New Hire CD - Santa Rosa City Schools

Transcription

Welcome to the Santa Rosa City School District
The Santa Rosa City Schools is incredibly rich in its history. Founded originally under the name ‘Courthouse
School District’ in 1858, the first school opened in the Christian Church on 5th Street in 1859. By September, 50
pupils between the ages of 4 and 18 were admitted at the cost of $1 per pupil per month. Today, there is no
tuition for a student to be educated, but the District spends approximately $9200 per pupil/per year.
In 1874, the John C. Fremont School (often referred to as the Fourth Street School) opened as the pride of the
town. At this time, public education stopped at 8th grade. In 1875, the District reorganized to include a high
school and Santa Rosa High School was born. Ten students were part of the first commencement exercise in
1878. The class consisted of eight girls and two boys.
School teachers in the 19th century were subjected to interesting public scrutiny. An annual exam was
administered and results were printed in the local newspaper! Examples
of questions were:
Santa Rosa Classroom in 1895
1. Music: Explain the differences in force indicated by the
following: f pp ff mp.
2. U.S. History: What was the cause of the greatest
excitement during the J. Q. Adams’ administration?
3. Physiology: How would you resuscitate a person asphyxiated by
coal gas?
Today, our District consists of more than 1500 employees who serve over 15,000 students in and around the
City of Santa Rosa.
When we contrast the Santa Rosa classroom seen above in 1895 to the
classroom of today, it is amazing to note the following fact. Students
today are exposed to more media in one day than students in the 1890’s
were exposed to in their entire lives!
With outstanding offerings such as the International Baccalaureate
programs, Advanced Placement, Art Quest and Career Pathways, as
well as targeted educational programs for students who need a more
focused classroom and instructional environment, Santa Rosa City
Schools continues to attract families to our comprehensive school
district.
Lewis School 1923
As a new employee, you are now part of our continuing 150 year mission, to
educate our next generation and prepare them for their future. We welcome
you to our District. Whether you are on the front lines as a Teacher or
Administrator, or are in one of our many support roles, we hope that you find
your experience rich and fulfilling. Welcome to the Santa Rosa City Schools,
where EXCELLENCE IS OUR COMMON GROUND!
Santa Rosa High School 1878
HV Satell/Elem
3555 Parker Hill
Lewis Opportunity
2230-2232 Lomitas
Comstock MS & Cesar
Chavez Language Academy
2750 W. Steele Lane
Grace HS
1702 Fulton
Hidden Valley Elem.
3435 Bonita Vista
Maria Carrillo HS
6975 Montecito
Rincon Valley MS
4650 Badger Rd.
Steele Lane Elem
301 Steele Lane
SR Accelerated
4650 Badger
Piner HS
1700 Fulton Rd.
James Monroe Elem
2567 Marlow Road
Proctor Terrace El
1711 Bryden Ln.
Biella Elementary
2140 Jennings Ave.
Herbert Slater MS
3500 Sonoma Ave.
Santa Rosa MS
500 E. Street
Helen Lehman Elem.
1700 Jennings Ave.
Montgomery HS
1250 Hahman Dr.
Lincoln Elementary
850 W. 9th Street
District Office
211 Ridgway Ave.
French-American
Charter & DHHI
1350 Sonoma Ave
Ridgway HS, Nueva
Vista & Mesa
325 Ridgway
1237 Mendocino
Cook MS
2480 Sebastopol Rd.
Elsie Allen HS
599 Bellevue
Elementary
Middle
SR Arts Charter
756 Humbolt
Midrose HS
597 Bellevue
High
Brook Hill Elem
1850 Vallejo St.
Santa Rosa HS
1235 Mendocino
Luther Burbank Elem
203 A St.
Charter/Small Necessary/Continuation
Santa Rosa City Schools
District Office
Updated July 2014
School
How It Got Its Name
Albert Biella Elementary
Named after the principal who opened Piner High School. He very much loved by staff and
students.
Named after a brook which ran along the side of this school and drained into a pond. There
was also a farm of this name on the property. Behind the school was a hill that was leveled to
put in Highway 12.
Named after a famous horticulturist who wanted to improve quality of plants to increase the
world’s food supply.
Part of this school was originally founded as a partnership between a local hi-tech company
and the Santa Rosa City School District.
Named after a noted author of over 5,000 articles and poems. Many of her biographical
sketches were published in the History of Sonoma County. A long standing member of the
Board of Education.
Named after the 16th President of the US who was born to a Kentucky frontiersman. He
struggled not only to live but to learn. The school had two names before this one, due to
lingering emotions after the Civil War.
Controversy exists as to whether this school was named after the 5th President of the United
States or a rancher in this area who donated the original land for this school.
Named after a prominent citizen who worked as an Express Agent (expediting items on the
railroad). He supported an indigent family which was a common practice. He was the original
owner of the Santa Rosa Paving Company that defined how roads would be built, once mud
was no longer an option.
Named after a street, which had been named after a prominent hops grower/farmer of the
late 1880’s. Santa Rosa was the Hop Capital at this time.
Named after a Superior Court Judge for 35 years. School Board President who oversaw
construction of Santa Rosa High and four elementary schools.
Named after the first principal at Herbert Slater Middle School. It is rumored that he may have
been in line to be the Principal at Cook Middle School when he passed away.
Likely named after a Native American word for the local landscape nearby. This area was
once the site of over 1,000 olive trees.
Named after a city whose co-founder was Julio Carrillo, son of Maria Carrillo and brother-inlaw of General Mariano Vallejo.
Named after a correspondent for the San Francisco Examiner and wrote an article that made
Luther Burbank a household name. He had been a California State Senator and was given
“the key to San Francisco” in 1919.
The school motto is, “A nice alternative”
Built in 1922. The oldest school standing in its original format. The original street, after which
the school was named, is after a local farmer.
Named after a professor of mathematics and explorer, who as a major-general in the Union
Army in the Civil War, was a strong opponent of slavery. He was also a participant in the
Bear Flag Revolt.
Named after a fourth generation Native American Pomo basket weaver, known worldwide for
her beautiful basketry.
Named after a woman known as the “Mother of Santa Rosa” who built one of the greatest
ranchos in Northern California.
Named after the first person from Santa Rosa to be killed in WWII. He was killed at Pearl
Harbor on December 7, 1941.
Named after an early and notorious pioneer family that settled in the area where the school
was built. This family helped found the Baptist Church in Santa Rosa, which was only the 4th
Baptist Church in California.
The 9th oldest High School to be chartered in California. Site of the filming of “Peggy Sue Got
Married.”
Brook Hill Elementary
Luther Burbank Elementary
Hidden Valley & Satellite Elementary
Helen Lehman Elementary
Abraham Lincoln Elementary
James Monroe Elementary
Proctor Terrace Elementary
Steele Lane Elementary
Hilliard Comstock Middle School
Lawrence Cook Middle School
Rincon Valley Middle School
Santa Rosa Middle School
Herbert Slater Middle School
Ridgway High School
Lewis Opportunity
Santa Rosa Arts Charter
(formerly John C. Fremont)
Elsie Allen High School
Maria Carrillo High School
Montgomery High School
Piner High School
Santa Rosa High School
Created by: Cindy Brennan, Director of Human Resources
Demographic Information – New Employee
EMPLOYEE
NAME
Last
First
M.I.
Please List an Emergency Contact Below
NAME OF
EMERGENCY
CONTACT
HOME PHONE
CELL PHONE
RELATIONSHIP OF
EMERGENCY CONTACT
E-MAIL ADDRESS
ADDRESS
Street Address/P.O. Box

City
State
Do you have a permanent disability that would require accommodation in order to successfully perform your job?
Yes
No
Nature of Disability
_______________________________________________________
Federal and State Laws require us to collect and report on the Ethnicity and the Race of our staff members.
Please select your data for both categories below:
Ethnicity: (Select one)
______No, not Hispanic or Latino
______Yes, Hispanic or Latino
Race: (Select one or more)
_____
American Indian or Alaska Native (N)
Native Hawaiian or Other Pacific Islander
Asian (Select from List Below)
_____
Chinese (AC)
_____
Japanese (AJ)
_____
Korean (AK)
_____
Vietnamese (AV)
_____
Asian Indian (AI)
_____
Laotian (AL)
_____
Cambodian (AM)
_____
Filipino (F)
_____
Hmong
_____
Other Asian (AX)
Demographic Form 2015
(Select from List Below)
_____
Hawaiian (PH)
_____
Guamanian (PG)
_____
Samoan (PS)
_____
Tahitian
_____
Other Pacific Islander (PX)
_____
Black or African American (B)
_____
White (W)
CONFIDENTIAL
This form can be used to manually compute your
withholding allowances, or you can electronically
compute them at www.taxes.ca.gov/de4.pdf
EMPLOYEE’S WITHHOLDING ALLOWANCE CERTIFICATE
Type or Print Your Full Name
Your Social Security Number
Home Address (Number and Street or Rural Route)
Filing Status Withholding Allowances
SINGLE or MARRIED (with two or more incomes)
MARRIED (one income)
HEAD OF HOUSEHOLD
City, State, and ZIP Code
1. Number of allowances for Regular Withholding Allowances, Worksheet A
Number of allowances from the Estimated Deductions, Worksheet B
Total Number of Allowances (A + B) when using the California
Withholding Schedules for 2014
OR
2. Additional amount of state income tax to be withheld each pay period (if employer agrees), Worksheet C
OR
3. I certify under penalty of perjury that I am not subject to California withholding. I meet the conditions set forth under
the Service Member Civil Relief Act, as amended by the Military Spouses Residency Relief Act.
(Check box here)

Under the penalties of perjury, I certify that the number of withholding allowances claimed on this certificate does not exceed the
number to which I am entitled or, if claiming exemption from withholding, that I am entitled to claim the exempt status.
Signature
Date
Employer’s Name and Address
California Employer Account Number
942-0544-0
Santa Rosa City Schools 211 Ridgway Avenue
Santa Rosa, CA 95401
cut here
Give the top portion of this page to your employer and keep the remainder for your records.
YOUR CALIFORNIA PERSONAL INCOME TAX MAY BE UNDERWITHHELD IF YOU DO NOT FILE THIS DE 4 FORM.
IF YOU RELY ON THE FEDERAL FORM W-4 FOR YOUR CALIFORNIA WITHHOLDING ALLOWANCES, YOUR CALIFORNIA STATE
PERSONAL INCOME TAX MAY BE UNDERWITHHELD AND YOU MAY OWE MONEY AT THE END OF THE YEAR.
PURPOSE: This certificate, DE 4, is for California Personal Income
Tax (PIT) withholding purposes only. The DE 4 is used to compute
the amount of taxes to be withheld from your wages, by your
employer, to accurately reflect your state tax withholding obligation.
You should complete this form if either:
(1) You claim a different marital status, number of regular allowances,
or different additional dollar amount to be withheld for California PIT
withholding than you claim for federal income tax withholding or,
(2) You claim additional allowances for estimated deductions.
THIS FORM WILL NOT CHANGE YOUR FEDERAL
WITHHOLDING ALLOWANCES.
The federal Form W-4 is applicable for California withholding
purposes if you wish to claim the same marital status, number
of regular allowances, and/or the same additional dollar amount
to be withheld for state and federal purposes. However, federal
tax brackets and withholding methods do not reflect state PIT
withholding tables. If you rely on the number of withholding
allowances you claim on your Form W-4 withholding allowance
DE 4 Rev. 42 (1-14) (INTERNET)
certificate for your state income tax withholding, you may
be significantly underwithheld. This is particularly true if your
household income is derived from more than one source.
CHECK YOUR WITHHOLDING: After your Form W-4
and/or DE 4 takes effect, compare the state income tax withheld
with your estimated total annual tax. For state withholding, use
the worksheets on this form, and for federal withholding use
the Internal Revenue Service (IRS) Publication 919 or federal
withholding calculations.
EXEMPTION FROM WITHHOLDING: If you wish to claim
exempt, complete the federal Form W-4. You may claim exempt
from withholding California income tax if you did not owe
any federal income tax last year and you do not expect to owe
any federal income tax this year. The exemption automatically
expires on February 15 of the next year. If you continue to
qualify for the exempt filing status, a new Form W-4 designating
EXEMPT must be submitted before February 15. If you are not
having federal income tax withheld this year but expect to have a
tax liability next year, the law requires you to give your employer
a new Form W-4 by December 1.
Page 1 of 4
CU
EXEMPTION FROM WITHHOLDING (continued): Under the Service Member Civil Relief Act, as amended by the Military Spouses
Residency Relief Act, you may be exempt from California income tax on your wages if (i) your spouse is a member of the armed forces
present in California in compliance with military orders; (ii) you are present in California solely to be with your spouse; and (iii) you
maintain your domicile in another state. If you claim exemption under this act, check the box on Line 3. You may be required to provide
proof of exemption upon request.
IF YOU NEED MORE DETAILED INFORMATION, SEE THE INSTRUCTIONS THAT CAME WITH YOUR LAST CALIFORNIA
INCOME TAX RETURN OR CALL THE FRANCHISE TAX BOARD (FTB).
IF YOU ARE CALLING FROM WITHIN THE UNITED STATES
800-852-5711 (voice)
800-822-6268 (TTY)
IF YOU ARE CALLING FROM OUTSIDE THE UNITED STATES (Not Toll Free)
916-845-6500
The California Employer’s Guide (DE 44) provides the income tax withholding tables. This publication may be found on the
Employment Development Department (EDD) website at www.edd.ca.gov/Payroll_Taxes/Forms_and_Publications.htm. To assist
you in calculating your tax liability, please visit the Franchise Tax Board website at www.ftb.ca.gov/individuals/index.shtml.
NOTIFICATION: Your employer is required to send a
copy of your DE 4 to the FTB if it meets either of the
following two conditions:
• You claim more than 10 withholding allowances.
