TEMPORARY EMPLOYEE CHECKLIST

TEMPORARY EMPLOYEE APPOINTMENT CHECKLIST

REQUIRED DOCUMENTS

NAME_________________________________ DEPARTMENT___________________________ ______REQUISITION

http://hr.wayne.edu/clientservices/recruiting/requisition-temporary-employee_direct_hire.pdf

______ HR-POS Completed via EPAF

______ APPLICATION FOR EMPLOYMENT http://hr.wayne.edu/clientservices/recruiting/temporary-employment-application.pdf

______ EMPLOYEE DATA SHEET http://hr.wayne.edu/clientservices/current/employee-data-sheet.pdf

______ CONDITIONS OF EMPLOYMENT http://hr.wayne.edu/clientservices/recruiting/conditions-of-employment-for-temporary-employees.pdf

______ *Employees must complete Section I of the employment eligibility verification via I-9 Express (http://www.newi9.com/) prior to the date of hire. *U.S. citizens, permanent residents and non-resident aliens must finalize the I-9 verification process by appearing in person with the appropriate ORIGINAL documents at the School of Medicine Human Resources/MPN Office located in room 154 Lande on or before the date of hire between 8:30 and 5:00. (PROVIDE the email approval copy of the Work Authorization Request Form where applicable).

The I-9 requirement is not necessary if the employee has completed the I-9 process at Wayne State University within the last three years.

______ U.S. VETERAN SURVEY http://oeo.wayne.edu/resources/forms.php

______ NEPOTISM STATEMENT (if applicable)

______ EXCEPTION TO HOURLY RATE MEMO (IF APPLICABLE)

______ TAX FORMS:

______ Federal (W-4)

______ State (MI-W4)

______ City (DW-4)

______ BACKGROUND CHECK SUBMITTED TO [email protected] on ___/___/_____ (request is attached)

COMMENTS:_____________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

QUESTIONS ABOUT THIS APPOINTMENT PACKET SHOULD BE DIRECTED TO: NAME________________________________________ TELEPHONE:______________________ (REVISED 4/15/2015)

School of Medicine ◊ UME Business Office ◊ 2305 Scott Hall 540 E. Canfield ◊ Detroit, MI 48201 ◊ Voice: 313-‐577-‐1415 ◊ Fax: 313-‐577-‐0033

EMPLOYMENT PROCEDURES FOR TEMPORARY EMPLOYEES Ø Complete and submit each of the following forms:

1. Employee Data Form (Be sure to put emergency contact information) 2. Application for Employment Form 3. Conditions for Employment 4. Veteran Survey Form 5. Tax Forms

a. Federal (W-‐4) b. State (MI-‐W4) c. City (DW-‐4)

Ø Fill out the online 1-‐9 form go to http://www.newi9.com/

1. Print off a completed copy of 1-‐9 form 2. The Human Resources Identification Requirements-‐ See List Attached 3. Identification Requirements you can choose one from List A or one from both

lists B and C for identification, which is required 4. Must take copy of 1-‐9 and required identification documents to Human

Resources at Lande Building, Room 154 between the hours of 8:30AM-‐ 5:00 PM, Monday through Friday-‐ 577-‐6824-‐ you must go to Human Resources/MPN for verification purposes

5. The 1-‐9 requirement is not necessary if this process has been completed at Wayne State University within the last three years

BACKGROUND CHECK INFORMATION-‐ CONTINGENCY STATEMENT Congratulations on your recent job offer! This offer is contingent upon a satisfactory background check that is required by University policy for this position, including, but not limited to, a criminal background check. If the University determines that your background check results are unsatisfactory, this offer shall be revoked or, if your employment has already commenced, your employment will be immediately terminated. As part of this process, you will receive an e-‐mail invitation with instructions from "A-‐CHECK AMERICA" to complete the screening application (reference guide has been included) or complete a paper Authorization for Background Check form.

Revised 9/25/2009

Requisition for Temporary Employee

Candidate Information

Date Prepared:

Candidate Name:

Banner/SS#:

Position#:

Assignment Start Date:

Assignment End Date:

Immediate Supervisor: School/College/Division:

Department and Code: Recommended Hourly Rate:

Approximate hours of work per week

Is the candidate related to anyone presently working for Wayne State University? Yes No If yes, indicate the following: Name: Position: Department:

Reason for Appointment

Short Term

Projects

Sick Leave Replacement

Vacation

Leave Replacement

Peak Period

Workload

Filling vacant position currently posted until

full-time employee can start work

Replacing (Last Name, First Name): If Applicable

Classification of Person Replaced: E-class Department:

Occupational Title Associated with Duties (i.e., Secretary, Research Assistant) Do not use Technician or Temporary as title:

Description of Duties

Supervisor Signature: Date:

School/College/Division Approval

Department Head Signature: Date:

School/College/Division Head Signature: Date:

NOTE: Candidate should not begin work until all personnel paperwork has been completed

Division of Human Resources Employment Service Center

Employee Data Sheet

Employment Resource Center5700 Cass Ave, Suite 3638

Detroit, MI 48202Phone: 313-577-3000

Fax: 313-577-0637www.hr.wayne.edu

Date:

New Revised

Employee's Legal Name: (Last, First, Middle) (As displayed on SSN/ITIN Card)

Home Address:

Home Phone:

Campus Address:

SSN:

Campus Phone:

Banner ID:

City/State/Zip:

Date of Birth:Male

Female

What is your race? (Select one or more):

Marital Status Citizenship

Married

Single

Citizen

Non-Citizen

Permanent Resident

In which languages are you fluent?

Are you Hispanic or Latino?

Yes

No

This information is voluntary and will be used for statistical purposes only.

AS, Asian

BL, Black or African-American

PH, Native Hawaiian and Other Pacific Islander

WH, White

AM, Native American/Native Alaskan

Will 100% of the work be performed in Detroit, MI? Yes No

If NO, what City, State/Province and Country will the work be performed in? State/Province Country

EndorsedExpiration Date

Year of Graduation

DegreeCity/State/Country

Education History

DateCertification

Professional Certifications and Licenses

Employee Signature

Institution

Date

Name:

Phone:

City/State/Zip:

Address:

Person to Notify in Case of Emergency

Revision (5/2015)

Posting Number:

Position Title:

Application Date and Time:

Personal Information Last Name:

First Name:

Middle Name:

Other names you have been known by or have used:

Social Security Number:

Address:

City:

State/Province:

Zip Code/Postal Code:

Home Phone:

Work Phone:

Cell/Other Phone:

International Phone:

E-mail:

Emergency Contact Name:

Emergency Contact Phone:

How much notice do you have to provide before starting?

Salary Desired:

What type of employment are you seeking?

Are you 18 years or older?

Are you legally authorized to work in the United States?

Are you currently employed by Wayne State University?

If yes, please provide your Banner ID:

If you are a member of a Wayne State bargaining unit, please select the bargaining unit:

Have you ever been employed by Wayne State University?

If yes, indicate location, position, and dates of employment:

Are you related to anyone presently working for Wayne State University?

If Yes, specify name, relationship and department:

Are you currently a student at Wayne State University?

If yes, indicate current term enrolled, give year and number of hours enrolled:

Have you ever been a student at Wayne State University?

How were you referred?

Friend Relative Walk-In

Job Fair Advertisement Employment Agency

WSU Employee Website Other

High School Name of High School:

City:

State/Province/Country:

Did you graduate?

Higher Education

Name of School:

Major:

Number of years completed:

Did you graduate?

Degree:

Work Experience

Employer Name:

Job Title:

Dates Employed:

From:

To:

Starting Salary:

Ending Salary:

Supervisor's Name:

Supervisor's Title:

Supervisor's Phone:

Reason for Leaving:

Work Performed:

May we contact this employer?

Type of Employment:

Employer Name:

Job Title:

Dates Employed:

From:

To:

Starting Salary:

Ending Salary:

Supervisor's Name:

Supervisor's Title:

Supervisor's Phone:

Reason for Leaving:

Work Performed:


Type of Employment:

Employer Name:

Job Title:

Dates Employed:

From:

To:

Starting Salary:

Ending Salary:

Supervisor's Name:

Supervisor's Title:

Supervisor's Phone:

Reason for Leaving:

Work Performed:


Type of Employment:

References

Name:

Occupation:

How do you know this reference?:

Address:

Phone number:

Email:

May we contact this reference?

Name:

Occupation:


Address:

Phone number:

Email:


Name:

Occupation:


Address:

Phone number:

Email:


Miscellaneous

Please provide any Licenses. (Please include license number, expiration date and sponsor/provider e.g. License XYZ, 02-02-2004, Provider):

Please provide any Certifications. (Please include certification number, expiration date and sponsor/provider e.g. Certification XYZ, 02-02-2004, Provider).

