Substitute/Contracted Labor Application

EDUCATION:
Name Address of High School Attended
Highest Grade Completed
Graduation Date

MonthDayYear
Date
Name Address of College Attended
Do you have a Degree? If yes, please provide a copy.

YesNo
Other Skills and Qualifications Licenses Trainings Awards etc
EMPLOYMENT HISTORY:
Present or Previous Position/Title
Employer
Address
Phone Number
Please enter a valid phone number.
Employed From: blanks . Employed To: blank .
Responsibilities & Job Duties:
Reason For Leaving
Prior or Previous PositionTitle
Employer
Address
Phone Number
Please enter a valid phone number.
Employed From: blanks . Employed To: blank .
Responsibilities & Job Duties:
Reason For Leaving
REFERENCES:
1. Name/Title/Phone:
2. Name/Title/Phone:
3. Name/Title/Phone:
I certify that information contained in this application is true and complete. I understand that false information may be grounds for not hiring me or for immediate termination of employment at any

point in the future. I authorize the verification of all information above.
Signature

Clear
Date

MonthDayYear
Date

Grant Parish School

Food Service Department

P.O. Box 208 512 Main Street Colfax, LA 71417
TO: Food Service Technician Substitutes

FROM: Melanie Chandler, Child Nutrition Supervisor

RE: Employment for the 2023-2024 school year

If you wish to work in any of the Grant Parish School Board Cafeterias as a food technician substitute, you must complete and mail back this letter. Even if you are an existing sub or have subbed in the past you must complete a new form each year. Updating your information each year also ensures that you will not have to pay to have your fingerprints taken again. Those that do not remain on our current list are required to have their fingerprints taken again before working in the schools.

Please be reminded of the following requirements for the Food Service Technician Substitutes:

1. Each sub must have their own home phone or cell phone and provide us with that number.

2. Each sub must have their own dependable mode of transportation to and from work.

3. Each sub must turn in a new information form each school year.

4. If it has been more than one year since you have worked for us you must pay $39.25 to the Grant Parish School Board to be fingerprinted again.

5. You will need to contact the school board office to arrange for the required trainings (Bullying, Ethics, and Suicide etc The training will need to be completed prior to working. Call 627-3274 to arrange for the training.

6. New subs must be drug tested prior to working in a school cafeteria.

You may mail your application in, and we will add your name to our 2023-2024 substitute list. We will give this list to our cafeteria managers. To make sure your name is added, please mail the below application back to the school board office.

Thank you for your cooperation. We look forward to working with you this school year.
I, blanks would like to substitute for the Grant Parish Food Service Department at the following schools:
AllGrant Jr High SchoolGeorgetown High SchoolGrant High SchoolMontgomery High SchoolPollock Elementary SchoolVerda Elementary SchoolSouth Grant Elementary School
Current Telephone Numbers
Please enter a valid phone number.
Current Telephone Numbers
Please enter a valid phone number.
Address
It is highly encouraged to be open to covering more schools, as this increases your chances of being called to sub and all of our schools would appreciate the help!

Subs are called in by the manager as needed. This is not a guaranteed position. In the instance that a sub is needed long- term, then dependable subs will move into a two-week rotation cycle. These subs will rotate every two weeks and also have the chance to fulfill rotations at other schools when needed. The rotation can stop or be changed at any time dependent upon the need and is in no way a guaranteed position. This procedure allows for training and experience for all of our subs at different schools as we work to grow our department. Procedures are subject to change at any time depending on the need.

Grant Parish School

Food Service Department

P.O. Box 208 512 Main Street

Colfax, LA 71417
GENERAL INFORMATION FOR SUBSTITUTING IN THE CAFETERIA
Information concerning uniforms:
- All leather shoes with non-slip tread that is totally enclosed.
- Khaki or black uniform bottoms, colored uniforms. Approved pants or split skirts (below the knee and full cut-these are not shorts) can be worn with colored t-shirts. Shirts must be appropriate and not have any disturbing/graphic images or language. You may ask the manager at the school you are subbing if they wear a particular color t-shirt. However, subs are not required to follow specific school uniform unless otherwise.
- Hair nets must be worn every day during food preparation and serving.
- Fingernails must be trimmed and clean. Nail polish is NOT allowed. Long, false, and acrylic nails aren't allowed.
- Jewelry must be restricted to plain wedding band and/or stud earrings; NO other jewelry is allowed including WATCHES, BRACELETS, DANGLING EARRINGS, or any other body piercings.
- Tattoos shall NOT be visible.
- Cell Phones are NOT to be used except on designated break time.
Working Conditions:
- Hot, humid area
- Contact with water (hot and cold), detergents and sanitizing agents
- Drastic temperature changes (when entering and exiting walk-in refrigerators and freezers) Lifting and carrying 25 pounds
- Lifting to 50 pounds with assistance
- To push or pull equipment such as food carts and mop buckets
- To bend to bottom shelves and climb step stool to top shelves to put up and pull inventory
Please sign and date below
Date

MonthDayYear
Date
I, blankshave read and understand the information provided in this document.

Grant Parish School Board

P O Box 208

COLFAX, LOUISIANA 71417-0208
AUTHORIZATION AND RELEASE

IMPORTANT: READ CAREFULLY

Louisiana Revised Statutes 17: 3884 provides that a school board considering the employment application ofa person who has been evaluated in another school system shall request such person's evaluation results as part of the application process and shall inform the applicant that his/her evaluation results will be requested. The applicant shall be given the opportunity to review any information received by the prospective employer as a result of such request and to provide any response or information the applicant deems appropriate. Please be advised, therefore, that the Grant Parish School Board will request evaluation results on you from each of the school districts you have listed in your application. You will be given an opportunity to review the evaluation results received and to provide a response or information if you would like to do so. Any written response or information you might provide will be retained with your application.