• You claim exemption from state or federal income tax
withholding and your employer expects your usual
weekly wages to exceed $200 per week.
IF THE IRS INSTRUCTS YOUR EMPLOYER TO
WITHHOLD FEDERAL INCOME TAX BASED ON
A CERTAIN WITHHOLDING STATUS, YOUR
EMPLOYER IS REQUIRED TO USE THE SAME
WITHHOLDING STATUS FOR STATE INCOME
TAX WITHHOLDING IF YOUR WITHHOLDING
ALLOWANCES FOR STATE PURPOSES MEET THE
REQUIREMENTS LISTED UNDER “NOTIFICATION.”
IF YOU FEEL THAT THE FEDERAL DETERMINATION
IS NOT CORRECT FOR STATE WITHHOLDING
PURPOSES, YOU MAY REQUEST A REVIEW.
To do so, write to:
W-4 Unit
Franchise Tax Board MS F180
P.O. Box 2952
Sacramento, CA 95812-2952
Fax: 916-843-1094
Your letter should contain the basis of your request for
review. You will have the burden of showing that the
federal determination is incorrect for state withholding
purposes. The FTB will limit its review to that issue. The
FTB will notify both you and your employer of its findings.
Your employer is then required to withhold state income
tax as instructed by the FTB. In the event the FTB or the
IRS finds there is no reasonable basis for the number
of withholding exemptions that you claimed on your
Form W-4/DE 4, you may be subject to a penalty.
PENALTY: You may be fined $500 if you file, with no
reasonable basis, a DE 4 that results in less tax being
withheld than is properly allowable. In addition, criminal
penalties apply for willfully supplying false or fraudulent
information or failing to supply information requiring an
increase in withholding. This is provided for by Section
13101 of the California Unemployment Insurance Code.
Page 2 of 4
INSTRUCTIONS — 1 — ALLOWANCES*
When determining your withholding allowances, you must consider
your personal situation:
— Do you claim allowances for dependents or blindness?
— Will you itemize your deductions?
— Do you have more than one income coming into the household?
TWO-EARNER/TWO-JOBS: When earnings are derived from more
than one source, underwithholding may occur. If you have a working
spouse or more than one job, it is best to check the box “SINGLE
or MARRIED (with two or more incomes).” Figure the total number
of allowances you are entitled to claim on all jobs using only one
DE 4 form. Claim allowances with one employer. Do not claim the
same allowances with more than one employer. Your withholding
will usually be most accurate when all allowances are claimed
on the DE 4 or Form W-4 filed for the highest paying job and zero
allowances are claimed for the others.
WORKSHEET A
MARRIED BUT NOT LIVING WITH YOUR SPOUSE: You may
check the “Head of Household” marital status box if you meet all
of the following tests:
(1) Your spouse will not live with you at any time during the year;
(2) You will furnish over half of the cost of maintaining a home
for the entire year for yourself and your child or stepchild who
qualifies as your dependent; and
(3) You will file a separate return for the year.
HEAD OF HOUSEHOLD: To qualify, you must be unmarried or
legally separated from your spouse and pay more than 50% of the
costs of maintaining a home for the entire year for yourself and your
dependent(s) or other qualifying individuals. Cost of maintaining the
home includes such items as rent, property insurance, property taxes,
mortgage interest, repairs, utilities, and cost of food. It does not include
the individual’s personal expenses or any amount which represents value
of services performed by a member of the household of the taxpayer.
REGULAR WITHHOLDING ALLOWANCES
.......................................
Allowance for your spouse (if not separately claimed by your spouse) — enter 1 . . . . . . . . . . . . . . .
Allowance for blindness — yourself — enter 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Allowance for blindness — your spouse (if not separately claimed by your spouse) — enter 1 . . . . . . . .
Allowance(s) for dependent(s) — do not include yourself or your spouse . . . . . . . . . . . . . . . . . . .
Total — add lines (A) through (E) above . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(A) Allowance for yourself — enter 1
(A)
(B)
(B)
(C)
(D)
(E)
(F)
(C)
(D)
(E)
(F)
INSTRUCTIONS — 2 — ADDITIONAL WITHHOLDING ALLOWANCES
If you expect to itemize deductions on your California income tax return, you can claim additional withholding allowances. Use Worksheet B to
determine whether your expected estimated deductions may entitle you to claim one or more additional withholding allowances. Use last year’s
FTB Form 540 as a model to calculate this year’s withholding amounts.
Do not include deferred compensation, qualified pension payments, or flexible benefits, etc., that are deducted from your gross pay but are not
taxed on this worksheet.
You may reduce the amount of tax withheld from your wages by claiming one additional withholding allowance for each $1,000, or fraction of
$1,000, by which you expect your estimated deductions for the year to exceed your allowable standard deduction.
WORKSHEET B
ESTIMATED DEDUCTIONS
1. Enter an estimate of your itemized deductions for California taxes for this tax year as listed in the
schedules in the FTB Form 540 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.....
1. __________________________
2. Enter $7,812 if married filing joint with two or more allowances, unmarried head of household, or
qualifying widow(er) with dependent(s) or $3,906 if single or married filing separately, dual income
married, or married with multiple employers . . . . . . . . . . . . . . . . . . . . . . . . . . . .
–
2. __________________________
3.
=
3. __________________________
+
4. __________________________
=
5. __________________________
–
6. __________________________
=
7. __________________________
4.
5.
6.
....
Subtract line 2 from line 1, enter difference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Enter an estimate of your adjustments to income (alimony payments, IRA deposits) . . . . . . . . . . . .
Add line 4 to line 3, enter sum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Enter an estimate of your nonwage income (dividends, interest income, alimony receipts) . . . . . . . . .
7. If line 5 is greater than line 6 (if less, see below);
Subtract line 6 from line 5, enter difference . .
8.
..............................
Divide the amount on line 7 by $1,000, round any fraction to the nearest whole number . . . . . . . . .
Enter this number on line 1 of the DE 4. Complete Worksheet C, if needed.
9. If line 6 is greater than line 5;
Enter amount from line 6 (nonwage income)
10.
11.
................................
Enter amount from line 5 (deductions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Subtract line 10 from line 9, enter difference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Complete Worksheet C
8. __________________________
9. __________________________
10. __________________________
11. __________________________
*Wages paid to registered domestic partners will be treated the same for state income tax purposes as wages paid to spouses for California Personal
Income Tax (PIT) withholding and PIT wages. This law does not impact federal income tax law. A registered domestic partner means an individual partner
in a domestic partner relationship within the meaning of Section 297 of the Family Code. For more information, please call our Taxpayer Assistance Center
at 888-745-3886.
Page 3 of 4
WORKSHEET C
TAX WITHHOLDING AND ESTIMATED TAX
.................................
Enter estimate of nonwage income (line 6 of Worksheet B) . . . . . . . . . . . . . . . . . . . . . . . . . . .
Add line 1 and line 2. Enter sum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Enter itemized deductions or standard deduction (line 1 or 2 of Worksheet B, whichever is largest) . . . . . .
Enter adjustments to income (line 4 of Worksheet B) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Add line 4 and line 5. Enter sum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Subtract line 6 from line 3. Enter difference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Figure your tax liability for the amount on line 7 by using the 2014 tax rate schedules below . . . . . . . . .
Enter personal exemptions (line F of Worksheet A x $116.60) . . . . . . . . . . . . . . . . . . . . . . . . .
Subtract line 9 from line 8. Enter difference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Enter any tax credits. (See FTB Form 540) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Subtract line 11 from line 10. Enter difference. This is your total tax liability . . . . . . . . . . . . . . . . . .
1. Enter estimate of total wages for tax year 2014
1.
2.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13. Calculate the tax withheld and estimated to be withheld during 2014. Contact your employer to
request the amount that will be withheld on your wages based on the marital status and number of
withholding allowances you will claim for 2014. Multiply the estimated amount to be withheld by
the number of pay periods left in the year. Add the total to the amount already withheld for 2014 .
......
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14. Subtract line 13 from line 12. Enter difference. If this is less than zero, you do not need to have additional
taxes withheld . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
14.
15.
15.
..
Divide line 14 by the number of pay periods remaining in the year. Enter this figure on line 2 of the DE 4 . . .
NOTE: Your employer is not required to withhold the additional amount requested on line 2 of your DE 4. If your employer does not
agree to withhold the additional amount, you may increase your withholdings as much as possible by using the “single” status with “zero”
allowances. If the amount withheld still results in an underpayment of state income taxes, you may need to file quarterly estimates on
Form 540-ES with the FTB to avoid a penalty.
THESE TABLES ARE FOR CALCULATING WORKSHEET C AND FOR 2014 ONLY
SINGLE OR MARRIED WITH DUAL EMPLOYERS
IF THE TAXABLE INCOME IS
OVER
$0
$7,582
$17,976
$28,371
$39,384
$49,774
$254,250
$305,100
$508,500
$1,000,000
BUT NOT
OVER
$7,582 ...
$17,976 ...
$28,371 ...
$39,384 ...
$49,774 ...
$254,250 ...
$305,100 ...
$508,500 ...
$1,000,000 ...
and over
MARRIED FILING JOINT OR QUALIFYING WIDOW(ER) TAXPAYERS
COMPUTED TAX IS
OF AMOUNT
OVER . . .
PLUS*
OVER
1.100%
$0
$0.00
2.200%
$7,582
$83.40
4.400%
$17,976
$312.07
6.600%
$28,371
$769.45
8.800%
$39,384
$1,496.31
10.230%
$49,774
$2,410.63
11.330% $254,250 $23,328.52
12.430% $305,100 $29,089.83
13.530% $508,500 $54,372.45
14.630% $1,000,000 $120,872.40
$0
$15,164
$35,952
$56,742
$78,768
$99,548
$508,500
$610,200
$1,000,000
$1,017,000
BUT NOT
OVER
$15,164 ...
$35,952 ...
$56,742 ...
$78,768 ...
$99,584 ...
$508,500 ...
$610,200 ...
$1,000,000 ...
$1,017,000 ...
and over
COMPUTED TAX IS
OF AMOUNT
OVER . . .
PLUS*
1.100%
$0
$0.00
2.200%
$15,164
$166.80
4.400%
$35,952
$624.14
6.600%
$56,742
$1,538.90
8.800%
$78,768
$2,992.62
10.230%
$99,548
$4,821.26
11.330% $508,500 $46,657.05
12.430% $610,200 $58,179.66
13.530% $1,000,000 $106,631.80
14.630% $1,017,000 $108,931.90
UNMARRIED HEAD OF HOUSEHOLD TAXPAYERS
OVER
$0
$15,174
$35,952
$46,346
$57,359
$67,751
$345,780
$414,936
$691,560
$1,000,000
BUT NOT
OVER
$15,174 ...
$35,952 ...
$46,346 ...
$57,359 ...
$67,751 ...
$345,780 ...
$414,936 ...
$691,560 ...
$1,000,000 ...
and over
COMPUTED TAX IS
OF AMOUNT
OVER . . .
PLUS*
1.100%
$0
$0.00
2.200%
$15,174
$166.91
4.400%
$35,952
$624.03
6.600%
$46,346
$1,081.37
8.800%
$57,359
$1,808.23
10.230%
$67,751
$2,722.73
11.330% $345,780 $31,165.10
12.430% $414,936 $39,000.47
13.530% $691,560 $73,384.83
14.630% $1,000,000 $115,116.76
IF YOU NEED MORE DETAILED INFORMATION, SEE THE INSTRUCTIONS THAT
CAME WITH YOUR LAST CALIFORNIA INCOME TAX RETURN OR CALL THE FTB:
IF YOU ARE CALLING FROM WITHIN THE UNITED STATES
800-852-5711 (voice)
800-822-6268 (TTY)
IF YOU ARE CALLING FROM OUTSIDE THE UNITED STATES
(Not Toll Free)
916-845-6500
*marginal tax
The DE 4 information is collected for purposes of administering the PIT law and under the authority of Title 22, California Code of
Regulations, and the Revenue and Taxation Code, including Section 18624. The Information Practices Act of 1977 requires that individuals
be notified of how information they provide may be used. Further information is contained in the instructions
that came with your last California income tax return.
Page 4 of 4
Form W-4 (2016)
Purpose. Complete Form W-4 so that your employer
can withhold the correct federal income tax from your
pay. Consider completing a new Form W-4 each year
and when your personal or financial situation changes.
Exemption from withholding. If you are exempt,
complete only lines 1, 2, 3, 4, and 7 and sign the form
to validate it. Your exemption for 2016 expires
February 15, 2017. See Pub. 505, Tax Withholding
and Estimated Tax.
Note: If another person can claim you as a dependent
on his or her tax return, you cannot claim exemption
from withholding if your income exceeds $1,050 and
includes more than $350 of unearned income (for
example, interest and dividends).
Exceptions. An employee may be able to claim
exemption from withholding even if the employee is a
dependent, if the employee:
• Is age 65 or older,
• Is blind, or
• Will claim adjustments to income; tax credits; or
itemized deductions, on his or her tax return.
The exceptions do not apply to supplemental wages
greater than $1,000,000.
Basic instructions. If you are not exempt, complete
the Personal Allowances Worksheet below. The
worksheets on page 2 further adjust your
withholding allowances based on itemized
deductions, certain credits, adjustments to income,
or two-earners/multiple jobs situations.
Complete all worksheets that apply. However, you
may claim fewer (or zero) allowances. For regular
wages, withholding must be based on allowances
you claimed and may not be a flat amount or
percentage of wages.
Head of household. Generally, you can claim head
of household filing status on your tax return only if
you are unmarried and pay more than 50% of the
costs of keeping up a home for yourself and your
dependent(s) or other qualifying individuals. See
Pub. 501, Exemptions, Standard Deduction, and
Filing Information, for information.
Tax credits. You can take projected tax credits into account
in figuring your allowable number of withholding allowances.
