the Hepatitis B form/training, and training instructions.
  6. Title IX, Mandatory Training, Sexual Harassment and Sexual Violence, and How to Report It Memo
     Los Rios requires that every new employee complete Title IX and sexual harassment prevention training within 30 days of their initial hire date. See the linked memo for training directions.
  7. Policy P-8631: Conflict of Interest Rules
  8. Computer Use Regulations: R-8811: Purpose and Definitions; R-8831: Statement of Rights and Responsibilities; R-8851: Privacy and Confidentiality; R-8871: Information Security
  9. Rights and Responsibilities Memo
  10. Employee Self-Service Information Form P-195
  11. Health Insurance Marketplace Notice to New Hires
  12. Paid Sick Leave – Notice to Employees
  13. Public Agency Retirement Services (PARS) Information
      The beneficiary form is optional and can be submitted with the intent to employ. The rest of the information should be given to the employee for their records.
  14. Employment Development Department Booklet
      By signing the "Compliance Checklist" form, employee acknowledges they have been informed that the district is in compliance with the Americans with Disabilities Act (ADA) and they have been given the attached brochure from the Employment Development Department (EDD) regarding State Unemployment Insurance. Please note: The district does not participate in State Disability Insurance because the district has its own disability plan.
  15. 403(b) Tax Sheltered Annuity (TSA) Plan information. Call or email Employee Benefits at (916) 568-3070 or benefits@losrios.edu – or visit Envoy Plan Services – for more information.
• Victims of Domestic Violence Leave Notice
• Demographic Survey
  This information is kept confidential (collected for reporting purposes only)
• Employment Eligibility Disclosure Form P-150
  Mandatory for all employees being fingerprinted and Report of Convictions P-881 (if applicable)
• I-9 Employment Eligibility Verification Form
  This form is required by law. Photo copies of the employees documents used to complete the I-9 must accompany the completed form. Please follow the instructions on the form or visit US Citizenship and Immigration Services website for the Handbook for Employees for more directions and examples of acceptable documentation.
• Fingerprint – Live Scan Receipt and Payroll Deduction Form. Fingerprint packet is available through the supervisor or the campus Business Office.
• Oath of Allegiance
• Social Security Card – photo copy required for IRS purposes
• Tax Withholding Information and Instructions
  Employees can view and update their Federal Employee Withholding Allowance Form W-4 and California State Withholding Allowance Form DE-4 online in Employee Self-Service.
• Freedom From Disabling Disease Form – Required for employees who are retired from CalSTRS, per Education Code 87408.5.
• Faculty Timesheet – ESA employees are required to submit timesheets in order for payment can be processed.
• CalSTRS Permissive Membership Elect/Declination Form ES-0350
  Do not use if already a member of CalSTRS. An employee who performs creditable service and who is excluded from mandatory membership may elect membership in the CalSTRS Defined Benefit Program at any time while employed to perform creditable service. If membership is elected, then the election becomes irrevocable until employment has been terminated. For additional information, please email HR-EmployeeAgreements@losrios.edu.
• Tuberculosis (TB) Requirement
  Must be on file within 15 days of the first date of employment and every four years thereafter
• Direct Deposit Information and Instructions
• The following Child Abuse Mandated Reporter Information:
  • Mandated Reporter Statement Form P-155
  • Reporting Tips
  • Mandated Reporter Guidebook
  • Suspected Child Abuse Report Form
  • California Department of Social Services Mandated Reporter Webpage
• Public Service Loan Forgiveness (PSLF) Memo

Submit the following forms for a first-time PEX employee who currently works at Los Rios.

• Professional Expert Agreement Form P-132P
• Address/Name Change Form P-113 – Submit if ESA employee has a new address or name. Do not submit address changes through the ESA. If a new address is used on the ESA in the employees "home address" field, then it will not change the address that the district has on file. For name changes, make sure the employee includes a copy of their social security card indicating the new name.
• A signed and dated copy of the Compliance Checklist. Provide the employee with a copy to keep for their records. By signing, the employee acknowledges receipt of the following information:
  1. New Employee Training Checklist P-202
     Ask employee to complete the entire form. Give employee the information attached to the form. Make sure that the person who explains this form to the employee signs and dates the bottom of this form in the "Hiring Representative Signature" field. Make sure to give the employee a copy of the appropriate job safety analysis. See temporary employment job safety analyses.
  2. Workers' Compensation Packet
     Includes information and optional pre-designation form. By signing, employee acknowledges their receipt of the additional Workers' Compensation information. Make sure that the hiring manager/representative also signs this form.
  3. Statement Concerning Your Employment in a Job Not Covered by Social Security Form SSA-1945
  4. Notice of Exclusion from CalPERS Membership
     This form must be re-submitted each time the employee has a break in service.
  5. Employee FERPA Agreement Form S-1
  6. Hepatitis B Information
     This includes the link to the Vaccination Acceptance/Declination Form GS-178, a list of positions that require the Hepatitis B form/training, and training instructions.
  7. Title IX, Mandatory Training, Sexual Harassment and Sexual Violence, and How to Report It Memo
     Los Rios requires that every new employee complete Title IX and sexual harassment prevention training within 30 days of their initial hire date. See the linked memo for training directions.
  8. Policy P-8631: Conflict of Interest Rules
  9. Computer Use Regulations: R-8811: Purpose and Definitions; R-8831: Statement of Rights and Responsibilities; R-8851: Privacy and Confidentiality; R-8871: Information Security
  10. Rights and Responsibilities Memo
  11. Employee Self-Service Information Form P-195
  12. Health Insurance Marketplace Notice to New Hires
  13. Paid Sick Leave – Notice to Employees
  14. Public Agency Retirement Services (PARS) Information
      The beneficiary form is optional and can be submitted with the intent to employ. The rest of the information should be given to the employee for their records.
  15. Employment Development Department Booklet
      By signing the "Compliance Checklist" form, employee acknowledges they have been informed that the district is in compliance with the Americans with Disabilities Act (ADA) and they have been given the attached brochure from the Employment Development Department (EDD) regarding State Unemployment Insurance. Please note: The district does not participate in State Disability Insurance because the district has its own disability plan.
  16. 403(b) Tax Sheltered Annuity (TSA) Plan information. Call or email Employee Benefits at (916) 568-3070 or benefits@losrios.edu – or visit Envoy Plan Services – for more information.
• Mandated Reporter Statement Form P-155
• Public Service Loan Forgiveness (PSLF) Memo

Submit the following forms for a first-time PEX employee who has never worked at Los Rios (or has worked at Los Rios but is returning after a break in service).