Louisiana Revised Statutes 17:15 also requires all applicants for employment to be fingerprinted in order to assist in background checks of those individuals. Should it be determined that any applicant (or employee)has been convicted of one or more of the criminal offenses set forth in Louisiana Revised Statutes 17: 587. (C), then that applicant (or employee) is generally precluded from further employment with the school system.

Louisiana Revised Statutes 17: 81.9 further requires a school board receiving an application to request that all current and prior school board employers of the applicant provide it with all information in their records relative to instances of sexual misconduct with students committed by the applicant (if any This law further provides that the applicant must release all such employers from liability arising from the release of such information to the prospective employer.

______________________________________________________________________________________

AUTHORIZATION AND RELEASE

I certify that the information which I have provided in the attached application is true and complete. I understand that furnishing false information or omitting information on this application could disqualify me from consideration for employment or could lead to my discharge from employment. I hereby authorize the Grant Parish School Board to request, receive, and review my prior evaluations and information relative to sexual misconduct with students (if any) from all of my current or previous school system employers. I further release the Grant Parish School Board and all current and former employers, their agents and employees afrom any liability connected with such disclosures and do hereby specifically authorize such employer(s) to release to the Grant Parish School Board such information and documentation as may be requested in connection with my application for employment with it.
Printed Name
Signature

Clear
Date

MonthDayYear
Date

Have you ever been terminated by a school system, resigned prior to the expiration of your contract, or asked to resign? If so, please attach an explanation identifying the employer, basis for termination or resignation, and the date of same.
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Have you ever been convicted, pled guilty, or no contest to a felony or other serious offense? If so, please attach an explanation identifying the charge, jurisdiction and court involved, date of conviction or plea, and factual basis of charge(s).
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Have you ever engaged in or been accused of engaging in sexual misconduct with a minor/student or the abuse or neglect of a minor? If so, please attach an explanation identifying the conduct or alleged conduct in question, including but not limited to the date(s), your employer at the time, criminal charges, jurisdiction and court involved, date of the conviction or plea, and factual basis of the charge(s) or allegations.
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Have you ever been the subject of any investigation of alleged sexual misconduct involving a minor or student, abuse of a minor or student or neglect of a minor or student? If so, please attach an explanation identifying the conduct or alleged conduct in question, including but not limited to the date(s), your employer at the time, the results of the investigation, criminal charges, jurisdiction, court involved, date of conviction or plea and factual basis of the charge(s) or allegations.
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I have read, understand and acknowledge the foregoing notice, conditions and directions for completing this application. I certify that the information provided herein and in the attachments hereto is accurate, true and complete to the best of my knowledge. I further certify that I have not been convicted, pled guilty or pled no contest to a felony or other serious offence, and have not engaged in physical or sexual misconduct, neglect or abuse with or toward a student. I hereby waive my confidentiality with regard to my work record or criminal record and consent to and authorize the release of information, including that which may have been sealed, from my current or former employers and/or law enforcement personnel upon inquiry in reference to this application. I release anyone responding to such inquiry from any liability for providing such information.
Signature

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Date

MonthDayYear
Date

Grant Parish School Board

P.O. Box 208

Colfax, Louisiana

71417-0208
To All Employees:

Act. No 619 was passed during the 1997 Regular Session of the Legislature, and we are taking this opportunity to advise each of you of its important provisions.

Louisiana school boards are obligated to provide all public school employees who are employed by city and parish school boards with legal defense and indemnification in the event an employee is sued for damages by any student, or other persons qualified to bring suit on behalf of any student, based on any action or statement, or the omission of any action or statement, by such employee when in the proper course and scope of the employees duties as defined by the employing school board. Grant Parish School Board will perform its duties to its employees under Act 619.

The Grant Parish School Board also purchases liability insurance from a financially strong insurance company, and that insurance will protect both the- school board and its employees from many of the claims which may be brought against an employee.

Please understand, however, no Louisiana school board is obligated to indemnify an employee against a judgment in which the employee's action is found to be maliciously, willfully, and deliberately intended to cause bodily harm or to harass or intimidate the student.

I have received a copy of the Indemnification Policy and understand its contents.
Printed Name
Signature

Clear
Date

MonthDayYear
Date

SUBMIT TO:
Louisiana State Police

Bureau of Criminal Identification and Information

P.O. Box 66614 (Mail Slip A-6)

Baton Rouge, LA 70896
Applicants Full Name:

First NameMiddle NameLast Name
(Include Maiden Name & Previous Married Names if Applicable
APPLICANTS SIGNATURE

Clear
Applicants Social Security #
Date of Birth:
Drivers License #StateRaceSex
POSITION OR LICENSE APPLIED FOR
____________________________________________________________________________AUTHORIZATION TO DISCLOSE CRIMINAL HISTORY RECORDS INFORMATION
By my signature above, I hereby authorize the Louisiana State Police to release all pertinent criminal record information maintained in their files, other states files, or the FBI files (if applicable) which may confirm or deny my eligibility with the facility or agency named above. Pursuant to Title 28, C.F.R., Section 16.34, officials making the determination of suitability for licensing or employment shall provide the opportunity to complete, or challenge the accuracy of the information contained in the FBI identification record.