Credits for child or dependent care expenses and the child
tax credit may be claimed using the Personal Allowances
Worksheet below. See Pub. 505 for information on
converting your other credits into withholding allowances.
Nonwage income. If you have a large amount of
nonwage income, such as interest or dividends,
consider making estimated tax payments using Form
1040-ES, Estimated Tax for Individuals. Otherwise, you
may owe additional tax. If you have pension or annuity
income, see Pub. 505 to find out if you should adjust
your withholding on Form W-4 or W-4P.
Two earners or multiple jobs. If you have a
working spouse or more than one job, figure the
total number of allowances you are entitled to claim
on all jobs using worksheets from only one Form
W-4. Your withholding usually will be most accurate
when all allowances are claimed on the Form W-4
for the highest paying job and zero allowances are
claimed on the others. See Pub. 505 for details.
Nonresident alien. If you are a nonresident alien,
see Notice 1392, Supplemental Form W-4
Instructions for Nonresident Aliens, before
completing this form.
Check your withholding. After your Form W-4 takes
effect, use Pub. 505 to see how the amount you are
having withheld compares to your projected total tax
for 2016. See Pub. 505, especially if your earnings
exceed $130,000 (Single) or $180,000 (Married).
Future developments. Information about any future
developments affecting Form W-4 (such as legislation
enacted after we release it) will be posted at www.irs.gov/w4.
Personal Allowances Worksheet (Keep for your records.)
A
Enter “1” for yourself if no one else can claim you as a dependent . . . . . . . . . . . . . . . . . .
A
• You are single and have only one job; or
Enter “1” if:
B
• You are married, have only one job, and your spouse does not work; or
. . .
• Your wages from a second job or your spouse’s wages (or the total of both) are $1,500 or less.
Enter “1” for your spouse. But, you may choose to enter “-0-” if you are married and have either a working spouse or more
than one job. (Entering “-0-” may help you avoid having too little tax withheld.) . . . . . . . . . . . . . .
C
Enter number of dependents (other than your spouse or yourself) you will claim on your tax return . . . . . . . .
D
Enter “1” if you will file as head of household on your tax return (see conditions under Head of household above) . .
E
Enter “1” if you have at least $2,000 of child or dependent care expenses for which you plan to claim a credit
. . .
F
(Note: Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for details.)
Child Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information.
• If your total income will be less than $70,000 ($100,000 if married), enter “2” for each eligible child; then less “1” if you
have two to four eligible children or less “2” if you have five or more eligible children.
G
• If your total income will be between $70,000 and $84,000 ($100,000 and $119,000 if married), enter “1” for each eligible child . .
▶
Add lines A through G and enter total here. (Note: This may be different from the number of exemptions you claim on your tax return.)
H
{
B
C
D
E
F
G
H
For accuracy,
complete all
worksheets
that apply.
}
{
• If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions
and Adjustments Worksheet on page 2.
• If you are single and have more than one job or are married and you and your spouse both work and the combined
earnings from all jobs exceed $50,000 ($20,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2
to avoid having too little tax withheld.
• If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W-4 below.
Separate here and give Form W-4 to your employer. Keep the top part for your records.
Form
W-4
Department of the Treasury
Internal Revenue Service
1
Employee's Withholding Allowance Certificate
OMB No. 1545-0074
▶ Whether you are entitled to claim a certain number of allowances or exemption from withholding is
subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.
Your first name and middle initial
2
Last name
Home address (number and street or rural route)
3
Single
Married
2016
Your social security number
Married, but withhold at higher Single rate.
Note: If married, but legally separated, or spouse is a nonresident alien, check the “Single” box.
City or town, state, and ZIP code
4 If your last name differs from that shown on your social security card,
check here. You must call 1-800-772-1213 for a replacement card. ▶
5
6
7
Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2)
5
Additional amount, if any, you want withheld from each paycheck . . . . . . . . . . . . . .
6 $
I claim exemption from withholding for 2016, and I certify that I meet both of the following conditions for exemption.
• Last year I had a right to a refund of all federal income tax withheld because I had no tax liability, and
• This year I expect a refund of all federal income tax withheld because I expect to have no tax liability.
If you meet both conditions, write “Exempt” here . . . . . . . . . . . . . . . ▶ 7
Under penalties of perjury, I declare that I have examined this certificate and, to the best of my knowledge and belief, it is true, correct, and complete.
Employee’s signature
(This form is not valid unless you sign it.)
8
Date ▶
▶
Employer’s name and address (Employer: Complete lines 8 and 10 only if sending to the IRS.)
Santa Rosa City Schools, 211 Ridgway Ave, Santa Rosa, CA. 95401
For Privacy Act and Paperwork Reduction Act Notice, see page 2.
9 Office code (optional)
10
Employer identification number (EIN)
68-0180139
Cat. No. 10220Q
Form W-4 (2016)
Page 2
Form W-4 (2016)
Deductions and Adjustments Worksheet
Note: Use this worksheet only if you plan to itemize deductions or claim certain credits or adjustments to income.
Enter an estimate of your 2016 itemized deductions. These include qualifying home mortgage interest, charitable contributions, state
1
and local taxes, medical expenses in excess of 10% (7.5% if either you or your spouse was born before January 2, 1952) of your
income, and miscellaneous deductions. For 2016, you may have to reduce your itemized deductions if your income is over $311,300
and you are married filing jointly or are a qualifying widow(er); $285,350 if you are head of household; $259,400 if you are single and
not head of household or a qualifying widow(er); or $155,650 if you are married filing separately. See Pub. 505 for details . . .
$12,600 if married filing jointly or qualifying widow(er)
2
Enter:
$9,300 if head of household
. . . . . . . . . . .
$6,300 if single or married filing separately
3
Subtract line 2 from line 1. If zero or less, enter “-0-” . . . . . . . . . . . . . . . .
4
Enter an estimate of your 2016 adjustments to income and any additional standard deduction (see Pub. 505)
Add lines 3 and 4 and enter the total. (Include any amount for credits from the Converting Credits to
5
Withholding Allowances for 2016 Form W-4 worksheet in Pub. 505.) . . . . . . . . . . . .
{
6
7
8
9
10
}
Enter an estimate of your 2016 nonwage income (such as dividends or interest) . . . . . . . .
Subtract line 6 from line 5. If zero or less, enter “-0-” . . . . . . . . . . . . . . . .
Divide the amount on line 7 by $4,050 and enter the result here. Drop any fraction . . . . . . .
Enter the number from the Personal Allowances Worksheet, line H, page 1 . . . . . . . . .
Add lines 8 and 9 and enter the total here. If you plan to use the Two-Earners/Multiple Jobs Worksheet,
also enter this total on line 1 below. Otherwise, stop here and enter this total on Form W-4, line 5, page 1
1
$
2
$
3
4
$
$
5
6
7
8
9
$
$
$
10
Two-Earners/Multiple Jobs Worksheet (See Two earners or multiple jobs on page 1.)
Note: Use this worksheet only if the instructions under line H on page 1 direct you here.
Enter the number from line H, page 1 (or from line 10 above if you used the Deductions and Adjustments Worksheet)
1
2
Find the number in Table 1 below that applies to the LOWEST paying job and enter it here. However, if
you are married filing jointly and wages from the highest paying job are $65,000 or less, do not enter more
than “3” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3
If line 1 is more than or equal to line 2, subtract line 2 from line 1. Enter the result here (if zero, enter
“-0-”) and on Form W-4, line 5, page 1. Do not use the rest of this worksheet . . . . . . . . .
1
2
3
Note: If line 1 is less than line 2, enter “-0-” on Form W-4, line 5, page 1. Complete lines 4 through 9 below to
figure the additional withholding amount necessary to avoid a year-end tax bill.
4
5
6
7
8
9
Enter the number from line 2 of this worksheet . . . . . . . . . .
4
Enter the number from line 1 of this worksheet . . . . . . . . . .
5
Subtract line 5 from line 4 . . . . . . . . . . . . . . . . . . . . . . . . .
Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here . . . .
Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed . .
Divide line 8 by the number of pay periods remaining in 2016. For example, divide by 25 if you are paid every two
weeks and you complete this form on a date in January when there are 25 pay periods remaining in 2016. Enter
the result here and on Form W-4, line 6, page 1. This is the additional amount to be withheld from each paycheck
Table 1
Married Filing Jointly
6
7
8
$
$
9
$
Table 2
All Others
Married Filing Jointly
If wages from LOWEST
paying job are—
Enter on
line 2 above
If wages from LOWEST
paying job are—
Enter on
line 2 above
$0 - $6,000
6,001 - 14,000
14,001 - 25,000
25,001 - 27,000
27,001 - 35,000
35,001 - 44,000
44,001 - 55,000
55,001 - 65,000
65,001 - 75,000
75,001 - 80,000
80,001 - 100,000
100,001 - 115,000
115,001 - 130,000
130,001 - 140,000
140,001 - 150,000
150,001 and over
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
$0 - $9,000
9,001 - 17,000
17,001 - 26,000
26,001 - 34,000
34,001 - 44,000
44,001 - 75,000
75,001 - 85,000
85,001 - 110,000
110,001 - 125,000
125,001 - 140,000
140,001 and over
0
1
2
3
4
5
6
7
8
9
10
Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this
form to carry out the Internal Revenue laws of the United States. Internal Revenue Code
sections 3402(f)(2) and 6109 and their regulations require you to provide this information; your
employer uses it to determine your federal income tax withholding. Failure to provide a
properly completed form will result in your being treated as a single person who claims no
withholding allowances; providing fraudulent information may subject you to penalties. Routine
uses of this information include giving it to the Department of Justice for civil and criminal
litigation; to cities, states, the District of Columbia, and U.S. commonwealths and possessions
for use in administering their tax laws; and to the Department of Health and Human Services
for use in the National Directory of New Hires. We may also disclose this information to other
countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal
laws, or to federal law enforcement and intelligence agencies to combat terrorism.
If wages from HIGHEST
paying job are—
$0 - $75,000
75,001 - 135,000
135,001 - 205,000
205,001 - 360,000
360,001 - 405,000
405,001 and over
Enter on
line 7 above
$610
1,010
1,130
1,340
1,420
1,600
All Others
If wages from HIGHEST
paying job are—
$0 - $38,000
38,001 - 85,000
85,001 - 185,000
185,001 - 400,000
400,001 and over
Enter on
line 7 above
$610
1,010
1,130
1,340
1,600
You are not required to provide the information requested on a form that is subject to the
Paperwork Reduction Act unless the form displays a valid OMB control number. Books or
records relating to a form or its instructions must be retained as long as their contents may
become material in the administration of any Internal Revenue law. Generally, tax returns and
return information are confidential, as required by Code section 6103.
The average time and expenses required to complete and file this form will vary depending
on individual circumstances. For estimated averages, see the instructions for your income tax
return.
If you have suggestions for making this form simpler, we would be happy to hear from you.
See the instructions for your income tax return.
SANTA ROSA CITY SCHOOLS
HUMAN RESOURCES RETIREMENT INFORMATION
Date: ____________
Name: _______________________________________________________________________________________
First
Middle
Last
Maiden
Former
Address: ____________________________________
Female [ ] Male [ ]
____________________________________________
Birthdate: ____________________
Telephone : __________________________________
Soc. Sec. #: __________________
--------------------------------------------------------------------------------
CLASSIFIED EMPLOYEES
1. Are you currently a member of Public Employees Retirement System (PERS)?
Yes [ ]
No [ ]
Are you currently a member of State Teachers Retirement System (STRS) ?
Yes [ ]
No [ ]
If YES, in what county? ___________________________ from ___________________ to ___________________
If NO:
a. Are you retired and receiving a monthly allowance from the PERS or STRS?
Yes [ ]
No [ ]
b. Have you withdrawn contributions:
Yes [ ]
No [ ]
Yes [ ]
No [ ]
Yes [ ]
No [ ]
date: ________________
If yes, from what county: _____________________________
c. Have you re-deposited contributions?
date: _________________
2. Are you currently a member of any other public agency retirement system?
--------------------------------------------------------------------------------
CERTIFICATED EMPLOYEES
1. Are you currently a member of State Teachers Retirement System (STRS)?
Are you currently a member of Public Employees Retirement System (PERS)?
Yes [ ]
No [ ]
Yes [ ]
No [ ]
If YES, in what county: _____________________ from __________________ to ___________________________
If NO,
a. Are you retired and receiving a monthly allowance from the STRS or PERS?
Yes [ ]
No [ ]
b. Have you withdrawn contributions?
Yes [ ]
No [ ]
Yes [ ]
No [ ]
2. Are you currently a member of any other public agency retirement system?
Yes [ ]
No [ ]
3. Have you ever taught in California?
Yes [ ]
No [ ]
c. Have you re-deposited contributions?
If YES:
a. When was the first date of service?
b. Where was last service?
date: _________________
date: _________________
_________________________________
month/year
_________________________________
county
4. If currently under a contract elsewhere, what is the percentage?
________%
-------------------------------------------------------------------------------(for Human Resources use only)
Date of hire: _________________________
(retirement info 11-14-07)
Indicate Service: ___________________________________
FT, PT, SUB; CERT, CLASS
California Public Employees’ Retirement System
Customer Account Services Division
Retirement Account Services Section
P.O. Box 942709
Sacramento, CA 94229-2709
TTY: (877) 249-7442
888 CalPERS (or 888-225-7377) phone • (916) 795-3005 fax
www.calpers.ca.gov
MEMBER RECIPROCAL SELF-CERTIFICATION FORM
Complete the following information and return this form to your Personnel Office within 10 business days:
EMPLOYEE NAME: ______________________________________________________________________
(Last)
(First)
(Middle)
SOCIAL SECURITY NUMBER OR CalPERS ID NUMBER: ______________________________________
NAME OF MOST RECENT RECIPROCAL RETIREMENT SYSTEM: _______________________________
PERMANENT SEPARATION DATE FROM MOST RECENT RECIPROCAL RETIREMENT SYSTEM: _____
_______________________________________________________________________________________
FIRST MEMBERSHIP DATE IN ANY PRIOR CALIFORNIA PUBLIC RETIREMENT SYSTEM THAT IS
SUBJECT TO RECIPROCITY: ______________________________________________________________
(Check the applicable statement)
_____
I have not been a member of another California Public Retirement System within the last six months.
