instructions for student assistant sign-in

INSTRUCTIONS FOR COMPLETING
STUDENT ASSISTANT NEW HIRE FORMS
A. The name you use to complete any payroll documents MUST match the name on your social security
card.
B. CSUDH STUDENT ASSISTANT HIRING FORM
1.
Part I to be completed by Student:
i.
ii.
iii.
iv.
v.
vi.
vii.
viii.
Date, Social Security, Student ID
Last Name, First Name, Phone #, E-mail (campus)
Check “Home” or “Mailing” address and include address.
Check “Yes” or “No” for current student status. Check Class level.
Previous employment at CSUDH, check “Yes” or “No”
Citizenship: Check the one that applies.
Include emergency contact Name, Phone #, address, and relationship.
Include “Student Signature and Date” certifying you have read your Position Description and
agree to the terms of employment.
**Do not write below Student Signature & Date. Department will complete information below. **
2. Department Use Only. Part II to be completed by Supervisor:
i.
ii.
iii.
iv.
Request to hire the above-named student for the position of (include job title)
Enter Department, Unit, Class, and PeopleSoft Position #
Enter Effective Date (in which student will begin work), Level, Step, & Hourly Rate
Include Supervisor Signature and Date, and Approved Signature (Pres., Vice Pres., Dean, or
Director) and Date.
3. Part III to be completed by Supervisor and Foreign Student Advisor if Student is on an F-1 Visa.
i. Please include required Signatures and date.
C. CSU STUDENT PAYROLL ACTION REQUEST FORM
Section B- Check “New Employee Information” (Must complete sections C thru I, K, L)
Section C- Enter your social security number, last name, and first name and middle initial as it appears
on your social security card.
Section D- Enter your mailing address. This is where your W-2 & Pay check will be sent. If you live on
campus, please use a permanent address.
Section E- Enter your birthdate.
Section F- Enter “M” for Male or “F” for Female.
Section G- “Z” will be pre-filled, since this information is now collected via Campus Solutions effective
07/01/2010.
Section H- Complete Part I, Part II, OR Part III, complete only ONE section.
Section I- Sign your name & date certifying to the accuracy of the information entered on the form.
Section J- Leave it Blank (CSU Representative will sign).
Section K- Designating someone to receive all State warrants (checks) due to you in case of your death.
The person you designate, must be 18 yrs or older. IF YOU MAKE A MISTAKE IN DESIGNEE
NAME, YOU MUST COMPLETE A NEW FORM. (No corrections or white-out)
Section L- Complete Part I OR Part II, DO NOT complete both sections. All State employees that are
U.S citizens must sign the Oath of Allegiance (Part I). Only complete Part II if you are NOT a U.S.
citizen.
**For further detailed instructions on completing form please refer to the back of the page**
updated on 07/31/2013
D. CSU FORM SSA-1945 FORM- (Statement concerning your employment in a job not covered by
social security)
1. Complete top section – Last name, First name, Initial, Campus, & Department (Employee ID may be left
blank)
2. Complete bottom section (I certify...) – Signature, Campus, and Date. (Employer ID may be left blank)
E. VETERAN SELF-IDENTIFICATION FORM
1. Please check all boxes that apply to you. Print and Sign your name, Date, & Department.
F. ACKNOWLEDGEMENT OF MANDATED REPORTER STATUS & LEGAL DUTY TO
REPORT CHILD ABUSE & NEGLECT FORM
1. Please read information printed on the front and back of page. Print name, sign, date, and include
department. (Bottom of back page)
G. I-9 (EMPLOYMENT ELIGIBILITY VERIFICATION)1. “STUDENTS” COMPLETE SECTION 1 ONLY.
i.
ii.
iii.
iv.
v.
vi.
Last name, First name
Address, City/Town, State, Zip Code
Date of Birth
Social Security Number
Telephone Number
Select your status (Citizen, Noncitizen, perm. resident, or alien authorized to work)
1. If the alien authorized to work box is selected, must provide expiration date if applicable. Must
complete item 1 or 2.
vii. Signature of Employee and Date
2. SECTION 2 to be completed by Employer or Authorized Representative (Department)
i. Certification- Include first day of employment, Employer or Authorized Rep signature,
First & Last Name, Date, Title, Business Name (CSUDH)
a. Take copy of required document from List A or one document from List B
& List C (Refer to Lists of Acceptable Documents)
b. SSC is required as a state employee. (Verify and take copy)
3. SECTION 3 to be completed by Payroll Department
i. Re-verification and Rehires
** Do not write below Employee’s Signature and Date
**Please provide the required documents from List A OR from List B & List C.
Refer to “Lists of Acceptable Documents” form.