ATN and SID# FOR OFFICIAL USE ONLY
ATN SID
APPLICANT PROCESSING - DISCLOSURE

BUREAU OF CRIMINAL IDENTIFICATION AND

INFORMATION

P.O. BOX 66614 (MAIL SLIP A-6)

BATON ROUGE, LA 70896
AGENCY, BUSINESS OR INDIVIDUAL NAME

Street Address Line

CityState / Province

Postal / Zip Code
Name of ApplicantDate of BirthPlace of BirthRace/Sex
WeightHeightHair ColorEye Color
SOCIAL SECURITY NUMBER
ALL INFORMATION RELEASED MUST REMAIN STRICTLY CONFIDENTIAL AND ONLY THOSE AUTHORIZED BY LAW TO RECEIVE THIS INFORMATION MAY SUBMIT A REQUEST.

DO NOT WRITE BELOW THIS LINE: (For Bureau of Criminal Identification and Information Use Only}

NOTICE: The response to your request for a criminal history check is based on a review of the State of Louisiana's criminal history records database as is available at the time of request. This does not preclude the possible existence of an arrest or conviction information not available in our database.

Type a question

	Date	Arresting Agency	Conviction Information
1
2
3
4
5

Employment Eligibility Verification
DEPARTMENT OF HOMELAND SECURITY

U.S. Citizenship and Immigration Services
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
Name

First Name Given NameMiddle Initial if anyOther Last Names Used if any
Address

Street Address

Apartment No (if any)

CityState / Province

Postal / Zip Code
Date of Birth mmddyyyy

MonthDayYear
Date
US Social Security Number
Employees Email Address
example@example.com
Employees Telephone Number
Check one of the following boxes to attest to your citizenship or immigration status(See page 2 and 3 of the Instructions.)

1. Citizen of the United States2. A noncitizen national of the United States (See Instructions)3. A lawful permanent resident (Enter USCIS or A-Number.)4. A noncitizen (other than Item Numbers 2, and 3. above) authorized to work until (exp.date, if any)
If you check Item Number 4., enter one of these:

Type a question

	USCIS A-Number	or Form I94 Admission Nmber	or Foreign Passport Number and Country of Issuance

Signature of Employee

Clear
If a preparer and/or translator assisted you In completing Section 1, that person MUST complete the Preparer and/or Translator Certification on Page 3.
Todays Date mmddyyyy

MonthDayYear
Date
Employers Business or Organization Name
Employers Business or Organization Address City or Town State ZIP Code
For reverification or rehire, complete Supplement B, Reverification and Rehire on Page 4.

My signature denotes that I have been provided with copies of the Privacy Act Statement and the Noncriminal Justice Applicant's Privacy Rights in reference to the national fingerprint-based criminal history record check that will be conducted as part of the employment process with the Grant Parish School Board.
Employee Name printed
Date

MonthDayYear
Date
Employee Signature

Clear
GPSB Witness Name printed
Date

MonthDayYear
Date
GPSB Witness Signature

Clear

Privacy Act Statement
Authority: The FBI's acquisition, preservation, and exchange of fingerprints and associated information is generally authorized under 28 U.S.C. 534. Depending on the nature of your application, supplemental authorities include Federal statutes, State statutes pursuant to Pub. L. 92-544, Presidential Executive Orders, and federal. Providing your fingerprints and associated information is voluntary; however, failure to do so may affect completion or approval of your application.

Social Security Account Number (SSAN) Your SSAN is needed to keep records accurate because other people may have the same name and birth date. Pursuant to the Federal Privacy Act of 1974 (5 USC 552a), the requesting agency is responsible for informing you whether disclosure is mandatory or voluntary, by what statutory or other authority your SSAN is solicited, and what uses will be made of it. Executive Order 9397 also asks Federal agencies to use this number to help identify individuals in agency records.

Principal Purpose: Certain determinations, such as employment, licensing, and security clearances, may be predicated on fingerprint-based background checks. Your fingerprints and associated information/biometrics may be provided to the employing, investigating, or otherwise responsible agency, and/or the FBI for the purpose of comparing your fingerprints to other fingerprints in the FBI's Next Generation Identification (NGI) system or its successor systems (including civil, criminal, and latent fingerprint repositories) or other available records of the employing, investigating, or otherwise responsible agency. The FBI may retain your fingerprints and associated information/biometrics in NGI after the completion of this application and, while retained, your fingerprints may continue to be compared against other fingerprints submitted to or retained by NGI.

Routine Uses: During the processing of this application and for as long thereafter as your fingerprints and associated information/biometrics are retained in NGI, your information may be disclosed pursuant to your consent, and may be disclosed without your consent as permitted by the Privacy Act of 1974 and all applicable Routine Uses as may be published at any time in the Federal Register, including the Routine Uses for the NGI system and the FBI's Blanket Routine Uses. Routine uses include, but are not limited to, disclosures to: employing, governmental or authorized non-governmental agencies responsible for employment, contracting licensing, security clearances, and other suitability determinations; local, state, tribal, or federal law enforcement agencies; criminal justice agencies; and agencies responsible for national security or public safety.

Additional Information: The requesting agency and/or the agency conducting the application- investigation will provide you additional information pertinent to the specific circumstances of this application, which may include identification of other authorities, purposes, uses, and consequences of not providing requested information. In addition, any such agency in the Federal Executive Branch has also published notice in the Federal Register describing any system(s) of records in which that agency may also maintain your records, including the authorities, purposes, and routine uses for the system(s

NONCRIMINAL JUSTICE APPLICANT'S PRIVACY RIGHTS

As an applicant who is the subject of a national fingerprint-based criminal history record check for a noncriminal justice purpose (such as an application for employment or a license, an immigration or naturalization matter, security clearance, or adoption), you have certain rights which are discussed below.
- You must be provided written notification¹ that your fingerprints will be used to check the criminal history records of the FBI.
- You must be provided, and acknowledge receipt of, an adequate Privacy Act Statement when you submit your fingerprints and associated personal information. This Privacy Act Statement should explain the authority for collecting your information and how your information will be used, retained, and shared. 2
- If you have a criminal history record, the officials making a determination of your suitability for the employment, license, or other benefit must provide you the opportunity to complete or challenge the accuracy of the information in the record.
- The officials must advise you that the procedures for obtaining a change, correction, or update of your criminal history record are set forth at Title 28, Code of Federal Regulations (CFR), Section 16.34.
- If you have a criminal history record, you should be afforded a reasonable amount of time to correct or complete the record (or decline to do so) before the officials deny you the employment, license, or other benefit based on information in the criminal history record.³
You have the right to expect that officials receiving the results of the criminal history record check will use it only for authorized purposes and will not retain or disseminate it in violation of federal statute, regulation or executive order, or rule, procedure or standard established by the National Crime Prevention and Privacy Compact Council.