_____
I was a member and am retired from the _______________________________ Retirement System and
subsequently became employed by a CalPERS-covered employer.
_____
I was a member of the _____________________________ Retirement System and became employed by
a CalPERS-covered employer within six months after separating from employment with the previous
reciprocal retirement system.
I understand that by accepting employment in a specific retirement system, I am subject to the applicable laws and
regulations of that system. I also understand that completing this form does not constitute a request to establish
reciprocity. I must complete and return the “Election to Coordinate Retirement When Changing Retirement
Systems,” (PERS-MSD-255) Form to CalPERS.
I hereby certify that the foregoing information is true and correct and any information found to be incorrect may
require corrections to my account in the California Public Employees’ Retirement System including, but not limited
to, my date of membership. CalPERS may make any necessary corrections to my account to ensure I am properly
enrolled and eligible to receive the correct retirement benefits.
______________________________________________
SIGNATURE OF EMPLOYEE
______________________________
DATE
TO BE COMPLETED BY EMPLOYER ONLY:
NAME OF CalPERS AGENCY:
CalPERS BUSINESS PARTNER ID:
______________________________________________
_______________________________________
CalPERS MEMBERSHIP ELIGIBILITY DATE
WITH YOUR AGENCY:
ORIGINAL HIRE DATE WITH YOUR AGENCY:
______________________________________________
_______________________________________
DATE MEMBER RECIPROCAL SELF-CERTIFICATION FORM GIVEN TO EMPLOYEE: ________________
DATE MEMBER RECIPROCAL SELF-CERTIFICATION FORM RECEIVED FROM EMPLOYEE: __________
______________________________________
(Please Print) DESIGNEE OF EMPLOYER
_________________
TITLE
_____________
DATE
________________________________________________________________________________________
DESIGNEE’S SIGNATURE
PERS-CASD-801 (12/12)
MEMBER RECIPROCAL SELF-CERTIFICATION FORM
Instructions
Reciprocity is an agreement among public retirement systems to allow members to separate from one
public employer and enter into employment with another public employer within a specific time limit
without losing some valuable retirement and related benefit rights.
The Public Employees’ Pension Reform Act of 2013 (PEPRA), effective January 1, 2013, requires a
CalPERS covered employer to determine the applicable PEPRA retirement benefit formula for new
employees. CalPERS refers to all members that do not fit within the PEPRA definition of a “new
member1” as “classic members” who are subject to the Public Employees’ Retirement Law (PERL).
PEPRA allows a member after January 1, 2013, to retain his/her classic member retirement benefit
status if the member continues his/her membership in all previous California Public Retirement
System(s) by leaving his/her service credit and contributions (if any) on deposit, and the member
enters into employment that results in CalPERS membership within six months of separating from the
most recent California Public Retirement System. Classic member status also requires the
membership date to be on or before December 31, 2012, in a California Public Retirement System in
which reciprocity is established.
EMPLOYER INSTRUCTIONS
1. Employers must provide the Member Reciprocal Self-Certification Form to all new employees
upon hire.
2. Employers must sign and date the Member Reciprocal Self-Certification Form on the date the form
is given to the employee.
3. Upon receipt of the completed Member Reciprocal Self-Certification Form, the employer will enter
the date the employee returns the form.
4. The employer will enroll the new employee into CalPERS membership through my|CalPERS
based on the information provided on the Member Reciprocal Self-Certification Form.
my|CalPERS will determine the proper retirement benefit formula. If an employer believes the
retirement benefit formula is incorrect, employers may contact CalPERS at 1-888-225-7377.
5. It is the responsibility of the employer to retain the completed Member Reciprocal Self-Certification
Form in the employee’s employment records for auditing purposes.
1
A new member is defined in PEPRA as any of the following:
• A new hire who is brought into CalPERS membership for the first time on or after January 1, 2013, who has
no prior membership in any California Public Retirement System.
• A new hire who is brought into CalPERS membership for the first time on or after January 1, 2013, who has
a break in service of greater than six months with another California Public Retirement System that is
subject to Reciprocity.
• A member who first established CalPERS membership prior to January 1, 2013, who is rehired by a
different CalPERS employer after a break in service of greater than six months.
PERS-CASD-801 (12/12)
EMPLOYEE INSTRUCTIONS
1. The Member Reciprocal Self-Certification Form will assist your employer in determining whether
you are considered a new member or a classic member under PEPRA.
2. As the new employee, you must complete, sign and date the Member Reciprocal Self-Certification
Form to self-certify your most recent service in a reciprocal California Public Retirement System,
your first membership date in any previous California Public Retirement System and your
permanent separation date from the most recent California Public Retirement System; or indicate
that you are not a member of any California Public Retirement System that is subject to
Reciprocity.
3. As the new employee, you must return the Member Reciprocal Self-Certification Form to your
Personnel Office within 10 business days of employment.
4. The completion of the Member Reciprocal Self-Certification Form does not establish reciprocity
and is not a request to establish reciprocity. In order to request that reciprocity be established,
visit the CalPERS web-site at: www.calpers.ca.gov and download the publication: “When You
Change Retirement Systems”, PUB-16. It is the responsibility of the employee to complete
and send the “Election to Coordinate Retirement When Changing Retirement Systems,”
PERS-MSD-255 Form to CalPERS.
Reciprocal 1937 Act Counties
Reciprocal Public Agencies
Alameda
Contra Costa
Fresno
Imperial
Kern
Los Angeles
Marin
Mendocino
Merced
Orange
*City of Concord
*City of Costa Mesa (Safety employees only)
City of Fresno (Miscellaneous and
Safety Retirement Systems)
City of Los Angeles (non-Safety only)
City of Oakland (non-Safety
employees only)
City of Pasadena (Fire and Police
Retirement System)
*City of Sacramento
*City of San Clemente (non-Safety
employees only)
City of San Diego
*City and County of San Francisco
City of San Jose
Contra Costa Water District
County of San Luis Obispo
East Bay Municipal Utility District
East Bay Regional Park District
(Safety employees only)
Los Angeles County Metropolitan
Transportation Authority
(Non-Contract Employees’ Retirement
Income Plan, formerly Southern
California Rapid Transit District)
Sacramento
San Bernardino
San Diego
San Joaquin
San Mateo
Santa Barbara
Sonoma
Stanislaus
Tulare
Ventura
Non-Reciprocal & UCRS Retirement Systems
Non-reciprocal systems are not covered by
reciprocity retirement laws, but participate
in retirement agreements with other systems.
State Teachers’ Retirement System
Legislators’ Retirement System
Judges’ Retirement System
Judges’ Retirement System II
University of California Retirement System
*Also CalPERS-covered agency
PERS-CASD-801 (12/12)
Loyalty Oath
I, _____________________________________, do solemnly swear (or affirm) that I
will support and defend the Constitution of the United States and the Constitution of
the State of California against all enemies, foreign and domestic; that I will bear true
faith and allegiance to the Constitution of the United States and the Constitution of
the State of California; that I take this obligation freely, without any mental
reservation or purpose of evasion; and that I will well and faithfully discharge the
duties upon which I am about to enter.
I understand that as a public employee I am a disaster service worker pursuant to
Government Code 3100 and 3102 and that I am required to take this oath before
entering the duties of my employment. In the event of natural, manmade, or warcaused emergencies which result in conditions of disaster or extreme peril to life,
property, and resources, I am subject to disaster services activities assigned to me by
my supervisor.
________________________________
Signature
________________________________
Address
________________________________
Subscribed and sworn to before me this
______ day of ____________, 20 ___
By: _____________________________
Deputy
loyalty oath
ADVICEOFDEPOSITVIAE‐MAIL
SRCS Payroll Is Going Green! SRCS employees on Direct Deposit will receive their paystub via their work email address. This saves SRCS substantial money on paper, labor, and service costs . . . not to mention saving a tree or two. To insure your paystub is secure, you will be asked to enter your birth date to access the paystub. Employees may request a printed copy instead, although that reduces the cost savings for SRCS. Here are some of the advantages to Direct Deposit:  Direct Deposit is fast, reliable, and safe.  Saves you time—no more driving to the bank and waiting in line.  You don't have to make special arrangements if you're out sick or on vacation on payday.  Since there's no paperwork, your paycheck can't get lost or stolen. If you have any questions, please contact your payroll technician. Certificated: Maria Khaleck, mkhaleck@srcs.k12.ca.us, 528‐5693 Classified: A‐L Erin McCarthy, EMcCarthy@srcs.k12.ca.us, 528‐5312, M‐Z Dayna Farber, dfarber@srcs.k12.ca.us, 528‐5354 J:MemorandumstoEEs/AdviceofDepositviaEmail Who is eligible for Direct Deposit?
Direct Deposit is available to all contracted employees
who bank with an ACH member.
SONOMA COUNTY
SCHOOLS
Can I discontinue Direct Deposit any time?
Direct Deposit for Payroll
Yes. To discontinue Direct Deposit, please contact your
payroll department and complete the cancellation
th
request no later than the 10 of the month in which
you wish to stop Direct Deposit.
What are the advantages of Direct Deposit?

Direct Deposit is fast, reliable, and safe.
What happens when I change my accounts?

If you intend to change or close your account(s) or
change banks, visit your payroll department and
complete the appropriate forms in a timely manner.
Save time—studies have shown that the average
worker spends anywhere from 8.5 to 24 hours a
year cashing payroll checks.

Save money—you won't be tempted to make a
withdrawal simply because you're already at the
bank to make a deposit.

You don't have to make special arrangements if
you're out sick or on vacation on payday.

Since there's no paperwork, your paycheck can't
get lost or stolen.

Help Us Go Green! Receiving Direct Deposit by
email uses less paper and it’s better for the
environment!
Is there a charge for Direct Deposit?
No. Direct Deposit is provided free of charge to the
employee. In fact, the district saves money when
employees choose to use Direct Deposit.
By choosing Direct Deposit and receiving your paystub
by email, we save thousands of dollars for paper, printing, folding, etc. It’s good for the environment, too!
How do I sign up for Direct Deposit?
When will my pay be deposited?
To start Direct Deposit, just complete and sign the
Direct Deposit Authorization form. Only one signature
is required for joint accounts.
With Direct Deposit, your pay is available to you on
payday at the bank where your account is held. Your
Advice of Deposit is your verification of deposit.
Return the authorization form to your district’s payroll
department, along with a “voided” pre-printed
personal check for checking accounts; and/or a notice
from your bank with your account number on it for
deposits to savings accounts.
Your payroll department will advise you of the date
when your Direct Deposit will begin. Your accounts will
be “pre-noted” the first month and then your deposit
will be automatic on the next payroll.
What record of earnings will I receive?
5340 Skylane Boulevard
Santa Rosa, CA 95403-8246
707-524-2600 • www.scoe.org
On payday, each employee on Direct Deposit will
receive an Advice of Deposit (paystub) via email. It will
contain the same information that currently appears
on the check stub. Employees may request a printed
paystub instead of receiving the paystub via email,
although that reduces the cost savings to the district.
SONOMA COUNTY OFFICE OF EDUCATION
DIRECT DEPOSIT AUTHORIZATION AGREEMENT
I, _________________________________________________________________________________________ employee of
(Print Employee Name)
______________________________________________________ hereby authorize the Sonoma County Office of Education
(District Name and Number)
and the financial institution(s) shown below, to directly deposit the amount I have indicated into my account(s). I understand
that all advices of deposit will be sent to my work email address unless I request a printed copy. If funds to which I am not
entitled are deposited, I hereby authorize the Sonoma County Office of Education either to direct the financial institution to
return such funds, or to request a “stop payment” of the Direct Deposit and to issue a warrant for the correct amount. The
authority will remain in effect until I have signed the CANCELLATION section below, or have terminated from the district.
____________________________________________
__________________
________________
(Employee’s Signature)
(Employee ID No.)
(Date)
Bank Name
Name on Account
Account #
Amount or
Percent
(C)hecking
or (S)avings
________________________
_____________________________
_________________________________
_________________
__________
________________________
_____________________________
_________________________________
_________________
__________
________________________
_____________________________
_________________________________
_________________
__________
________________________
_____________________________
_________________________________
_________________
__________
ATTACH INFORMATION HERE
For deposits to checking accounts, ATTACH A VOIDED PREPRINTED CHECK,
and/or for deposits to savings accounts, ATTACH A NOTICE OF YOUR ACCOUNT NUMBER from your financial institution.
DIRECT DEPOSIT CANCELLATION
I, _________________________________________________________________________________ employee of
(Print Employee Name)
______________________________________________ hereby request that Direct Deposits to my accounts(s) previously
(District Name and Number)
authorized by the Direct Deposit Authorization Agreement be discontinued effective one pay period after receipt of this
request by the above-mentioned school district.
____________________________________________
(Employee’s Signature)
____________________________________________
(Date Processed by District)
__________________
(Employee ID No.)
_____________________
(Date)
DATE:
__________________
TO:
Payroll Services
FROM:
Print Name: ______________________________________
Employee ID Number or Last 4 of SSN: ________________
SUBJECT:
DEFERRED NET PAY (DNP)
The following is my choice of the DNP Pay Plan:
Please check () the appropriate box:
 No –
10 month employee:
(Teachers, classified:
School Year and 10 option)
 No –
11 month employee:
(Full months: August-June)
I do not wish
to participate in
the DNP plan
or
I do not wish
to participate in
the DNP Plan
or
 Yes - I understand that 16.67% of
my net pay will be set aside
for payment on June 30th.
 Yes - I understand that 8.33% of
my net pay will be set aside
for payment on June 30th.