updated on 07/31/2013
New Student Assistant Hiring Form
PART I
Date: __________________________
Social Security # ________________________
Student ID_____________________________
Name __________________ _____________ ______ Phone No. __________________E-mail_______________
Last
First Name
MI
(Campus)
 Home  Mailing Address:
_________________________
(Street)
__________________
_____
(City)
Currently Enrolled as CSUDH Student:
Yes
No 
Class Level: Freshman _____ Junior ____Sophomore ____
Previous employment at CSU Dominguez Hills?
Citizenship: (check one)
_____________________
(State) (Zip Code)
Senior ____ Graduate ____
Yes  No 
If yes, where? ____________________
U.S. ___ Immigrant _____ Non-immigrant _____
If non-immigrant, type of visa ______________________
Valid From:____________
For emergency, contact: ______________________________________
Name
To:_____________________
______________________
Phone
Address_______________________________________________________________________________
Relationship _____________________________
I certify that I have read my Position Description and agree to the terms of employment. I understand that I will
receive payment only for work performed upon submission of the required pay voucher and that I will be
expected to perform my job duties in a responsible manner. I will not work as a Student Assistant and as a
Work Study simultaneously and will not work more than two jobs simultaneously.
Student’s signature: _________________________________ Date ________________________
Revised July 31, 2013
Page 1 of 2
Name:______________________________________
Student ID#:____________________________________
PART II
Request to hire the above-named student for the position of: _______________________________
Job Title
_________________________________
Department ID
___________________
Effective Date
_________ _________ __________________
Unit
Class
PeopleSoft Pos. #
______________
Level
____________
Step
$________________
Hourly Rate
We certify that we have read, understand, and will abide by the conditions in the current Attendance Reporting
Procedural Manual; certify the availability of funds to pay the employee; and will submit pay vouchers on the
required due dates. We also certify that this student is currently enrolled at California State University,
Dominguez Hills.
_____________________________________
Supervisor
______________________
Date
_____________________________________
Approved (Pres., Vice Pres., Dean, Director)
______________________
Date
PART III
(If student is on an F-1 visa, the supervisor must sign the statement below.)
I certify that this student will not displace a U.S. citizen or permanent resident and may work up to 20 hours per
week during the academic year and full-time during the summer and other vacation periods.
__________________________________________
Supervisor
________________________
Date
(The following certification must be completed by the Foreign Student Advisor.)
I certify that this student is in good academic standing and enrolled in a full course of study.
_____________________________________
Foreign Student Advisor
________________________
Date
Revised July 31, 2013
CSUDH is an Equal Opportunity Employer
Individuals with disabilities requesting accommodations under the Americans with Disabilities Act (ADA)
may contact the Human Resources Department.
Page 2 of 2
Technical Letter
HR/Benefits 2005-05
Attachment A
ST
INFORMATION ABOUT SOCIAL SECURITY FORM SSA-1945
STATEMENT CONCERNING YOUR EMPLOYMENT IN A JOB NOT COVERED BY SOCIAL SECURITY
LEGAL REQUIREMENT
The Social Security Protection Act of 2004 (SSPA), Public Law 108-203, requires State, including the California State University
(CSU), and local government employers to provide a statement to employees hired January 1, 2005, or later, in a job not covered
under Social Security. The statement explains how a pension from that job could affect future Social Security benefits to which
they may become entitled.
CSU FORM SSA-1945, Statement Concerning Your Employment in a Job Not Covered by Social Security, is the document
campuses should use to meet the requirements of the law. CSU FORM SSA-1945 explains the potential effects of two provisions
in the Social Security law for workers who also receive a pension based on their work in a job not covered by Social Security. The
Windfall Elimination Provision can affect the amount of a worker’s Social Security retirement or disability benefit. The
Government Pension Offset Provision can affect a Social Security benefit received as a spouse or an ex-spouse.
In accordance with the Social Security Protection Act of 2004, employers must:
• Give the statement to the employee prior to the start of employment;
• Obtain the employee’s signature on the form; and
• Submit a copy of the signed form to the pension-paying agency, if appropriate.
Social Security will not be setting any additional guidelines concerning the use of this form.