If agency policy permits, the officials may provide you with a copy of your FBI criminal history record for review and possible challenge. If agency policy does not permit it to provide you a copy of the record, you may obtain a copy of the record by submitting fingerprints and a fee to the FBI. Information regarding this process may be obtainedat https://www.fbi.gov/services/cjis/identity-history-summary-checks.

If you decide to challenge the accuracy or completeness of your FBI criminal history record, you should send your challenge to the agency that contributed the questioned information to the FBI. Alternatively, you may send your challenge directly to the FBI. The FBI will then forward your challenge to the agency that contributed the questioned information and request the agency to verify or correct the challenged entry. Upon receipt of an official communication from that agency, the FBI will make any necessary changes/corrections to your record in accordance with the information supplied by that agency. (See 28 CFR 16.30 through 16.34)

1 Written notification includes electronic notification, but excludes oral notification. 2https://www.fbi.gov/services/cjis/compact-council/privacy-act-statement 3 See 28 CFR 50.12(b 4 See 5 U.S.C. 552a(b); 28 U.S.C. 534(b); 34 U.S.C. § 40316 (formerly cited as 42 U.S.C. § 14616), Article IV(c); 28 CFR 20.21(c), 20.33(d) and 906.2(d

Updated 05/10/2017 Non-substantive updates incorporated in January 2018

W-4 Employee's Withholding Certificate 2024
First name and middle initial
Last Name
b Social security number
Address
City or town, state, and ZIP code
Does your name match the name on your social security card? If not, to ensure you get credit for your earnings, contact SSA at 800-772-1213 or go to www.ssa.gov. Single or Married filing separately Married filing jointly or Qualifying surviving spouse Head of household (Check only if you're unmarried and pay more than half the costs of keeping up a home for yourself and a qualifying individual
Single or Married filing separatelyMarried filing jointly or Qualifying surviving spouseHead of household (Check only if you're unmarried and pay more than half the costs of keeping up a home for yourself and a qualifying individual)
Complete Steps 2-4 ONLY if they apply to you; otherwise, skip to Step 5.

Step 2: Complete this step if you (1) hold more than one job at a time, or (2) are married filing jointly and your spouse also works. The correct amount of withholding depends on income earned from all of these jobs. Multiple Jobs or Spouse

Do only one of the following.

(a) Use the estimator at www.irs.gov/W4App for most accurate withholding for this step (and Steps 3-4 If you or your spouse have self-employment income, use this option; or

(b) Use the Multiple Jobs Worksheet on page 3 and enter the result in Step 4(c) below; or

(c) If there are only two jobs total, you may check this box. Do the same on Form W-4 for the other job. This option is generally more accurate than (b) if pay at the lower paying job is more than half of the pay at the higher paying job. Otherwise, (b) is more accurate

Complete Steps 3-4(b) on Form W-4 for only ONE of these jobs. Leave those steps blank for the other jobs. (Your withholding will be most accurate if you complete Steps 3-4(b) on the Form W-4 for the highest paying job

If your total income will be $200,000 or less ($400,000 or less if married filing jointly):

Claim Dependent and Other Credits
Step 3. Multiply the number of qualifying children under age 17 by 2000
Step 3. Multiply the number of other dependents by $500
Step 3. Add the amounts above for qualifying children and other dependents. You may add to this the amount of any other credits. Enter the total here.
Step 4 (optional): (a) Other income (not from jobs). If you want tax withheld for other income you expect this year that won't have withholding, enter the amount of other income here. This may include interest, dividends, and retirement income.
Step 4 Other Adjustments (b) Deductions. If you expect to claim deductions other than the standard deduction and want to reduce your withholding, use the Deduction Worksheet and enter the results here
Step 4 Other Adjustments (c) Extra withholding. Enter any additional tax you want withheld each pay period.
Signature

Clear
Date

MonthDayYear
Date
Employers name and address
First date of employment

MonthDayYear
Date
Employer identification number EIN
For Privacy Act and Paperwork Reduction Act Notice, see page 3.

Employee Withholding Exemption Certificate (L-4)

Louisiana Department of Revenue

______________________________________________________________________________

Purpose: Complete form L-4 so that your employer can withhold the correct amount of state income tax from your salary.
Block A: Enter "0" to claim neither yourself nor your spouse, and check "no exemptions or dependents claimed" under number 3 below. You may enter "0" if you are married, and have a working spouse or more than one job to avoid having too little tax withheld. Enter "1" to claim yourself, and check "Single" under number 3 below. If you did not claim this exemption in connection with other employment, or if your spouse has not claimed your exemption. Enter "1" to claim one personal exemption if you will file as head of household, and check "Single" under number 3 below. Enter "2" to claim yourself and your spouse, and check "Married" under number 3 below.
Block B: Enter the number of dependents, not including yourself or your spouse, whom you will claim on your tax return. If no dependents are claimed, enter "0".
Employee's Withholding Allowance Certificate
1 Type or print first name and middle initial
Last name
2 Social Security Number
3. Select One