Please cancel my DNP:
Deferred Net Pay (DNP) is a method in which a percentage of net salary is deducted from
an employee’s paycheck during working months in order to cover the employee during
non-working months. Once you elect DNP, you do not need to re-elect each year. DNP
is not paid out early unless employee is terminated or resigns.
To cancel DNP a new form must be submitted to payroll.
**** DNP is paid out on June 30th ****
Signature of Employee: ____________________________________
Entered in Escape by:
Date:
J:Forms/DNPSignupForm-3/9/16
TRANSFER OF ACCUMULATED SICK LEAVE
(Title 5, Section 5601)
Mr.
Ms.
Employee
Certificated
Classified
(E.C. 44979)
(E.C. 45202)
Please provide the following information within ten days to:
Human Resources Department
211 RIDGWAY AVENUE
SANTA ROSA, CA 95401
District (new employer)2
Address
Thank you for this service.
(Signed)
Employee
Date
Days of accumulated (earned but unused) leave of absence for illness or injury1
Date service began in transferring district
Date such service terminated
X
Transferring district (or agency)
Address
I certify the above statement of accumulated sick leave to be true and correct.
X (Signed)
Title
1
Date
Days of accumulated sick leave other than days regularly earned in the transferring district include:
Days transferred to this district (after 9/17/65) for certificated, after 9/18/59 for classified. If none, use a
dash.
Extra days earned during summer session or in accordance with local board-established policy.
If accumulated days were on less than a full-day basis, show the equivalent full days. Explain the
computation.
2
Certificated illness leave at Santa Rosa City Schools will be accepted after employment of at least one full
school year or more in the transferring district and within the school year following termination in that district.
(OR) Classified employment in this district has been accepted after employment for one calendar year or more
in the transferring district and within 30 days of termination for the sole purpose of accepting a new position.
F:\Hiring Process-Recruitment\New Hire Paperwork\Working File for New Hires\Januay 2015\Transfer sick
leave 2015.doc
benefitsconnect
Making Changes at Open Enrollment
benefitsCONNECT is Santa Rosa City Schools’ online enrollment system, and is your one-stop
hub for all benefits-related items throughout the year. This is the second year of the system’s
implementation, which means the system will be rolling over your plans automatically unless
you would like to make changes to your plans this year. (Please note: the Healthcare FSA and
Dependent Care FSA require re-enrollment every plan year.)
!
TABLE OF CONTENTS
1. How do I get to the website? (Page 2)
!
2. How do I log in? What is my password? (Page 2)
!
3. What can I do from the Main Menu? (Page 3)
!
4. How do I make changes to my benefits this year/review my
new rates? (Page 4)
!
5. I’ve made my election changes. Now what? (Page 5)
!
1
1. HOW DO I GET TO THE WEBSITE?
!
The URL for Santa Rosa City Schools is: https://www.benefitsconnect.net/srcs
!
Please note the system is not compatible with Google Chrome. Depending on the web browser
you use (Internet Explorer, Safari, Firefox, etc.), the page may redirect you to a different page of
the website. Thus, it is important that you enter in the web address exactly as seen above
(including the “s” in “https”). When done successfully, you should see the screen below:
If you are experiencing problems logging in or you can’t get to the Santa Rosa City Schools login
page, please contact your HR Technician or e-mail Daniele Dale at ddale@thessmgroup.com.
2. HOW DO I LOG IN? WHAT IS MY PASSWORD?
All Passwords have been reset for Open Enrollment.
When you’ve reached the login page, your user name will be the following equation:
the first six characters of your last name
+ the first letter of your first name
+ the last four digits of your SSN
your password to start is your full nine-digit
Social Security Number (no dashes)
For example: If your name is Kim Peterson and your Social Security Number is
123-45-6789, your login would be: petersk6789
!
If your name is Tim Cain and your Social Security Number is 234-56-7890, your
login would be: caint7890
2
3. WHAT CAN I DO FROM THE MAIN MENU?
!
When you log into your benefitsCONNECT account, you will come to the following screen:
Review
demographic
information
on file and
update
emergency
contact
information!
Click here to
add/edit
dependents!
Click here to review/
make changes to
benefit elections!
Personal Information:
!
You may access and edit profile information here. You can also change your password or update
your emergency contact information.
!
Dependent Information:
!
You may access and edit information regarding your dependents in this section. If you are
looking to add a dependent at Open Enrollment, this is the place to do it! Once you have
added the dependent here, you will need to go into the individual benefit plans to add
them to the actual benefit.
!
Benefit Plan Information:
!
This section is where you will make any plan changes during this Open Enrollment and
view the new rates for the July 1 plan year. When you have completed your changes, please click
the “Consolidated Enrollment Form” link from this section and send to Human Resources.
!
Company Communications:
!
Items such as forms that are commonly used by Santa Rosa City School employees, News
Bulletins, the latest quarterly newsletter, your PocketPal, etc. reside here for you to access at any
time!
!
!
3
4. HOW DO I MAKE CHANGES TO MY BENEFITS THIS YEAR
OR SEE MY NEW RATES?
From the employee menu, select “Benefits Plan Information”
Select “Benefit Plan Enrollment,” the first option from the drop-down list. This will take you
to the screen showing your new benefits and new rates, should you wish to not make any
changes. (Please note the FSA plans require re-enrollment each year.)
This page
gives a recap
of the plans
and rates you
would be
rolling over
starting
7/1/2014
should you not
make any
changes. To
review or make
a change, click
on the benefit
in either
location above.
Please Note: ALL
Dependents you wish to
enroll must be added by
going into the individual
benefit plan
Click on the benefit you want to review or change. So, if you want to review or switch to a
different Medical plan this Open Enrollment, click, either your plan above, or click the
“Medical” option on the navigation pane over on the right.
DO NOT FORGET TO CLICK “SAVE” WHEN MAKING CHANGES!!!
SEE NEXT PAGE FOR INSTRUCTIONS ON NOTIFYING HR.
4
5. I’VE MADE MY ELECTION CHANGES. NOW WHAT?
!
After you’ve made changes to benefitsCONNECT for the 2014 plan year, will want to confirm
that the changes you have made are correct. Your changes can be confirmed by going to the
Consolidated Enrollment Form, which can be found below.
This button
will always
show what
the system
has as your
current/
future
benefits.
!
Please review the Consolidated Enrollment Form and print it out if you have made any
change. Sign the document and submit it back to your Human Resources Technician if
you have made any changes.
Questions on benefits at Open Enrollment?
Call Daniele Dale of The SSM Group at !
(707) 992-3797.!
!
Technical questions on benefitsCONNECT?
Call Michael Galagaran of The SSM Group at
(707) 992-3773.
Richard Stein Campus
Roundbarn Circle
O
3975 Old Redwood Hwy
160
Oncology Infusion
170A
180
East
Pharmacy
Infusion Ctr
Lower Level:
Info Desk
145
190
Health Ed
140 Allergy
Injection Clinic
110
Family Medicine
120
Orthopedics
2nd Floor:
Elevator
H Conference
Rooms
Cafeteria
Kaiser Permanente
Santa Rosa
106
• Child & Family
Psychiatry
Financial
Counselors
2 West
Pharmacy
240 GI
220
250
Family Medicine
235 Endoscopy
230
Family Medicine
Stairs
• OB-Gyn
210 OB-Gyn
• Cardiology
• Cardiac Lab Svcs
• Pulmonary
• Sleep Lab Svcs
215 OB-Gyn
Bicentennial Way
Member
Services
195
260
270
Elevator
• Nephrology
• Palliative Care
• BP Clinic
• HIV Srvcs • Travel
• Inf Diseases • Wound Care
285B
285A
• Surgery
• Breast Care Clinic
Family Medicine
310
Dermatology
320
Stein Pharmacy
M-F 8:30a-6:15p
East Lab
M-F 7:00a-8:30p
Stein Lab
M-F 7:00a-6:00p
Family Medicine
3rd Floor:
East Pharmacy
M-F 8:30a-5:30p
Lab Hours:
Hospital Lab
M-F 7:00a-1:00p
Sat 7:00a-1:00p
Chronic
Conditions
2nd Floor:
Elevator
• Family Medicine
Elevator
185 Lab
2 West Pharmacy
M-F 9:00a-5:30p
e
Family Medicine
Stairs
• Head & Neck
• Audiology
• Neurotology
u
Aven
150 A/B
130
Main Entrance
3558
Pharmacy Hours:
1 West Pharmacy
6:00a-1:00a
7 Days Week
cino
1 West
Pharmacy
Info Desk
Info Desk
• Adult Psychiatry
• Chem Dependency
1st Floor:
170B
Oncology
Family Medicine
Gift
Shop
100
East Building
1st Floor:
Lab
3554
do
Men
• Medical
Secretaries
• Business
Office
3550
d
Blv
rn
y
Hw
Elevator
dba
d
West Building
1st Floor:
Medical
Imaging
Roundbarn
Fountaingrove Parkway
Hospital
Emergency
Dept
Chronic
Pain
Endocrinology
oo
• Pediatrics
• Foot & Ankle
• Optometry
• Ophthalmology
• Optical Sales
• Health Education
• Lab
• Stein Pharmacy
Neurology
un
Ro
dw
Re
MOB 4
• Surgery Center
• Occ Medicine
• Phys Medicine
• Physical Therapy
• Sports Medicine
• Medical Imaging
3559 Roundbarn Blvd.
ld
MOB 5
Updated 04.04.12
E Conf
Rooms
Urology & Pre-Op
3333 Mendocino Ave.
130 Cosmetic Svcs
(1st Floor)
240 Hearing Center
(2nd Floor)
Centro Médico Richard Stein
O
MOB 5
y
Hw
Laboratorio
Oncología Infusión
Oncología
170A
Centro de Infusión
180
• Cuello y Cabeza
• Audiología
• Neurotología
Farmacia
Este
185
Escaleras
Medicina Familiar
H Sala de
conferencias
Restaurante de
autoservios
Kaiser Permanente
Santa Rosa
Educación para
la Salud
140 Alergias
Clínica de Inyección
110
Elvador
145
120
Ortopedia
2o Piso:
Asesores
Financieros
Farmacia
2 Oeste
240
Gastroenterología
Informaciones
190
• Cardiología
• Services de Laboratorio
Cardiológico
• Pulmonología
• Services de Laboratorio
de Sueno
260
Elvador
235 Endoscopía
285B
Medicina Familiar
230
Medicina Familiar
Escaleras
Medicina Familiar
310
Servicio al
Cliente
195
Crónicas
Condiciónes
2o Piso:
• Clínica de Cirugía
• Centro de Cuidado
de los Senos
250
220
• Nefrología
• Cuidado Pallativo
Clínica de la Presión Arterial
Clínica de Viajeros
Clínica de Heridas
Enfermedades Infecciosas
270
•
•
•
•
285A
• Psiquiatría
Niños y Familia
Elvador
215 Ginecología
Bicentennial Way
Farmacia Este
L-V de 8:30a-5:30p
Farmacia de Stein
L-V de 8:30a-6:15p
Laboratorios:
Laboratorio de Hospital
M-F 7:00a-1:00p
Sat 7:00a-1:00p
Laboratorio Este
LV de 7:00a-9:00p
Laboratorio de Stein
L-V de 7:00a-6:00p
Medicina Familiar
3o Piso:
Dermatología
• Ginecología
• Medicina Familiar
210 Ginecología
Laboratorio
e
Medicina Familiar
Nivel Inferior:
106
Farmacia 2 Oeste
L-V de 9:00a-5:30p
u
Aven
150 A/B
130
Entrada Principal
3558
Farmacias:
Farmacia 1 Oeste
L-D de 6:00a-1:00a
cino
Farmacia 1
Oeste
Informaciones
Informaciones
• Psiquiatría Adultos
• Dependencia
Farmacológica
1er Piso:
170B
160
Medicina Familiar
Tienda
de
regalos
100
do
Men
Elvador
3550
MOB Este
1er Piso:
Diagnóstico
por Imágenes
Médicas
Roundbarn
3554
d
Blv
rn
d
MOB Oeste
1er Piso:
• Secretaria Médica
• Oficina de
Negocios
Dolor
Crónico
Fountaingrove Parkway
Hospital
Emergencia
Endocrinología
oo
• Pediatría
• Cirugía de Pie y Tobillo
• Optometría
• Oftalmología
• Optica
• Educación para la Salud
• Laboratorio
• Farmacia de Stein
Neurología
dba
dw
Re
MOB 4
• Centro de Cirugía
• Medicina Ocupacional
• Medicina Fiscia
• Fisioterapia
• Sports Medicine
• Diagnóstico por Imágenes
Médicas
3559 Roundbarn Circle
ld
un
Ro
Roundbarn Circle
320
E Sala de
conferencias
Urología
3333 Mendocino Ave.
130 Servicios de
Cosmetología (1er Piso)
240 Centro de
Audiología (2o Piso)
Dear Santa Rosa City Schools Job Applicant,
Thank you for your interest in working with us at Santa Rosa City Schools. Assembly Bill 1432
will become effective on January 1, 2015. This will require school districts to provide training on
the mandated reporting requirements of the Child Abuse and Neglect Reporting Act, to
employees who have contact with students.
Beginning with any newly hired employees as of January 1st, 2014, anyone who has student
contact will be required to complete the free, online training module developed by the State
Department of Education, prior to the first day of work. Human Resources will collect the
certificate of completion as part of our new hire process. All new employees must complete both
the General Training and the Educator Training. It will take up to four (4) hours to complete
these modules. If you do not have computer access, we will make arrangements to have you
complete the training at the District Office.
If you wish to get a head start on the training, here are the links to the training. All School
Districts in California will have this requirement.
General Training: http://mandatedreporterca.com/training/generaltraining.htm
Educator Training: http://mandatedreporterca.com/training/educators.htm
Thank you.