WHO MUST SIGN THE FORM
All new hires who fall into the following categories must complete the form:
• Public Safety employees who participate in the CalPERS public safety retirement plan and do not
pay Social Security taxes;
• Student employees who are exempt from paying social security taxes, including those who do not
contribute to a retirement system;
• Employees who are exempt from paying social security taxes due to non-resident alien
tax status; or
• Part-time, seasonal and temporary employees who participate in a defined contribution plan in
lieu of Social Security (DPA PST Retirement Plan and the UCDC plan) authorized by the
Omnibus Budget and Reconciliation Act (OBRA).
FORM COMPLETION DEADLINE
Employees in above categories must receive, complete and sign the form prior to the start of employment. Please note: an employee
must complete the form each time he or she is newly hired or rehired in a new appointment in one of the above categories.
COMPLETING THE FORM
The designated University representative responsible for disseminating the form must make sure that the form is filled out
completely and includes a signature and date.
DISTRIBUTION OF SIGNED FORM:
For employees eligible for the UCDC plan, please mail form to:
UC HR/Benefits - Records Management
P.O. Box 24570
Oakland, CA 94623-1570
For employees eligible for CalPERS membership, please mail form to:
CalPERS – Form SSA-1945
P.O. Box 942715
Sacramento, CA 94229-2715
Note: Do not mail forms for the DPA PST Plan, as this plan does not meet the criteria of a pension-paying agency.
ADDITIONAL INSTRUCTIONS:
Provide a photocopy of the form to the employee.
Technical Letter
HR/Benefits 2005-05
Attachment B
ST
CSU FORM SSA-1945
STATEMENT CONCERNING YOUR EMPLOYMENT IN A JOB NOT
COVERED BY SOCIAL SECURITY
EMPLOYEE AND CAMPUS INFORMATION
EMPLOYEE NAME (Last, First, Middle Initial)
EMPLOYEE ID #
CAMPUS
DEPARTMENT
Please be advised that your earnings from this position are not covered under Social Security. When you retire, or
if you become disabled, you may receive a pension based on earnings from this position. If you do, and you are also
entitled to a benefit from Social Security based on either your own work or the work of your husband or wife, or former
husband or wife, your pension benefit may affect the amount of the Social Security Benefit you receive. Your Medicare
benefits, however, will not be affected.
Under the Social Security law, there are two (2) ways your Social Security benefit amount may be affected:
1. Windfall Elimination Provision
Under the Windfall Elimination Provision, your Social Security retirement or disability benefit is figured using a
modified formula when you are also entitled to a pension from a job where you did not pay Social Security tax. As a
result, you will receive a lower Social Security benefit than if you were not entitled to a pension from this job.
For example, if you are age 62 in 2005, the maximum monthly reduction in your Social Security benefit as a result of
this provision is $313.50. This amount is updated annually. This provision reduces, but does not totally eliminate, your
Social Security benefit.
2. Government Pension Offset Provision
Under the Government Pension Offset Provision, any Social Security spouse or widow(er) benefit to which you become
entitled will be offset if you also receive a Federal, State, or local government pension based on work where you did not
pay Social Security tax. The offset reduces the amount of your Social Security spouse or widow(er) benefit by two-thirds
(2/3) of the amount of your pension.
For example, if you get a monthly pension of $600 based on earnings that are not covered under Social Security, twothirds of that amount, $400, is used to offset your Social Security spouse or widow(er) benefit. If you are eligible for a
$500 widow(er) benefit, you will receive $100 per month from Social Security ($500-$400 = $100). Even if your
pension is high enough to totally offset your spouse or widow(er) Social Security benefit, you are still eligible for
Medicare at age 65.
FOR ADDITIONAL INFORMATION
For more information, please refer to Social Security Publications “Windfall Elimination Provision,” and
“Government Pension Offset Provision.” These publications, and additional pertinent information, including
information about exceptions to each provision, are available at www.socialsecurity.gov. You may also call toll free at
(800) 772-1213, or the TTY number at (800) 325-0778, or contact your local Social Security Office.
REQUIRED SIGNATURE
I certify that I have received CSU FORM SSA-1945 that contains information about the possible effects of the
Windfall Elimination Provision and the Government Pension Offset Provision on my potential future Social
Security benefits.