• Professional Expert Agreement Form P-132P
• Address/Name Change Form P-113 – Submit if ESA employee has a new address or name. Do not submit address changes through the ESA. If a new address is used on the ESA in the employees "home address" field, then it will not change the address that the district has on file. For name changes, make sure the employee includes a copy of their social security card indicating the new name.
• CalSTRS Working After Retirement Fact Sheet – All new or returning employees who have already retired from CalSTRS should be provided this information prior to starting work. The purpose of this fact sheet is to ensure that employees who are CalSTRS retirees are aware of the post-retirement work stipulations and annual earnings limitations as set forth by CalSTRS.
• Emergency Contact Information – Provide updated emergency contact information to Human Resources.
• A signed and dated copy of the Compliance Checklist . Provide the employee with a copy to keep for their records. By signing, the employee acknowledges receipt of the following information:
  1. New Employee Training Checklist P-202
     Ask employee to complete the entire form. Give employee the information attached to the form. Make sure that the person who explains this form to the employee signs and dates the bottom of this form in the "Hiring Representative Signature" field. Make sure to give the employee a copy of the appropriate job safety analysis. See temporary employment job safety analyses.
  2. Workers' Compensation Packet
     Includes information and optional pre-designation form. By signing, employee acknowledges their receipt of the additional Workers' Compensation information. Make sure that the hiring manager/representative also signs this form.
  3. Statement Concerning Your Employment in a Job Not Covered by Social Security Form SSA-1945
  4. Notice of Exclusion from CalPERS Membership
     This form must be re-submitted each time the employee has a break-in-service.
  5. Employee FERPA Agreement Form S-1
  6. Hepatitis B Information
     This includes the link to the Vaccination Acceptance/Declination Form GS-178, a list of positions that require the Hepatitis B form/training, and training instructions.
  7. Title IX, Mandatory Training, Sexual Harassment and Sexual Violence, and How to Report It Memo
     Los Rios requires that every new employee complete Title IX and sexual harassment prevention training within 30 days of their initial hire date. See the linked memo for training directions.
  8. Policy P-8631: Conflict of Interest Rules
  9. Computer Use Regulations: R-8811: Purpose and Definitions; R-8831: Statement of Rights and Responsibilities; R-8851: Privacy and Confidentiality; R-8871: Information Security
  10. Rights and Responsibilities Memo
  11. Employee Self-Service Information Form P-195
  12. Health Insurance Marketplace Notice to New Hires
  13. Paid Sick Leave-Notice to Employees
  14. Public Agency Retirement Services (PARS) Packet
      PEX assignments are covered by PARS. This packet includes basic information about the PARS retirement system as well as the designated beneficiary form and distribution form. Learn more about PARS.
  15. Employment Development Department Booklet
      By signing the "Compliance Checklist" form, employee acknowledges they have been informed that the district is in compliance with the Americans with Disabilities Act (ADA) and they have been given the attached brochure from the Employment Development Department (EDD) regarding State Unemployment Insurance. Please note: The district does not participate in State Disability Insurance because the district has its own disability plan.
  16. 403(b) Tax Sheltered Annuity (TSA) Plan information. Call or email Employee Benefits at (916) 568-3070 or benefits@losrios.edu – or visit Envoy Plan Services – for more information.
• Victims of Domestic Violence Leave Notice
• Demographic Survey
  This information is kept confidential (collected for reporting purposes only)
• Employment Eligibility Disclosure Form P-150
  Mandatory for all employees being fingerprinted and Report of Convictions P-881 (if applicable)
• I-9 Employment Eligibility Verification Form
  This form is required by law. Photo copies of the employees documents used to complete the I-9 must accompany the completed form. Please follow the instructions on the form or visit US Citizenship and Immigration Services website for the Handbook for Employees for more directions and examples of acceptable documentation.
  Note: This form is a secure document and may not automatically open. You may see the words "Please wait." If the form does not open, then you will have to download and save the document in order to fill it out.
• Fingerprint – Live Scan Receipt and Payroll Deduction Form. Fingerprint packet is available through the supervisor or the campus Business Office.
• Oath of Allegiance
• Social Security Card – photo copy required for IRS purposes
• Tax Withholding Information and Instructions
  Employees can view and update their Federal Employee Withholding Allowance Form W-4 and California State Withholding Allowance Form DE-4 online in Employee Self-Service.
• Freedom From Disabling Disease Form – Required for employees who are retired from CalSTRS, per Education Code 87408.5.
• Faculty Timesheet Form BS-71 – PEX employees are required to submit timesheets in order for payment can be processed.
• Direct Deposit Information and Instructions
• The following Child Abuse Mandated Reporter Information:
  • Mandated Reporter Statement Form P-155
  • Reporting Tips
  • Mandated Reporter Guidebook
  • Suspected Child Abuse Report Form
  • California Department of Social Services Mandated Reporter Webpage
• Public Service Loan Forgiveness (PSLF) Memo