Sincerely,
Cindy Brennan
Director of Human Resources
cbrennan@srcs.k12.ca.us
INSCRIBASE EN:kp.org
Reciba acceso instantáneo
KAISER PERMANENTE • Centro Medico de Santa Rosa • Centro Medico de Rohnert Park
Use su iPhone o
iTouch:
Nos gustaría que se inscribiera en kp.org hoy mismo. Solo
necesitará unos minutos. Contar con una cuenta activada le
permite enviar correos electrónicos a su médico, conectarse a su
registro de salud, ver la mayoría de los resultados de los
exámenes, solicitar citas de rutina, resurtir medicamentos
recetados para usted y los miembros de su familia y participar en
programas de salud en línea, como “Health Coach” (Asesor de
salud).
Visite kp.org y haga clic en “Register to get a user ID”
(Registrarse para obtener una identificación de usuario).
Paso 1: Ingrese su nombre, número de membresía a Kaiser,
fecha de nacimiento y dirección de correo electrónico. Haga clic
en “Submit” (Enviar)
Paso 2: Lea y confirme su acuerdo con los términos y
condiciones del sitio web.
Paso 3: Elija sus preferencias para recibir anuncios e
información por correo electrónico.
Paso 4: Elija una identificación de usuario exclusiva.
Paso 5: Confirme su dirección postal actual.
Paso 6: Confirme su identidad ingresando los últimos cuatro
dígitos de su número de Seguro Social.
Paso 7: Responda cinco preguntas cuyas respuestas solo sepa
usted. (Este paso garantizará la protección de su identidad.
Contará con aproximadamente un minuto para responder cada
pregunta. Sus respuestas no se incluirán en su expediente de
Kaiser Permanente).
Paso 8: Elija una contraseña exclusiva y asegúrela
seleccionando 3 preguntas de seguridad a las que usted
proporcionará sus propias respuestas.
¡Ha terminado!. Anote su identificación de usuario y su
contraseña, y guárdelas en un lugar seguro.
Para recibir ayuda telefónica relacionada con la inscripción y activación, llame
al 1-800-556-7677.
Si usted prefiere usar su iPhone,
iPad o iTouch, vaya a la tienda virtual
de Apple en su dispositivo donde
podrá descargar la aplicación “KP
Preventive Care for Northern
California” (Cuidado preventivo de
Kaiser Permanente) para el norte de
California. Es gratis. Hable con su
médico y vigile las necesidades de
salud de su familia desde su teléfono
o tableta. Inscríbase en kp.org
(según se indica arriba) después
descargue la aplicación y listo.
Conéctese desde cualquier lugar
donde se encuentre.
Sign up for kp.org today!
It just takes a few minutes
KAISER PERMANENTE • Santa Rosa • Rohnert Park
Available on iPhone,
iTouch, and iPad:
An activated account allows you to email your doctor,
connect with your health record, view most test results,
request routine appointments, refill prescriptions for you
and your family members, and participate in online health
programs such as Health Coach.
Go to kp.org and click "Register to get a user ID”.
Step 1: Enter your name, Medical Record Number, date of
birth, and e-mail address.
Step 2: Read and confirm that you agree to the Web site
terms and conditions.
Step 3: Choose your preferences for e-mail
announcements and information.
Step 4: Choose a unique user ID.
Step 5: Confirm your current mailing address.
Step 6: Confirm your identity by entering the last four digits
of your Social Security Number.
Step 7: Answer five questions that only you will know the
answers to. (This step will ensure that your identity is
protected. You will have approximately one minute to
answer each question. Your responses will not become
part of your Kaiser Permanente record.)
Step 8: Choose a unique password and secure that
password by selecting 3 security questions for which you’ll
provide your own answers.
You’re done! Make a note of your user ID and password
and store it in a safe place.
For help related to registration and activation call 1-800-556-7677.
If you prefer to use your iPhone, iPad or
iTouch, go to the virtual Apple store
where you can obtain the application
"KP Preventive Care for Northern
California". It is free. From this app,
you can send a secure message to your
physician and review your preventive
health care needs and those of your
family from your phone or tablet. Sign
up for kp.org, obtain the application and
you are ready. Connect from wherever
you are.
Dental Plan
Your
Dental
Plan
The Santa Rosa
City Schools
dental plan is a
self-funded
plan designed
to minimize
administrative
costs and
maximize the
benefits to our
covered
employees and
their
dependents
A dental plan is more than just about having a nice smile. Research indicates that
regular preventive dental visits can yield health benefits beyond improved teeth and
gums. The Santa Rosa City Schools provide the dental plan to its employees to help
them be healthy, and we recommend regular cleanings and preventive visits (the plan
pays for four such cleanings and preventive visits per year).
The dental plan pays an increasing percentage of dental claims depending on how long
the employee has been employed (and presuming the member used the plan at least
once in the contract year). The plan includes a special network of Northern California
dentists, but any dentist may be seen.
This booklet constitutes the plan’s Summary Plan Description. If you have any
questions on the plan, please contact the plan’s administrator:
Shirrell Consulting Services
320 College Avenue, Suite 340
P.O. Box 329
www.shirrell.members.sonic.net
707-544-1801
800-479-8479
2
YOUR
GROUP DENTAL INSURANCE
PLAN
TABLE OF CONTENTS
IMPORTANT NOTICE !
DENTAL HIGHLIGHTS
An Important Notice About Continuation Rights
ELIGIBILITY FOR DENTAL COVERAGE
Employee Coverage
Dependent Coverage
DENTAL EXPENSE INSURANCE
Covered Charges
Alternate Treatment
Proof of Claim
Pre-Treatment Review
Benefits From Other Sources
The Benefit Provision - Qualifying For Benefits
After This Insurance Ends
Special Limitations
Exclusions
List of Covered Dental Services
Preventive & Diagnostic Dental Services
Basic Dental Services
Major Dental Services
COORDINATION OF BENEFITS
GLOSSARY
Qualified Medical Child Support Order
Shirrell Consulting Services’ Responsibilities
Group Health Benefits Claims Procedure
Termination of This Group Plan
!
!
3
4
5
!
!
5
5
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
7
7
7
7
8
8
8
8
8
9
9
9
11
12
13
14
14
14
16
IMPORTANT NOTICE
SECTION I The Dental benefits are directly funded through and provided by Shirrell Consulting Services, and are not insured by Shirrell
Consulting Services. Shirrell Consulting Services has the sole responsibility and liability for payment of Dental benefits.
3
DENTAL HIGHLIGHTS
This page provides a quick guide to some of the Dental Expense Insurance plan features which people most often want to know
about. But it’s not a complete description of your Dental Expense Insurance plan. Read the following pages carefully for a
complete explanation of what the plan pays, limits and excludes.
Benefit Year Cash Deductible
None
This plan is an incentive plan. If the patient has utilized the program during the contract year (December 1 - November 30), the
percentage of payment (other than for Major Services) will increase each year to the fourth year, at which point the employee and
dependent will be at the maximum percentage. If the member did not use the program during the prior contract year, the percentage
reimbursement amount will remain level, but if the member lost eligiblity for the program and then regained eligibility the member
would start over at the First Contract Year reimbursement level below. Separate from the above, the plan covers accidents at
100% up to a separate $1,500/year limit at 100% of eligible charges, if the covered service is performed within 180 days of
the accident.
Payment Rates:
For Preventive and Diagnostic (P&D) Services
For Basic Services
For Major Services
Acccidents (if treated within 180 days)
Payment Rates:
For Basic Services
For Major Services
Payment Rates:
For Basic Services
For Major Services
Payment Rates:
For Basic Services
For Major Services
First Contract Year of Coverage:
70%
70%
50%
100%
Second Contract Year of Coverage:
80%
80%
50%
100%
Third Contract Year of Coverage:
90%
90%
50%
100%
Fourth Contract Year of Coverage:
100%
100%
50%
100%
Benefit Year Payment Limit for Covered Services (Regardless of Year of Coverage):
For P&D, Basic and Major Services
Up to $1,500.00
4
An Important Notice About Continuation Rights
This plan complies with applicable federal continuation laws under the Consolidated Omnibus Budget Reconcilation Act of 1985
(COBRA), and the Family and Medical Leave Act of 1993, as amended.
ELIGIBILITY FOR COVERAGE
Employee Coverage
Eligible Employees
Employees are eligible if they work full-time on an active basis and belong to an eligible class of employees. To be eligible,
employee must have met the waiting period mentioned below in “When Your Coverage Begins.”
Other Potential Requirements
In the case of contributory coverage, where employees are required to pay all or part of the cost of employee coverage, you must
agree in writing to such an election before you will be eligible for coverage. This election must be made not more than 31 days
after first becoming eligible. However, you will be allowed to enter later if you lost other group dental coverage for any of the
following reasons: (a) termination of your spouse’s employment; (b) loss of eligibility under your spouse’s group dental plan; (c)
divorce; (d) death of your spouse; or (e) termination of the other group dental plan. This except only applies if you sign up for
coverage under this plan and agree to any employee contributions within 30 days of the loss of the other coverage for any of the
reason listed. In addition, you will be allowed to enter late if an Open Enrollment period is set up and you sign up during that Open
Enrollment.
When Your Coverage Begins
Coverage begins for active full-time employees on the the following schedule: on the first day of the month following date of hire.
through the 14th of the month, and you work a minimum number of hours to qualify, coverage would start on the date of hire; if
you start on the 15th through the end of the month, and you work a minimum number of hours to qualify, coverage would start on
the first day of the following month. If you are not actively at work on the date that coverage would otherwise start, the coverage
will be postponed until the day you return to work on a full-time basis.
When Your Coverage Ends
Coverage ends on the last of the month in which your full-time employment ends. However, coverage ends on the date that you
die, you cease to belong to class of eligible employees or this plan is cancelled for all employees. If you are required to pay part or
all of the cost of the plan and you fail to do so, the coverage will end as of the last day of the period for which you paid the
necessary premium.
If coverage ends, you are eligible for continuation coverage under COBRA for a limited period of time if your loss of coverage is
due to one of the defined Qualifying Events under COBRA, including reduction in hours or termination of employment.
Dependent Coverage
Eligible Dependents For Dependent Dental Benefits
Eligible dependents are: your legal spouse and domestic partners as defined by Santa Rosa City Schools; your children who are
under age 26 and such children of your domestic partner.
Definition of a Domestic Partner
Domestic partners must be able to attest to the following statement:
“We are not related by blood in a degree that would prohibit marriage in the State of California (which bars marriages between
parents and children; ancestors and descendants of every degree; brothers and sisters of the half as well as the whole blood; and
between aunts or uncles and their nieces or nephews).
Each of us is at least 18 years of age, and otherwise capable or entering into a legally binding contract.
Each of us is the sole domestic partner of the other, and neither of us has any other domestic partner. We consider each other to be,
and hold ourselves out as engaged in a relationship of mutual caring and commitment.
Neither of us has any other domestic partner and neither of us has had a spouse or other domestic partner within the last six months.
We have resided together for at least the past six (6) consecutive months, currently reside together, and intend to continue residing
together indefinitely.
5
We are financially interdependent and consider ourselves responsible for each other’s basic support, including living and medical
expenses, and anyone owed such expenses by either one of us can collect them from either of us.”
Adopted Children And Step-Children
“Unmarried dependent children" includes any child legally adopted by you, including if the child is in your custody under an
interim court order of adoption. In addition, any step-children of yours are eligible if they depend upon you for the majority of their
support.
Dependents Not Eligible
Any dependents of yours are ineligible if they are on active duty in the armed forces.
Handicapped Children
If you have an unmarried child who is older than the normal age limit for dependent coverage and was covered by the plan prior to
reaching the plan’s normal age limit, he or she may continued to be covered if he or she has a physical or mental handicap or a
developmental disability and is unable to support himself or herself and relies on you for support. The child may remain covered so
long as he or she remains unmarried, disabled, and unable to provide for his or her support and remains supported by you. In order
to maintain coverage under this provision, you must provide proof in writing that the child is disabled and dependent upon you for
support. You have 31 days after the child reaches the normal limiting age to provide this proof. The plan reserves the right to ask
for periodic proof of the child’s then current situation.
Waiver Of Dental Late Entrants Penalty
The Late Entrant penalty will not apply if, when first becoming eligible, you waived the coverage for your spouse, domestic partner
or children because they were then eligible for group dental coverage from another employer’s group dental plan but you now wish
to enroll them within 30 days of the loss of such other group dental coverage due to any of the following family status events: (a)
termination of your spouse’s employment; (b) loss of eligibility under your spouse’s plan; (c) divorce; (d) death of your spouse; or
(e) termination of the other plan.
The Late Entrants penalty will also not apply to your spouse, domestic partner or eligible dependent children if you are legally
obligated to provide group dental coverage under a court order and you enroll them within 30 days of the issuance of such court
order.
When Dependent Coverage Starts
You must already be insured for employee coverage or enroll for employee and dependent coverage at the same time, in order to
provide coverage for your dependents.. Subject to the "Exception" stated below and to the terms of this plan, the date your
dependent coverage starts depends on when you elect to enroll your initial dependents and agree to make any required payments, or
you enroll your dependents later as explained below:
Dependents Added at Initial Enrollment
If you do this on or before your eligibility date, the dependent’s coverage is scheduled to start on the later of the first of the month
which coincides with or next follows your eligibility date and the date you become insured for employee coverage.
If you do this within the enrollment period, the coverage is scheduled to start on the later of the first of the month which coincides
with or next follows the date you sign the enrollment form; and the date you become insured for employee coverage.
Dependents Added After the Initial Enrollment
Once you have dependent coverage for your initial dependents, you must notify the plan when you acquire any new dependents
and agree to make any additional payments required for their coverage.
If you do this within 31 days of the date the newly acquired dependent becomes eligible, the dependent’s coverage will start on the
date the dependent first becomes eligible.