SIGNATURE OF EMPLOYEE
DATE
CAMPUS NAME
EMPLOYER ID#
CSU FORM SSA-1945
VETERAN SELF-IDENTIFICATION FORM
(for use by new hires and current employees only)
The California State University (CSU) is a federal contractor subject to the Vietnam Era Veterans Readjustment Assistance Act of 1974 (VEVRAA), as amended, which requires that federal contractors take affirmative action to employ and advance in employment qualified individuals without discrimination based on a covered veteran status. To fulfill statistical reporting and affirmative action monitoring requirements, the CSU invites you to voluntarily identify your veteran status1 by answering the questions below. Submission of this information is voluntary and no adverse consequences will result from either providing this information or declining to provide it. Information you submit will be kept confidential as required under applicable federal and state law. Should you decide not to self‐identify at this time, you may do so at any time in the future. Note: If you are disabled, and need accommodation to perform the job properly and safely, please contact your Human Resources or Faculty Affairs Office to begin an interactive discussion to identify and provide you a reasonable accommodation. Please check all boxes that apply to you: I do not want to identify my veteran status Not a veteran Disabled Veteran Either (1) 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 administrated by the Secretary of Veterans Affairs, or (2) a person who was discharged or released from active duty because of a service‐connected disability. Recently Separated Veteran Any 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. Discharge Date __________________ Armed Forces Service Medal Veteran Any 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 Forces service medal was awarded pursuant to Executive Order 12985 2. (For the current list of military operations for which an Armed Forces service medal was awarded, visit http://www.opm.gov/Veterans/html/vgmedal2.htm.) Other Protected Veteran A veteran who served on active duty in the U.S. military, ground, naval or air service during a war or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense. (For the current list of campaigns and expeditions for which a campaign badge was authorized, visit http://www.opm.gov/Veterans/html/vgmedal2.htm.) Employee Name: ____________________________ Department:_____________________________ Employee Signature: ____________________________ Date:____________________________________ It is the policy of California State University to provide equal employment opportunity without regard to race, color, religion, national origin, ancestry, age, physical disability, mental disability, medical condition, veteran status, marital status, pregnancy, sex, sexual orientation, or gender identity. The CSU administers all personnel actions without regard to any characteristic protected by law and bases all employment decisions on valid job requirements. ______________________ 41 CFR 60‐300 and 41 CFR 61‐300. 61 FR 1209. 1
2
Revised 08/2008 Employment Eligibility Verification
USCIS
Form I-9
Department of Homeland Security
U.S. Citizenship and Immigration Services
OMB No. 1615-0047
Expires 03/31/2016
START HERE. Read instructions carefully before completing this form. The instructions must be available during completion of this form.
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)
Apt. Number
Address (Street Number and Name)
Date of Birth (mm/dd/yyyy)
Middle Initial Other Names Used (if any)
First Name (Given Name)
U.S. Social Security Number
City or Town
State
E-mail Address
Zip Code
Telephone Number
I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in
connection with the completion of this form.
I attest, under penalty of perjury, that I am (check one of the following):
A citizen of the United States
A noncitizen national of the United States (See instructions)
A lawful permanent resident (Alien Registration Number/USCIS Number):
(See instructions)
For aliens authorized to work, provide your Alien Registration Number/USCIS Number OR Form I-94 Admission Number:
1. Alien Registration Number/USCIS Number:
3-D Barcode
Do Not Write in This Space
OR
2. Form I-94 Admission Number:
If you obtained your admission number from CBP in connection with your arrival in the United
States, include the following:
Foreign Passport Number:
Country of Issuance:
Some aliens may write "N/A" on the Foreign Passport Number and Country of Issuance fields. (See instructions)
Signature of Employee:
Date (mm/dd/yyyy):
Preparer and/or Translator Certification (To be completed and signed if Section 1 is prepared by a person other than the
employee.)
I attest, under penalty of perjury, that I have assisted in the completion of this form and that to the best of my knowledge the
information is true and correct.
Signature of Preparer or Translator:
Last Name (Family Name)
Address (Street Number and Name)
Date (mm/dd/yyyy):
First Name (Given Name)
City or Town
State
Zip Code
Employer Completes Next Page
Form I-9 03/08/13 N
Page 7 of 9
Section 2. Employer or Authorized Representative Review and Verification
(Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You
must physically examine one document from List A OR examine a combination of one document from List B and one document from List C as listed on
the "Lists of Acceptable Documents" on the next page of this form. For each document you review, record the following information: document title,
issuing authority, document number, and expiration date, if any.)