Please list any special skills or qualifications:

Agreement I certify that my statements are true and accurate. I understand that my employment is contingent upon satisfactory verification of the information indicated on this application and other information submitted in support of my application for employment. If employed, I understand that any misrepresentation found after I am on the job will be considered sufficient grounds for dismissal. I hereby authorize Wayne State University to investigate my past employment and/or activities and statements contained in this application and release from all liability and responsibility all persons, companies, or corporations supplying such information. I understand that such information may include reports or records of disciplinary action assessed by previous employers, and specifically waive written notice of such disclosure and release such parties from any obligation to provide me with such notification, in accordance with Michigan Complied Laws 423.506. Applicants or employees who need any accommodation for a disability should request one by contacting the Employment Services Center at 313-577-2010. In consideration of my employment, I agree to conform to all Wayne State University policies and procedures, including applicable collective bargaining agreements and employee handbooks. Except to the extent that such then current policies and procedures explicitly provide otherwise, I agree that my employment and compensation may be terminated, with or without cause and with or without notice at any time, at the option of either Wayne State University or myself, I understand that no manager, faculty member, or other representative of Wayne State University, other than the President, has any authority to enter into any agreement, oral or otherwise, contrary to the foregoing, and that no such agreement shall be given effect unless it has been reduced to writing and signed by both the president and me.

BY SIGNING BELOW, I certify that I have read and agree with these statements.

Applicant's Name Applicant's Signature Date

Wayne State University is an affirmative action/equal opportunity employer.

MEMORANDUM

TO: All Faculty and Staff

FROM: Office of Equal Opportunity

RE: Confidential Survey to Identify Faculty and Staff with Disabilities and U.S. Veterans

Wayne State University is committed to equal opportunity, non discrimination and affirmative action. Federal regulations require Wayne State to maintain data on persons with disabilities and U.S. Veterans. The questionnaire printed on the next page(s) will allow you to self-identify as a person with a disability and/or a U.S. Veteran. This data will be used to evaluate Wayne State’s efforts in assuring access, promotional and equal opportunities to the disabled and veterans. We will routinely request this information from new employees to update this data.

The data you provide is considered CONFIDENTIAL. However, for affirmative action or safety purposes, data may be submitted to the following:

1. Applicable supervisors or managers to facilitate the provision of reasonable accommodations in the design or renovation/alteration of buildings, facilities, fixtures, furniture or job structures;

2. Government officials during review of Wayne State University legal compliance; 3. Human Resources ADA Coordinator for notification of opportunities or activities for

employees with disabilities or veterans; 4. First aid or safety personnel.

Your participation in this survey is VOLUNTARY and helps the University’s equal opportunity, non-discrimination and affirmative action efforts.

Please complete the survey, seal and return the form to the Office of Equal Opportunity. If you should have any questions, please contact the Office of Equal Opportunity at (313) 577-2280.

Thank you for your cooperation.


WAYNE STATE UNIVERSITY OFFICE OF EQUAL OPPORTUNITY

DISABLED PERSONS & U.S. VETERANS VOLUNTARY SURVEY

THIS INFORMATION IS VOLUNTARY AND CONFIDENTIAL

PRINT NAME:___________________________________ BANNER ID # _________________

Please check one: Faculty □ Staff □

FOR EMPLOYEES WITH DISABILITIES

Disability Definitions: A determinable physical or mental characteristic of an individual, which may result from disease, injury, congenital condition of birth, or functional disorder, if the characteristic substantially limits one or more major life activities of that individual, and is unrelated to the individual’s ability to perform the duties of a particular job or position or substantially limits one or more of the major life activities of that individual, and is unrelated to the individual’s qualifications for employment or promotion (Persons With Disabilities Civil Rights Act). Or, a person who has a physical or mental impairment that substantially limits one or more major life activities; has a record of such impairment or is regarded as having such impairment (Americans with Disabilities Act).

Please Check one: Do you believe you have a disability? YES □ NO □

Do you use disability accommodations provided

by the University? YES □ NO □

If “yes”, please check all of the following types of accommodations you use: ____ Access (e.g. ramps, disability parking, special

classroom location, etc.) ____ Job restructuring ____ Special equipment (e.g., amplifying device, special

computer, etc.) ____ Other ___________________________

Would you like to receive a packet of information on requesting an accommodation, including the necessary request forms?

YES □ NO □ If yes, please provide your mailing address the appropriate information may be sent to you. ___________________________ _____________________ ______ ____________

Address City State Zip Code


FOR U.S. VETERANS

The following are definitions of various categories of U.S. Veterans. Please read them carefully and determine which category or categories describes you and check ALL of the categories which describe you.

� ‘Disabled Veteran’ means (i) a veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs, or (ii) a person who was discharged or released from active duty because of a service-connected disability.