Exception If a dependent, other than a newborn child, is confined to a hospital or other health care facility; or is home-confined; or
is unable to carry out the normal activities of someone of like age and sex on the date his dependent benefits would otherwise start,
the plan will postpone the effective date of such benefits until the day after his discharge from such facility; until home
confinement ends; or until he or she resumes the normal activities of someone of like age and sex.
Newborn Children the plan covers your newborn child for dependent benefits, from the moment of birth if: (a) you are already
covered for dependent child coverage when the child is born; or (b) you enroll the child and agree to make any required premium
6
payments within 31 days of the date the child is born. If you fail to do this, once the child is enrolled, the child is a late entrant, is
subject to any applicable late entrant penalties, and will be covered as of the date you sign the enrollment form.
When Dependent Coverage Ends
Dependent coverage ends for all of your dependents at the same time that your coverage ends. It also ends when this plan ends, or
when dependent coverage is dropped from this plan for all employees or for an employee’s class.
If you fail to make any required payments for dependent coverage the coverage for your dependents will end. It ends on the last day
of the period for which you made any required payments (unless coverage ended earlier for other reasons).
An individual dependent’s coverage ends when he or she stops being an eligible dependent. This happens to a child at 12:01 a.m.
on the date the child attains the coverage age limit. It happens to a spouse when a marriage ends in legal divorce or annulment.
Group Open Enrollment Period
A group Open Enrollment period may be offered by the plan. If it is offered, it is generally held from May to June for an effective
date change of July 1. During this period, you would be able elect to enroll in dental insurance under this plan.
DENTAL EXPENSE INSURANCE
This insurance will pay many of your and your covered dependents’ dental expenses. What the plan pays and the terms for payment
are explained below.
Covered Charges
Covered charges are reasonable and customary charges for the dental services named in the List of Covered Dental Services.
Shirrell Consulting Services maintains a database of average dental costs in its network, and if in-network dental providers are
utilized the fees from such providers are deemed approved (for covered expenses). If a non-network dental provider is used,
covered fees from such providers are limited to the average fee as determined by Shirrell Consulting Services.
This plan only pays for covered services incurred by a covered person while that person is insured. A covered charge for a crown,
bridge or cast restoration is incurred on the date the tooth is prepared. A covered charge for any other prosthetic device is incurred
on the date the master impression is made. A covered charge for root canal treatment is incurred on the date the pulp chamber is
opened.
Alternate Treatment
The plan reserves the right to base its benefit payments on the least expensive service within a range of professionally accepted
standards of dental practice.In the case of bilateral multiple adjacent missing teeth, the benefit will be based on a removable partial
denture.
If more than one type of service can be used to treat a dental condition, the plan has the right to base benefits on the least expensive
service which is within the range of professionally accepted standards of dental practice. In the case of bilateral multiple adjacent
missing teeth, the benefit will be based on a removable partial denture.
Proof of Claim
In order for a claim to be paid, it is required that information acceptable to Shirrell Consulting Services be provided. This
information can consist of x-rays, study models, narratives or other diagnostic materials. If the necessary information is not
provided, no benefit will be paid.
Pre-Treatment Review
When the expected cost of a proposed course of treatment is expected to be expensive, the covered person’s dentist may send to
Shirrell Consulting Services a treatment plan before treatment is started. This must be done on a form acceptable to Shirrell
Consulting Services. The treatment plan must include: (a) a list of the services to be done, using the American Dental Association
Nomenclature and codes; (b) the itemized cost of each service; and (c) the estimated length of treatment. Dental X-rays, study
models and whatever else the plan needs to evaluate the treatment plan must be sent to us, too.
Once the treatment plan is received, Shirrell Consulting Services will review it and estimate what the plan will pay. The estimate
will be sent to the covered person’s dentist. If Shirrell Consulting Services does not agree with a treatment plan, or if one is not sent
in, it reserves the right to base plan payments on treatment suited to the covered person’s condition by accepted standards of dental
practice. This does not guarantee a specific payment by the plan unless the work is performed as stated in the plan and the person
remained insured. Such treatment remains subject to all of the other limitations of the plan.
7
Benefits From Other Sources
If you are covered by this plan and a similar plan, such as through your spouse’s employer, the plan will coordinate its benefits
with the benefits from the other plan. For more information on this, see the section on COORDINATION OF BENEFITS.
The Benefit Provision - Qualifying For Benefits
Preventive & Diagnostic, Basic, and Major Services
There is no deductible for Preventive & Diagnostic, Basic or Major services. The plan pays for such services at the applicable
payment rate.
All charges must be incurred while the covered person is insured. The plan has an annual maximum payment each benefit year of
$1,500. In addition, the plan pays 100% of eligible expenses for covered treatment for a dental accident, if the member has
treatment within 180 days of accident, up to a separate limit of $1,500 per benefit year.
Orthodontic Services
No coverage is provided for orthodontic services.
After This Insurance Ends
The plan will not pay for charges incurred after this insurance ends. But the plan will pay for the following if all work is finished in
the 31 days after this insurance ends: (a) a crown, bridge or cast restoration, if the tooth is prepared before the insurance ends; (b)
any other prosthetic device, if the master impression is made before the insurance ends; and (c) root canal treatment, if the pulp
chamber is opened before the insurance ends.
Special Limitations
Teeth Lost Or Missing Before A Covered Person Becomes Insured By This Plan
A covered person may have one or more congenitally missing teeth. The plan will not pay for a prosthetic device which replaces
such teeth.
Exclusions
The plan will not pay for:
- Oral hygiene, plaque control or diet instruction.
- Precision attachments.
- Desensitizing medicaments.
- Prescription medication.
- Treatment which does not meet accepted standards of dental practice.
- Treatment which is experimental in nature.
The plan will not pay for any appliance or prosthetic device used to:
- Change vertical dimension.
- Restore or maintain occlusion.
- Splint or stabilize teeth for periodontic reasons.
- Replace tooth structure lost as a result of abrasion or attrition.
The plan will not pay for any service furnished for cosmetic reasons. This includes, but is not limited to:
- Characterizing and personalizing prosthetic devices.
- Services with respect to congenital (hereditary) or development (following birth) malformations, surgery or dentistry for purely
cosmetic reasons, including but not limited to; cleft, palate, maxilliary and mandibular (upper and lower jaw) malformations,
enameled hyposplasia (lack of development), flourosis (a type of discoloration of the teeth), and anodontia (congenitally missing
teeth).
- Making facings on prosthetic devices for any teeth in back of the second bicuspid.
The plan will not pay for replacing an appliance or prosthetic device or processed veneer with a like appliance or device, unless:
- It is at least five years old and can’t be made usable.
- It is damaged while in the covered person’s mouth in an injury suffered while insured, and can’t be made serviceable.
The plan will not pay for any service, appliance, device or modality intended to treat disturbances of the temporo-mandibular joint.
The plan will not pay for:
- Replacing a lost, stolen or missing appliance or prosthetic device.
- Making a spare appliance or device.
- Implants.
- Sealants.
- Tooth transplants,
- Surgical repositioning of the jaw.
- The plan will not pay for treatment needed due to:
- An on-the-job or job-related injury.
8
- Overdentures
- A condition for which benefits are payable by Workers’ Compensation or similar laws.
The plan will not pay for treatment for which no charge is made. This usually means treatment furnished by:
- The covered person’s employer, labor union or similar group, in its dental or medical department or clinic.
- A facility owned or run by any governmental body.
- Any public program, except Medicaid, paid for or sponsored by any government body. But if a charge is made and the plan is
legally required to pay it, we will.
- Experimental procedures.
- All hospital costs and any additional fees charged by the dentist for hospital treatment.
- Extra-oral grafts (grafting of tissues from outside of the Temporomandibular Jaw (jaw joints)).
- Orthodontic services (treatment of malalignment of teeth and/or jaws) including orthondontic surveys.
- Composite restorations for posterior teeth.
- If an eligible person selects a more expensive plan of treatment than is customarily provided, or specialized techniques rather
than standard procedure, the plan will pay the applicable percentage of the lesser fee and the patient is responsible for the
remainder of the dentist’s fee. For example, a gold crown where a filling would restore the tooth, or a precision denture where a
standard denture would suffice.
- Services for restoring tooth structure lost from wear, for rebuilding or maintaining chewing services due to malocculsion, or for
stabilizing the teeth. Such services include, but are not limited to, equilibration and periodontal splinting.
List of Covered Dental Services
The services covered by this plan are named in this list. Each service on this list has been placed in one of three sections, which are
explained below. A separate payment rate applies to each section. All covered dental services must be furnished by or under the
direct supervision of a dentist. And they must be usual and necessary treatment for a dental condition.
Preventive & Diagnostic Dental Services
Prophylaxis, including periodontal prophylaxis (Topical application of fluoride is limited to covered persons under age 15 and
limited to four treatments in any one contract year) - Allowance includes examination, scaling and polishing.
Office Visits And Examinations
Initial or periodic oral examination (limited to four (4) examinations and prophylaxis treaments in one contract year).
- Emergency palliative treatment and other non-routine, unscheduled visits.
Space Maintainers (Limited to covered persons under age 16 and limited to initial appliance only) Allowance includes all
adjustments in the first six months after installation:
- Fixed, unilateral, band or stainless steel crown type.
- Fixed, unilateral, cast type.
- Removal, bilateral type.
Fixed And Removable Appliances
To Inhibit Thumbsucking - (limited to covered persons under age 14 and limited to initial appliance only) - Allowance includes all
adjustments in the first 6 months after installation.
Diagnostic Services Allowance includes examination and diagnosis.
- X-Rays
- Full mouth series of at least 14 films including bitewings, if needed (limited to once in any 36 consecutive month period).
- Bitewing films (limited to a maximum of four films in one visit, in any six consecutive month period).
- Other intraoral periapical or occlusal films - single films (limited to 4 periapical & 2 occlusal in any 12 consecutive month
period).
- Extraoral superior or inferior maxillary film (limited to 2 in any 12 consecutive month period).
- Panoramic film, maxilla and mandible.
Basic Dental Services
Office Visits And Examinations
Diagnostic consultation with a dentist other than the one providing treatment (limited to one consultation for each dental specialty
in any 12 consecutive month period) - The plan pays for this only if no other service is rendered during the visit.
Diagnostic Services Allowance includes examinations and diagnosis.
- Diagnostic casts - complex restorative cases only.
- Biopsy and examination of oral tissue.
Restorative Services Multiple restorations on one surface will be considered one restoration. Also see “Restorative Services”
below.
- Amalgam restorations.
- Synthetic restorations: Silicate cement, Acrylic or plastic, and Composite resin.
- Crowns: Stainless steel.
9
- Pins: Pin retention, exclusive of restorative material.
Endodontic Services
Allowance includes routine X-Rays and cultures, but excludes final restoration.
- Pulp capping, direct.
- Remineralization (Calcium Hydroxide), as a separate procedure.
- Vital pulpotomy.
- Apexification.
- Root canal therapy on non-vital (nerve-dead) teeth: Traditional therapy, and Medicated paste therapy, N2 Sargenti.
- Apicoectomy, as a separate procedure or in conjunction with other endodontic procedures.
Periodontic Services
Allowance includes the treatment plan, local anesthetics and post-surgical care.
- Gingivectomy or gingivoplasty, per quadrant (limited to once in 36 months, per quandrant.)
- Gingivectomy or gingivoplasty, per tooth (limited to once in 36 months, one to three contiguous teeth or tooth bounded spaces per
quadrant).
- Sub-gingival curettage and root planing, per quadrant (limited to a maximum of 4 quadrants in any 24 consecutive month period).
- Periodontal scaling and root planing, per quadrant (limited to once in 24 months, per quadrant)
- Periodontal scaling and root planing, per tooth (limited to once in 24 months, one to three teeth per quadrant)
- Pedicle or free soft tissue grafts, including donor sites.
- Osseous surgery, including flap entry and closure, per quadrant (once every 3 years).
- Osseous grafts, including flap entry, closure and donor sites.
- Muco-gingival surgery (unless for orthodontic services)
- Occlusal adjustment, not involving restorations and done in conjunction with periodontic surgery, per quadrant (limited to a
maximum of 4 quadrants in any 36 consecutive month period).
Oral Surgery Allowance includes routine X-Rays, the treatment plan, local anesthetics and post-surgical care.
- Extractions
- Uncomplicated non-surgical extraction, one or more teeth.
- Surgical removal of erupted teeth, involving tissue flap and bone removal.
- Surgical removal of impacted teeth.
Other Surgical Procedures
- Alveolectomy, per quadrant.
- Stomatoplasty with ridge extension, per arch.
- Removal of mandibular tori, per quadrant.
- Excision of hyperplastic tissue.
- Excision of pericoronal gingiva, per tooth.
- Removal of palatal torus.
- Removal of cyst or tumor.
- Incision and drainage of abscess.
- Closure of oral fistula or maxillary sinus.
- Reimplantation of tooth.
- Frenectomy.
- Suture of soft tissue injury.
- Sialolithotomy for removal of salivary calculus.
- Closure of salivary fistula.
- Dilation of salivary duct.
- Sequestrectomy for osteomyelitis or bone abscess, superficial.
- Maxillary sinusotomy for removal of tooth fragment or foreign body.
Prosthodontic Services
Specialized techniques and characterization are not covered. Also see “Prosthodontic Services” under Major Dental Services.
- Adding teeth to partial dentures to replace extracted natural teeth.
- Repairs to crowns - allowance based on the extent and nature of damage and the type of material involved.
Other Services - General anesthesia in connection with surgical procedures only.
- Injectable antibiotics needed solely for treatment of a dental condition.
Restorative Services Cast restorations and crowns are covered only when needed because of decay or injury, and only when the
tooth cannot be restored with a routine filling material. Also see “Restorative Services” above.
- Inlays
- Onlays, in addition to inlay allowance.
- Crowns and Posts
- Acrylic with metal.
- Porcelain.
10
- Porcelain with metal.
- Full cast metal (other than stainless steel).