Employee Last Name, First Name and Middle Initial from Section 1:
List A
OR
AND
List B
List C
Identity and Employment Authorization
Document Title:
Identity
Document Title:
Employment Authorization
Document Title:
Issuing Authority:
Issuing Authority:
Issuing Authority:
Document Number:
Document Number:
Document Number:
Expiration Date (if any)(mm/dd/yyyy):
Expiration Date (if any)(mm/dd/yyyy):
Expiration Date (if any)(mm/dd/yyyy):
Document Title:
Issuing Authority:
Document Number:
Expiration Date (if any)(mm/dd/yyyy):
3-D Barcode
Do Not Write in This Space
Document Title:
Issuing Authority:
Document Number:
Expiration Date (if any)(mm/dd/yyyy):
Certification
I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee, (2) the
above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the
employee is authorized to work in the United States.
(See instructions for exemptions.)
The employee's first day of employment (mm/dd/yyyy):
Signature of Employer or Authorized Representative
Last Name (Family Name)
Date (mm/dd/yyyy)
First Name (Given Name)
Title of Employer or Authorized Representative
Employer's Business or Organization Name
Employer's Business or Organization Address (Street Number and Name) City or Town
State
Zip Code
Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.)
A. New Name (if applicable) Last Name (Family Name) First Name (Given Name)
Document Title:
Document Number:
Signature of Employer or Authorized Representative:
Date (mm/dd/yyyy):
Form I-9 03/08/13 N
Middle Initial B. Date of Rehire (if applicable) (mm/dd/yyyy):
Print Name of Employer or Authorized Representative:
Page 8 of 9
LISTS OF ACCEPTABLE DOCUMENTS
All documents must be UNEXPIRED
Employees may present one selection from List A
or a combination of one selection from List B and one selection from List C.
LIST A
Documents that Establish
Both Identity and
Employment Authorization
1. U.S. Passport or U.S. Passport Card
2. Permanent Resident Card or Alien
Registration Receipt Card (Form I-551)
3. Foreign passport that contains a
temporary I-551 stamp or temporary
I-551 printed notation on a machinereadable immigrant visa
4. Employment Authorization Document
that contains a photograph (Form
I-766)
5. For a nonimmigrant alien authorized
to work for a specific employer
because of his or her status:
a. Foreign passport; and
b. Form I-94 or Form I-94A that has
the following:
(1) The same name as the passport;
and
(2) An endorsement of the alien's
nonimmigrant status as long as
that period of endorsement has
not yet expired and the
proposed employment is not in
conflict with any restrictions or
limitations identified on the form.
6. Passport from the Federated States of
Micronesia (FSM) or the Republic of
the Marshall Islands (RMI) with Form
I-94 or Form I-94A indicating
nonimmigrant admission under the
Compact of Free Association Between
the United States and the FSM or RMI
LIST B
LIST C
Documents that Establish
Employment Authorization
Documents that Establish
Identity
OR
AND
1. Driver's license or ID card issued by a
State or outlying possession of the
United States provided it contains a
photograph or information such as
name, date of birth, gender, height, eye
color, and address
2. ID card issued by federal, state or local
government agencies or entities,
provided it contains a photograph or
information such as name, date of birth,
gender, height, eye color, and address
3. School ID card with a photograph
4. Voter's registration card
5. U.S. Military card or draft record
1. A Social Security Account Number
card, unless the card
2. Certification of Birth Abroad issued
by the Department of State (Form
FS-545)
3. Certification of Report of Birth
issued by the Department of State
(Form DS-1350)
7. U.S. Coast Guard Merchant Mariner
Card
4. Original or certified copy of birth
certificate issued by a State,
county, municipal authority, or
territory of the United States
bearing an official seal
8. Native American tribal document
5. Native American tribal document
9. Driver's license issued by a Canadian
government authority
6. U.S. Citizen ID Card (Form I-197)
6. Military dependent's ID card
For persons under age 18 who are
unable to present a document
listed above:
10. School record or report card
7. Identification Card for Use of
Resident Citizen in the United
States (Form I-179)
8. Employment authorization
document issued by the
Department of Homeland Security
11. Clinic, doctor, or hospital record
12. Day-care or nursery school record
Illustrations of many of these documents appear in Part 8 of the Handbook for Employers (M-274).
Refer to Section 2 of the instructions, titled "Employer or Authorized Representative Review
and Verification," for more information about acceptable receipts.
Form I-9 03/08/13 N
Page 9 of 9