No exemptions or dependents claimedSingleMarried
4 Home address number and street or rural route
CityStateZipcode
6. Total number of exemptions claimed in Block A
7. Total number of dependents claimed in Block B
8. Increase or decrease in the amount to be withheld each pay period Decreases should be indicated as a negative amount
I declare under the penalties imposed for filing false reports that the number of exemptions and dependency credits claimed on this certificate do not exceed the number to which I am entitled.
Employees signature

Clear
Date

MonthDayYear
Date
Address

9 Employers name and address

Street Address Line 2

City10 Employers state withholding account number

Postal / Zip Code

LOUISIANA WORKERS' COMPENSATION SECOND INJURY BOARD POST-HIRE/CONDITIONAL JOB OFFER KNOWLEDGE QUESTIONNAIRE

EMPLOYEE: The intent of this questionnaire is to provide your employer with knowledge about any pre- existing medical condition or disability which may entitle your employer to reimbursement from the Louisiana Workers' Compensation Second Injury Board in the event you suffer an on-the-job injury. 1 This reimbursement in no way affects the benefits owed to you by your employer or its insurance company under the Louisiana Workers' Compensation Act. La. R.S. 23:1021-1361. However, your failure to answer truthfully and/or correctly to any of the question on this questionnaire may result in a forfeiture of your workers' compensation benefits. In order for your employer to be considered for reimbursement from the Second Injury Board, it has to show that it knowingly hired or retained you with a pre-existing medical condition or disability. To establish its knowledge, your employer is requesting that this questionnaire be completed.

INSTRUCTIONS: Please answer ALL questions completely. If a response requires an explanation, please provide a brief description on the Explanation Page. If you have any questions or need help in answering the questions on this form, please ask for assistance from the Employer Representative signing this form.

NOTE: Since this questionnaire contains medical information, you can request that the form be kept CONFIDENTIAL and not made part of your personnel file. Please let your employer know that you want the completed questionnaire placed in a sealed folder for confidentiality purposes.

EMPLOYEE WARNING

FAILURE TO ANSWER TRUTHFULLY AND/OR CORRECTLY TO ANY OF THE QUESTIONS ON THIS FORM MAY RESULT IN A FORFEITURE OF YOUR WORKERS' COMPENSATION BENEFITS UNDER La.R.S. 23:1208.1.
Employee Signature

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Date

MonthDayYear
Date
Employer Representative Signature

Clear
Date

MonthDayYear
Date
Employee Name
Date of Birth mmddyyyy

MonthDayYear
Date
Select one.

MaleFemale
Soc Sec last 4 digits only
Home Address
Phone Number
Please enter a valid phone number.
I Under La. R.S. 23:1371(A), the purpose of the Second Injury Board is to encourage the employment, re- employment, or retention of employees who have a permanent partial disability.

Page 1 of 6

Disease and Other Medical Conditions you currently have or have ever had.

For all conditions that you check yes, write a brief explanation on the Explanation Page. (Please check the appropriate box next to each. Every illness/injury requires a Yes (Y) or No (N) answer)
Year approximate if unsure
Year approximate if unsure
Year approx if unsure
Year approx if unsure
Year approx if unsure
Year approx if unsure
Year approx if unsure
Year approx if unsure
Joint
Year
Year
Year
Procedure
Year
Year
Employee Signature

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Date

MonthDayYear
Date
Employer Representative
Date

MonthDayYear
Date
PAGE 2 OF 6
EXPLANATION PAGE
Please use the space below to explain the illnesses and/or conditions that you checked a Yes (Y) or any other medical conditions that may not be listed on this form. Ask your employer for additional copies of this page if needed.
CONDITION
Year Diagnosed approx
Are you still treating for this condition? Are you taking medication for this condition? Do you have any permanent restrictions for this condition? Brief Explanation:
CONDITION
Year Diagnosed approx
Are you still treating for this condition? Are you taking medication for this condition? Do you have any permanent restrictions for this condition? Brief Explanation:
CONDITION
Year Diagnosed approx
Are you still treating for this condition? Are you taking medication for this condition? Do you have any permanent restrictions for this condition? Brief Explanation:
CONDITION
Year Diagnosed approx
Are you still treating for this condition? Are you taking medication for this condition? Do you have any permanent restrictions for this condition? Brief Explanation:
Employee Signature

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Date

MonthDayYear
Date
Employer Representative
Date

MonthDayYear
Date
PAGE
SIB FORM D (10/17)
Please answer the following questions.

1. Has any doctor ever restricted your activities?YesNo If "Yes," please list the restrictions: Were the restrictions: PermanentTemporary Are your activities currently restricted?No Yes What is the medical condition for which you have restrictions?
If Yes please list the restrictions
Permanent
Temporary
What is the medical condition for which you have restrictions
2. Are you presently treating with a doctor, chiropractor, psychiatrist, psychologist or other health-care provider?YesNo
Please list the medical condition being treated
Doctors Name
Specialty
Doctors Address
3. If you are currently taking prescription medication other than those listed on the Explanation Page, please complete the requested information below.
Medication
Prescribing Doctor
Medication
Prescribing Doctor
4. Have you ever had an on the job accident?YesNo If you answered "YES," please provide the date for each injury and the nature of the injury:
If you answered YES please provide the date for each injury and the nature of the injury

MonthDayYear
Date
How long were you on compensation
Name of Employer
5. Has a doctor recommended a surgical procedure, which has not been completed prior to this date, Yes including but not limited to knee, hip or shoulder replacement?No If you answered YES, please provide:
Recommended surgery
Approximate date of recommendation

MonthDayYear
Date
Doctors Name
Specialty
Doctors Address
Employee Signature

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Date

MonthDayYear
Date
Employer Representative
Date

MonthDayYear
Date
TO BE COMPLETED BY EMPLOYEE
EMPLOYEE WARNING
FAILURE TO ANSWER TRUTHFULLY AND/OR CORRECTLY TO ANY OF THE QUESTIONS ON THIS FORM MAY
RESULT IN A FORFEITURE OF ANY AND ALL WORKERS COMPENSATION BENEFITS UNDER La. R.S. 23:1208.1.