� Special Disabled Veteran’ means a veteran who is entitled to compensation under laws administered by the Department of Veterans Affairs for a disability rated at 30 percent or more; or, rated at 10 or 20 percent, if it has been determined that the individual has a serious employment disability; or, a person who was discharged or released from active duty because of a service-connected disability.

� ‘Other Protected Veteran’ means a veteran who served on active duty during a war or in a campaign or expedition for which a campaign badge has been authorized.

� ‘Newly Separated Veteran’ means any veteran who served on active duty in the U.S. military, ground, naval or air service during the one-year period beginning on the date of such veteran’s discharge or release from active duty. (If you were discharged from active duty within a 12-month period prior to beginning employment.)

� ‘Recently Separated Veteran’ means a veteran during the three-year period beginning on the date of such veteran’s discharge or release from active duty in the U.S. Military, ground, naval or air service. (If you were discharged from active duty within a 3-year period prior to beginning employment.)

� ‘Veteran of the Vietnam Era’ means a veteran who (1) served on active duty for a period of more than 180 days, any part of which occurred between August 5, 1964 and May 7, 1975, and was discharged or released with other than a dishonorable discharge; (2) was discharged or released from active duty for a service connected disability if any part of such active duty was performed between August 5, 1964 and May 7, 1975; or (3) served on active duty for more than 180 days and served in the Republic of Vietnam between February 28, 1961 and May 7, 1975.

� ‘Armed Forces Service Medal Veteran’ means a veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Force service medal was awarded pursuant to Executive Order 12985 (see http://www.opm.gov/veterans/html/vgmedal2.asp)

___________________________ _____________________ Signature Date Print Name

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. 8-08)

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 fromwithholding, you must file their original MI-W4form with the Michigan Department of Treasury.Mail to: New Hire Operations Center, P.O. Box85010; 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 License Number

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.Members of flow-through entities may not claim exemptionfrom nonresident flow-through withholding. For moreinformation on Renaissance Zones call the Michigan Tele-HelpSystem, 1-800-827-4000. Full-time students that do not satisfyall of the above requirements cannot claim exempt status.

Web SiteVisit the Treasury Web site at:www.michigan.gov/businesstax

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 both employed, 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):

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Candidate Reference Guide - Background Screening Application Congratulations on your recent job offer at Wayne State University. As previously mentioned, this offer is contingent upon the completion of a satisfactory background check that is required by University policy for this position, including, but not limited to, a criminal background check. If the University determines that your background check results are unsatisfactory, this offer shall be revoked. As part of this process, you will receive an e-mail invitation with instructions from A-Check America to complete the background screening application. IMPORTANT NOTE: You have been given 72 hours to complete the background screening application. Failure to complete this application may result in revocation of your job offer.

Please find below a helpful guide to assist you in completing the background screening application. Once the background process has been completed, you will be contacted by the Hiring Manager or Human Resources (for Non-Academic positions only).

1. You will receive an e-mail invitation from with the Subject “A-CHECK AMERICA – BACKGROUND SCREENING INVITATION”

2. The e-mail will contain a system generated Login information. You will need this information to access the website.

3. Select Accept Invitation to begin the

background screening application. Note: Your job offer is contingent upon successful completion of a background check. By selecting “Decline Invitation” you are disqualifying yourself from consideration.

1. Once you select the Accept Invitation link,

you will be directed to the Applicant Portal at A-Check America.

2. Enter your username and password from the e-mail invitation you received.

3. Click the Login button.

STEP 1: E-MAIL INVITATION FROM A-CHECK

STEP 2: LOGIN

For assistance in completing your background application please contact: A-Check America

Toll free: 877-345-2021 Direct: 951-750-1501

http://www.acheckamerica.com/

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1. After reading the welcome message, click Start Application.

2. At this point, you will be taken to the application wizard to complete the following sections:

� Personal Information: Be sure to

enter your full legal name as it appears on your Government documents.

� Driver’s Record: Make sure you have a valid Driver’s license number ready.

� Education: You will be asked to provide the highest level of education completed.

� Employment History: You will be asked to provide all employment history within the past 7 years

� Disclosed Offenses: You will be given an opportunity to disclose any criminal records. Please provide as much accurate information as you have available to you.

1. Once you have completed all sections, click Complete Application. IMPORTANT: You MUST click the Complete Application button in order for A-Check to begin the screening process

2. You will receive a confirmation message and file number. For your record, you should retain the file number or print a copy by clicking the Print Confirmation button.

STEP 3: COMPLETING THE BACKGROUND SCREENING APPLICATION

STEP 4: COMPLETING THE BACKGROUND SCREENING APPLICATION – FINAL STEPS

TEMPORARY EMPLOYEE CHECKLIST

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