I have completed this form honestly and to the best of my knowledge. I understand that providing false information or omitting pertinent information could result in loss of my workers compensation benefits should I become injured on the job.
Employee Signature

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Date

MonthDayYear
Date
Employee Printed Name
SIB FORM D (10/17)
TO'BE COMPLETED BY EMPLOYER REPRESENTATIVE

PURSUANT TO La. R.S. 23:1208 OF THE LOUISIANA WORKERS' COMPENSATION ACT, IT SHALL BE UNLAWFUL

FOR A PERSON, FOR THE PURPOSE OF OBTAINING OR DEFEATING ANY BENEFIT PAYMENT UNDER THE PROVISIONS OF THIS CHAPTER, EITHER FOR HIMSELF OR FOR ANY OTHER PERSON, TO WILLFULLY MAKE A FALSE STATEMENT OR REPRESENTATION PENALTIES FOR VIOLATIONS INCLUDE IMPRISONMENT, FINES, AND/OR THE FORFEITURE OF BENEFITS.

You must certify the following:

1. That I am an authorized representative of the employer designated to obtain and review the information provided by the employee on this questionnaire; 2. That I have provided the employee with as many copies of the Explanation Page as needed and have confirmed the number of and labeled the pages of this questionnaire;

3. That I have provided assistance to the employee (if requested) in responding to the questions on this questionnaire; 4. That the information sought by this authorization is made on an applicant for employment only after a conditional job offer has been made and accepted, or on a current employee; and 5. That the information obtained in the authorization will NOT be used to discriminate in any manner against the individual who is the subject of this authorization on any basis, in violation of the Americans with Disabilities Act of 1990, 42 U.S.C. $12101, et seq., or any other state or federal law;

6. That if requested, a photocopy of this fully completed and signed form will be provided to the employee.
Employer Representative Signature

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GRANT PARISH SCHOOL BOARD DRUG-FREE WORKPLACE AND EMPLOYEE DRUG TESTING POLICIES

I do hereby certify that I have received and read Grant Parish School Board's Drug-Free Workplace and Employee Drug Testing policies. I understand and agree that compliance with these policies is a condition of employment and if violated, I am subject to disciplinary action up to and including DISCHARGE.
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Witness
DRUG-FREE WORKPLACE
Grant Parish School Board is dedicated to providing and maintaining a drug-free workplace as defined in the Drug-Free Workplace Act of 1988. Unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance in or on School Board property presents serious risks and problems for employees with resulting negative effects on students, co-workers, and the public. The intent of this policy is to prohibit unlawful actions related to illegal controlled substances in the workplace by employees. The Grant Parish School Board recognizes that alcohol abuse and drug use pose a significant threat to the goals of the School Board. The Grant Parish School Board has established policies that balance respect for individuals with the need to maintain an alcohol and drug-free environment, This policy recognizes that employee involvement with alcohol and other drugs can be very disruptive, adversely affect the quality of work and performance of employees, pose serious health risks to users and others, and have a negative impact on productivity and morale. The School Board has no intention of interfering with the private lives of its employees unless involvement with alcohol and other drugs off the job affects job performance or public safety. As a condition of employment, the School Board requires that employees adhere to a strict policy regarding the use and possession of drugs and alcohol. The School Board encourages employees to voluntarily seek help with drug and alcohol problems.
DRUG-FREE WORKPLACE CERTIFICATION
In order for Grant Parish School Board to meet the requirements for certification that are required by the Drug-Free Workplace Act of 1988, 34 CFR Part 84, Subpart F, the School Board shall: 1. Publish this document as a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance is prohibited in the workplace and specific actions will be taken against employees for violation of such prohibition. 2. Establish a drug-free awareness program to inform employees about: A. the dangers of drug abuse in the workplace B. the policy of maintaining a drug-free workplace C. the availability of drug counseling, rehabilitation, and employee assistance program D. the penalties that may be imposed upon employees if drug abuse violations occur in the workplace 3. Make it a requirement that each employee who is engaged by the Grant Parish School Board be given a copy of this policy and sign a document yearly that he/she has read and received this document.

4. Notify all regular employees and substitute employees in the statement required by paragraph (1) that, as a condition of employment, the employee shall:
A. abide by the terms of the statement

B. notify the School Board of any criminal drug statute conviction for violation occurring in the workplace no later than five (5) days after such conviction 5. Notify the appropriate federal agency within ten (10) days after receiving notice under subparagraph (4) (B) from an employee or otherwise receive actual notice of such conviction. 6. Take appropriate personnel action against such an employee up to and including termination, within thirty (30) days of receiving notice under subparagraph (4) (B) with respect to any employee who is so convicted.

7. Any person convicted of a drug-related offense outside of the workplace shall have his/her employment terminated. 8. Make a good faith effort to continue to maintain a drug-free workplace through implementation of the above criteria.

(The term "workplace" for the purpose of this Drug-Free Workplace policy and for certification that Grant Parish School Board maintains a drug-free workplace shall mean any Grant Parish School Board property or any other site used for the performance of work done in connection with employment by the School Board

COVERED WORKERS AND APPLICABILITY

Any individual who conducts business for the School Board, is applying for a position, or is conducting business on the School Board's property is covered by this and other related substance abuse policies. The policy includes, but is not limited to exempt and non-exempt employees. This policy is intended to apply whenever anyone is representing or conducting business for the School Board. Therefore, this policy applies during all working hours, whenever conducting business or representing the School Board, and while on School Board premises.

Substance abuse/alcohol tests may be administered for employees on the following grounds:

1. Pre-employment; 2. Return-to-duty; 3. Reasonable suspicion; 4. Post-accident; 5. Random; 6. As otherwise allowed by law.
2 Returntoduty
1 Preemployment
5 Random
4 Postaccident
Employees found to be under the influence of alcohol or illegal drugs at work shall be immediately removed from their assignments. Continued employment of individuals with problems resulting from the use of alcohol or drugs shall depend on the seriousness of the condition and the employee's willingness to seek and respond to treatment. Any employee found to be selling or distributing unauthorized drugs or alcohol shall be subject to immediate termination.
EMPLOYEE DRUG TESTING -- GENERAL EMPLOYEES
Grant Parish School Board believes in and is committed to providing a safe workplace by establishing policies promoting high standards of health and safety. In keeping with this objective, it is Grant Parish School Board's intent to maintain a drug/alcohol-free workplace and workforce. All employees are expected to report to work in a physical and emotional condition that allows them to perform their assigned tasks in a competent and safe manner. Therefore, the use, abuse, presence in the body or reporting to work under the influence of alcohol, drugs or other impairing substances by an employee is strictly prohibited. These scenarios limit the ability of the user to exercise good judgment, to react properly in unexpected situations or to perform tasks safely and efficiently. They endanger not only that employee, but also coworkers, the public and property. Everyone shares responsibility for maintaining a safe work environment. Employees with drug/alcohol problems are encouraged to seek early assistance from an approved counseling/rehabilitation program. The goal of this policy is to provide a safe, productive and healthful working environment for employees of Grant Parish School Board while maintaining respect for individual privacy rights and confidentiality.
STATEMENT OF POLICY PURPOSES
Grant Parish School Board recognizes the problem of drug/alcohol abuse in today's society. In addition, substance abuse as a serious threat (to the abusing employee, staff, and the public Though employees may be required by a physician to use prescription drugs, abuse of prescribed medications shall be handled the same as the abuse of illegal substances. Therefore, this workplace drug testing policy shall be established to ensure to the extent possible that the work sites operated by the Grant Parish School Board shall have a drug/alcohol-free environment. Objectives of this policy include: 1. To assist in maintaining a safe and healthful working environment for employees of Grant Parish School Board. 2. To maintain a drug/alcohol-free workplace and workforce.

3. To inform employees of the availability of counseling, rehabilitation, and employee assistance programs. 4. To prevent accidental injuries or deaths and to protect property. 5. To minimize absenteeism and tardiness, to improve productivity and to ensure quality workmanship. 6. To protect the reputation of Grant Parish School Board and its employees within the community. 7. To maintain respect for individual privacy rights and confidentiality through fair and reasonable procedures and protocols.
GUIDELINES
GrantCAPS
At any time employees are on School Board premises or on School Board business, the following activities are strictly prohibited: the illegal use of any drug, narcotic or controlled substance; the possession, transit, transfer or purchase of illegal or unauthorized drugs; the use, abuse, presence in the body or reporting to work under the influence of drugs/alcohol or other intoxicants; the sale of illegal or unauthorized drugs or substances or drug-related paraphernalia. Any employee in violation of this policy is subject to disciplinary action, including immediate discharge. Depending on the circumstances, other action, including notification of appropriate law enforcement agencies, may be taken against any employee who violates this policy.

For the purpose of this policy, School Board premises shall encompass all Grant Parish School Board property or any other site used for the performance of work done in connection with employment by the School Board. For the purpose of this policy, employees are on School Board business whenever on duty and under Grant Parish School Board's control, whether at other worksites or during transit to and from those worksites or while in the course and scope of Grant Parish School Board's employment or pay status. For the purpose and application of this policy, employees shall include all full-time, part-time, contract, and temporary workers. This policy equally applies to all employees. Compliance with this policy shall be required as a condition of continued employment for all employees. 3. Drug Classification The prohibitions addressed by this policy pertain to, but are not limited by, the following overview of drugs/alcohol. Their presence, or the presence of any other illegal or unauthorized drug in the employee in any detectable amount (unless stipulated) while working, shall be prohibited. A. Illegal Drugs, Unauthorized Controlled Substances, Look-a-Likes, Inhalants of Abuse, Designer and Synthetic Drugs. These include, but are not limited to, central nervous system stimulants such as cocaine and amphetamines; hallucinogens; PCP or Phencyclidine; narcotic analgesics as found in opium (like morphine and codeine) or opium derivatives (heroin); inhalants from volatile solvents like glue, paint or gasoline or from aerosols like hair sprays, deodorants or insecticides or from anesthetic gases like ether, chloroform or amyl nitrate; cannabis such as found in marijuana, hashish or has oil. B. Unauthorized Use of Intoxicating Beverages. An employee who tests positive during a post-accident; or just cause/post-incident alcohol screening shall be in violation of this policy. C. Prescription Drugs (Legally Controlled Substances) and Off-The-Shelf Medicines. The use of off-the-shelf drugs/medicines or those prescribed by a licensed physician for a given employee is permitted, provided work performance is not affected, under the following conditions: employees must only possess a reasonable amount of medication; employees must not consume prescribed drugs more often than prescribed by their doctor and employees must not allow any other person to consume their prescribed drugs.
4 Circumstances for Workplace Drug Testing
Grant Parish School Board reserves the right in certain circumstances to require employees to submit to drug testing to determine the presence of illegal or unauthorized drugs/alcohol or other substances prohibited by this policy. Each employee so tested shall be required to provide written consent prior to testing. All testing shall be performed with concern for each employee's personal privacy, dignity and confidentiality. The test results shall be disclosed on a need-to-know basis in order to administer the policy or as may be legally required. Substance abuse/alcohol tests may be administered for employees on the following grounds:

A. Pre-employment; B. Return-to-duty; C. Reasonable suspicion; D. Post-accident; E. Random; F. As otherwise allowed by law.
B Returntoduty
E Random
5. Notice of Grounds for Termination or Disciplinary Action for Violations of Workplace Substance Abuse Policy A. Employee Request for Help. No employee's job shall be placed in jeopardy, nor shall any employee be subject to disciplinary action for voluntarily requesting help for alcohol and other drug addictions. However, a request for assistance shall not excuse an employee from a policy violation immediately prior to or while an actual drug screen is being conducted or after the screen has been completed. B. Failure to Comply. Failure to comply with the provisions of this policy, including not submitting to required medical examinations or tests when requested to do so, constitutes a policy violation and shall be considered grounds for disciplinary action. Termination or suspension without pay from employment may occur even for a first offense, except as otherwise provided in this policy.

C. Substance Abuse Violations.

1. Illegal Drug Use. Any employee found in violation of this policy due to the use, abuse, presence in the body or reporting to work under the influence of illegal drugs or the bringing of illegal drugs onto Grant Parish School Board's premises; the use, possession, transit, transfer, storage, concealment, promotion, sale or attempt to sell any form of illegal drugs or substances while on School Board premises or on School Board business, at any time during the hours between the beginning and ending of the employee's work day; or the possession or sale or attempt to sell drug-related paraphernalia shall be subject to disciplinary action, up to and including termination 2. Alcohol Abuse. Any employee who is under the influence of alcoholic beverages (any detectable amount) at any time while on School Board premises, on School Board business or at any time during the hours between the beginning and ending of the employee's work day shall be in violation of this policy and is subject to disciplinary action, up to and including termination.

6. Counseling/Rehabilitation Programs

Employees with drug/alcohol problems shall be encouraged to seek early assistance from an approved counseling/rehabilitation program. Any employee participating in such a program shall be expected to maintain satisfactory job performance while doing so. Confidentiality, in
GrantCAPS
accordance with Grant Parish School Board's policies, shall be followed regarding a rehabilitation program. If an employee must be away from work to receive treatment under a prescribed rehabilitation program, the employee's absences shall be handled according to existing School Board policies regarding sick leave or leave of absence. Employees shall be responsible for all costs associated with such counseling/rehabilitation programs.
DISCIPLINE
Employees found to be under the influence of alcohol or illegal drugs at work shall be immediately removed from their work assignments. Continued employment of individuals with problems resulting from the use of alcohol or drugs shall depend on the seriousness of the condition and the employee's willingness to seek and respond to treatment. Any employee found to be selling or distributing unauthorized drugs or alcohol shall be subject to immediate termination.
Welcome to the Grant Parish School Board's Learning Management System.

Mandatory Training for Ethics, Bullying, Suicide Prevention, and Mandatory Reporting of Child Abuse

STEP 1: Go to https://www.gpsb.org/bus/safepupil/safepupil.htm

STEP 2: Cick "Login to SafePupil". Your SafePupil username and password will bc assigned to you by Ty Melton or by your school administrator. The other two links on the image above has "How To" documents to help you navigate the "Infiniti" website that tracks our training assignments. "Infiniti" and "SafePupil" arc the same thing.

STEP 3: Assignments will appear. Click "Start Class" and then "Not Attempted" to begin the training module. Many of the training modules are located on other websites. Most will require you to create a username and password in order to complete their training. Write down the username and password that you create for future reference. Then watch their videos and follow the instructions until a certificate is earned.

STEP 4: After completing the training module, log back into your SafePupil account and open the same assignment again that you just completed and click the red "next" button at the bottom right of the screen. Follow the prompts so the assignment will show completed in your records. Some of the prompts may include additional questions from the training material. Repeat this same process for each assignment that is assigned to you in your "Classroom" on the SafcPupil platform.

*Note* Ty Melton and/or your school administrator can reset your SafePupil password if needed. They cannot help you with retrieval for usernames/passwords that you created on other websites (examples: Ethics, Jason Foundation or LCWTA It is recommended to save all certificates for your records. The Central Office does not need copies of your certificates.

Contact Information: Ty Melton (Central Office), 318-627-3274 or tmelton@rgpsb.org
Employed From: blanks . Employed To: blank .
Should be Empty:

Substitute/Contracted Labor Application

EMPLOYMENT APPLICATION FOR SUBSTITUTES

GENERAL INFORMATION:

PERSONAL INFORMATION:

GENERAL INFORMATION FOR SUBSTITUTING IN THE CAFETERIA

SUBMIT TO:

____________________________________________________________________________AUTHORIZATION TO DISCLOSE CRIMINAL HISTORY RECORDS INFORMATION

DEPARTMENT OF HOMELAND SECURITY

Privacy Act Statement

PAGE 2 OF 6

EXPLANATION PAGE

PAGE

SIB FORM D (10/17)

TO BE COMPLETED BY EMPLOYEE

EMPLOYEE WARNING

FAILURE TO ANSWER TRUTHFULLY AND/OR CORRECTLY TO ANY OF THE QUESTIONS ON THIS FORM MAY

SIB FORM D (10/17)

DRUG-FREE WORKPLACE

DRUG-FREE WORKPLACE CERTIFICATION

EMPLOYEE DRUG TESTING -- GENERAL EMPLOYEES

STATEMENT OF POLICY PURPOSES

GUIDELINES

DISCIPLINE