- 3/4 cast metal (other than stainless steel).
- Cast post and core, in addition to crown (not a thimble coping).
- Steel post and composite or amalgam core, in addition to crown.
- Cast dowel pin (one-piece cast with crown) - Allowance based on type of crown.
- Acrylic or plastic, without metal
- Crown buildup.
- Labial veneers.
- Recementation
- Inlay or onlay.
- Crown.
Major Dental Services
Prosthodontic Services
Specialized technique and characterizations are not covered.
- Fixed bridges - Each abutment and each pontic makes up a unit in a bridge.
- Bridge abutments - See inlays and crowns under “Restorative Services.”
- Bridge Pontics
- Cast metal, sanitary.
- Plastic or porcelain with metal.
- Slotted facing.
- Slotted pontic.
- Simple stress breakers, per unit.
- Removable bridges, unilateral partial, one piece chrome casting, clasp attachment, including pontics.
- Dentures - Allowance includes all adjustments done by the dentist furnishing the denture in the first 6 months after installation.
- Full dentures, upper or lower.
- Partial dentures - Allowance includes base, all clasps, rests and teeth.
- Upper, with two chrome clasps with rests, acrylic base.
- Upper, with chrome palatal bar and clasps, acrylic base.
- Lower, with two chrome clasps with rests, acrylic base.
- Lower, with chrome lingual bar and clasps, acrylic base.
- Stayplate base, upper or lower (anterior teeth only).
- Denture repairs, acrylic
- Repairing dentures, no teeth damaged.
- Repairing dentures and replace one or more broken teeth.
- Replacing one or more broken teeth, no other damage.
- Denture repairs, metal - Allowance based on the extent and nature of damage and on the type of materials involved.
- Denture duplication, jump case (limited to once per denture in any 48 consecutive month period).
- Denture reline (limited to once per denture in any 24 consecutive month period):
- Office reline.
- Laboratory reline.
- Denture adjustments (limited to adjustments made by a dentist other than the one providing the denture, and adjustments are more
than 6 months after the initial installation).
- Tissue conditioning (limited to a maximum of 2 treatments per arch in any 24 consecutive month period).
- Repairs to bridges - allowance based on the extent and nature of damage and the type of materials involved).
- Bridge.
Prosthodontic appliances (including, but not limited to, fixed bridges and partial or complete dentures) will be replaced only after
five (5) years have elapsed following any prior provision of such applicances under the plan.
The plan will pay the applicable percentage of the dentist’s fee for a standard cast chrome, acrylic partial denture or a standard
complete denture, up to a maximum fee allowance which is at least the Prevailing Fee for a standard denture. (A “standard”
complete or partial denture is defined as a removable prosthetic applicance provided to replace missing natural, permanent teeth
and which is constructed using accepted and conventional procedures and materials.) The maximum allowance is revised
periodically as dental fees change. Any denture and/or related service for which a charge is made which exceeds this allowance is
considered an optional service, and the patient is responsible for the portion of the dentist’s fee in excess of the plan’s allowable
amount.
11
COORDINATION OF BENEFITS
Important Notice This provision applies to all dental expense benefits under this plan. It does not apply to death, dismemberment,
or loss of income benefits.
Purpose Of This Provision
An employee may be covered for health expense benefits by more than one plan. For instance the covered person may be covered
by this plan as an employee and by another plan as a dependent of his or her spouse. If he or she is, this provision allows us to
coordinate what we pay with what another plan pays. We do this so the covered person doesn’t collect more in benefits than he or
she Incurs in charges.
Definitions
“The plan” means this self-funded dental plan, as administered by Shirrell Consulting Services.
“Plan” means any of the following that provides health expense benefits or services:
(A) group, blanket, or franchise insurance plans;
(B) group Blue Cross plans, group Blue Shield plans, or other service or prepayment plans on a group basis;
(C) union welfare plans, employer plans, employee benefits plans, trusteed labor and management plans, or other plans for
members of a group;
(D) programs or coverages required or provided by law, including Medicare or other similar governmental benefits.
“Plan” does not include Medicaid or any other government program or coverage which the plan is not allowed to coordinate with
by law or the medical payment benefits included in traditional "fault-type" automobile contracts. Nor does it include any plan
which this plan supplements.
“This plan” means the part of the group plan subject to this provision.
“Member” means the person who receives a certificate or other proof of coverage from a plan that covers him or her for health
expense benefits.
“Dependent” means a person who is covered by a plan for health expense benefits, but not as a member.
“Allowable expense” means any needed, reasonable, and usual expense for health care incurred by a member or dependent under
this plan and at least one other plan. When a plan provides service instead of cash payment, the plan views the reasonable cash
value of each service as an allowable expense and as a benefit paid. The plan also views benefits payable by another plan as an
allowable expense and as a benefit paid, whether or not a claim is filed under that plan.
“Claim determination period” means a calendar year in which a member or dependent is covered by this plan and at least one other
plan and incurs one or more allowable expense under such plans.
How This Provision Works
The plan applies this provision when a member or dependent is covered by more than one plan. When this happens the plan
considers each plan separately when coordinating payments.
In order to apply this provision, one of the plans is called the primary plan. All other plans are called secondary plans. The primary
plan pays first, ignoring all other plans. The secondary plans then pay the remaining unpaid allowable expenses, but no plan pays
more than it would have without this provision.
If a plan has no coordination provision, it is primary. But, during any claim determination period, when this plan and at least one
other plan have coordination provisions, the rules that govern which plan pays first are as follows:
(A) A plan that covers a person as a member pays first; the plan that covers a person as a dependent pays second; except that, if the
person is also a Medicare beneficiary, Medicare is secondary to the plan covering the person as a dependent.
(B) A plan that covers a person as an active employee or as a dependent of such employee pays first. A plan that covers a person as
a laid-off or retired employee or as a dependent of such employee pays second.
But, if the plan that the plan is coordinating with does not have a similar provision for such persons, then (B) will not apply.
(C) A plan that covers a person as an active employee or as a dependent of such employee pays first. A plan that covers a person or
that person’s dependent under a right of continuation pursuant to federal or state law pays second. But, if the plan that the plan is
coordinating with doesn’t have a similar provision for such persons, then (C) will not apply.
(D) Except for dependent children of separated or divorced parents, the following governs which plan pays first when the person is
a dependent of a member:
A plan that covers a dependent of a member whose birthday falls earliest in the calendar year pays first. The plan that covers a
dependent of a member whose birthday falls later in the calendar year pays second. The member’s year of birth is ignored.
But, if the plan that the plan is coordinating with does not have a similar provision for such persons, then (D) will not apply and the
other plan’s coordination provision will determine the order of benefits.
(E) For a dependent child of separated or divorced parents, the following governs which plan pays first when the person is a
dependent of a member:
(1) When a court order makes one parent financially responsible for the health care expenses of the dependent child, then that
parent’s plan pays first.
(2) If there is no such court order, then the plan of the natural parent with custody pays before the plan of the stepparent with
custody;
(3) The plan of the stepparent with custody pays before the plan of the natural parent without custody.
If rules (A), (B), (C), (D) and (E) don’t determine which plan pays first, the plan that has covered the person for the longer time
pays first.
12
If, when the plan applies this provision, it pays less than it would otherwise pay, it will apply only that reduced amount against
payment limits of this plan.
The Plan’s Right To Certain Information
In order to coordinate benefits, the plan needs certain information. An employee must supply the plan with as much of that
information from any source. And if another insurer needs information to apply its coordination provision, the plan has the right to
give that insurer such information. If the plan gives or gets information under this section it can’t be held liable for such action.
When payments that should have been made by this plan have been made by another plan, the plan have the right to repay that
plan. If it does so, it is no longer liable for that amount. And if it pays out more than it should have, it has the right to recover the
excess payment.
Small Claims Waiver The plan doesn’t coordinate payments on claims of less than $50.00. But if, during any claim determination
period, more allowable expenses are incurred that raise the claim above $50.00, it will count the entire amount of the claim when it
coordinates payment.
GLOSSARY
This Glossary defines the italicized terms appearing in your booklet.
Active Appliance means an appliance, like braces or a functional orthotic used for orthodontic treatment to move teeth or
reposition the jaw.
Appliance means any dental device other than a prosthetic device.
Benefit Year with respect to this plan’s dental expense insurance, means a 12 month period which starts on December 1st and ends
on November 30th of each year.
Close Relative means: (a) a covered person’s spouse, children, parents, brothers and sisters; and (b) any other person who is part of
a covered person’s household. The plan does not pay for services and supplies furnished by close relatives.
Covered Person with respect to this plan’s dental expense insurance, means an employee or any of his or her covered dependents.
Dentist means any dental or medical practitioner the plan is required by law to recognize who: (a) is properly licensed or certified
under the laws of the state where he practices; and (b) provides services which are within the scope of his license or certificate and
covered by this plan.
Eligibility Date for dependent coverage is the earliest date on which: (a) you have initial dependents; and (b) are eligible for
dependent coverage.
Eligible Dependent is defined in the provision entitled "Dependent Coverage."
Employee means a person who works for the employer at the employer’s place of business, and whose income is reported for tax
purposes using a W-2 form.
Employer means Santa Rosa City Schools.
Enrollment Period with respect to dependent coverage, means the 31 day period which starts on the date that you first become
eligible for dependent coverage.
Full-time means the employee regularly works at least the number of hours in the normal work week set by the employer, at his
employer’s place of business.
Initial Dependents means those eligible dependents you have at the time you first become eligible for employee coverage. If at this
time you do not have any eligible dependents, but you later acquire them, the first eligible dependents you acquire are your initial
dependents.
Injury with respect to this plan’s dental expense insurance, means all damage to a covered person’s mouth due to an accident, and
all complications rising from that damage. But the term injury does not include damage to teeth, appliances or prosthetic devices
which results from chewing or biting food or other substances.
Newly Acquired Dependent means an eligible dependent you acquire after you already have coverage in force for initial
dependents.
Orthodontic Treatment means the movement of one or more teeth by the use of active appliances. It includes: (a) diagnostic
services; (b) the treatment plan; (c) the fitting, making and placement of an active appliance; and (d) all related office visits,
including post-treatment stabilization.
13
Plan means group plan administered by Shirrell Consulting Services.
Prosthetic Device means a restorative service which is used to replace missing or lost teeth or tooth structure. It includes all types
of dentures, crowns, bridges, veneers, pontics and cast restorations.
--------
Qualified Medical Child Support Order
Federal law requires that group health plans provide medical care coverage of a dependent child pursuant to a qualified medical
child support order (QMCSO). A “qualified medical child support order” is a judgment or decree issued by a state court that
requires a group medical plan to provide coverage to the named dependent child(ren) of an employee pursuant to a state domestic
relations order. For the order to be qualified it must include:
• The name of the group health plan to which it applies.
• The name and last known address of the employee and the child(ren).
• A reasonable description of the type of coverage or benefits to be provided by the plan to the child(ren).
• The time period to which the order applies.
• A dependent enrolled due to a QMCSO will not be considered a late enrollee in the plan.
Note: A QMCSO cannot require a group health plan to provide any type or form of benefit or option not otherwise available under
the plan except to the extent necessary to meet medical child support laws described in Section 90 of the Social Security Act. If you
have questions about this statement, see the plan administrator.
Shirrell Consulting Services’ Responsibilities
The dental expense benefits provided by this plan are funded solely by the employer. The benefits are not guaranteed by a policy
of insurance. Shirrell Consulting Services supplies administrative services, such as claims services, including the payment of
claims, preparation of employee benefit booklets, and changes to such benefit booklets.
Group Health Benefits Claims Procedure
If you seek benefits under the plan you should complete, execute and submit a claim form. Claim forms and instructions for filing
claims may be obtained from the Plan Administrator. Shirrell Consulting Services is the Claims Administrator with respect to
processing claims. Shirrell Consulting Services has the right to secure independent professional healthcare advice and to require
such other evidence as needed to decide your claim. The Plan Administrator has discretionary authority to determine eligibility for
benefits and to construe the terms of the plan with respect to claims.
Definitions "Adverse determination" means any denial, reduction or termination of a benefit or failure to provide or make payment
(in whole or in part) for a benefit. A failure to cover an item or service: (a) due to the application of any utilization review; or (b)
because the item or service is determined to be experimental or investigational, or not medically necessary or appropriate, is also
considered an adverse determination.
"Group Health Benefits" means any dental, out-of-network point-of-service medical, major medical, vision care or prescription
drug coverages which are a part of this plan.
"Pre-service claim" means a claim for a medical care benefit with respect to which the plan conditions receipt of the benefit, in
whole or in part, on approval of the benefit in advance of receipt of care.
"Post-service claim" means a claim for payment for medical care that already has been provided.
"Urgent care claim" means a claim for medical care or treatment where making a non-urgent care decision: (a) could seriously
jeopardize the life or health of the claimant or the ability of the claimant to regain maximum function, as determined by an
individual acting on behalf of the plan applying the judgment of a prudent layperson who possesses an average knowledge of health
and medicine; or (b) in the opinion of a physician with knowledge of the claimant’s medical condition, would subject the claimant
to severe pain that cannot be adequately managed without the care.
Note: Any claim that a physician with knowledge of the claimant’s medical condition determines is a claim involving urgent care
will be treated as an urgent care claim for purposes of this section.
Timing For Initial Benefit Determination
The benefit determination period begins when a claim is received. Shirrell Consulting Services will make a benefit determination
and notify a claimant within a reasonable period of time, but not later than the maximum time period shown below. A written or
electronic notification of any adverse benefit determination must be provided.
Urgent Care Claims. Shirrell Consulting Services will make a benefit determination within 72 hours after receipt of an urgent care
claim. If a claimant fails to provide all information needed to make a benefit determination, Shirrell Consulting Services will notify
the claimant of the specific information that is needed as soon as possible but no later than 24 hours after receipt of the claim. The
claimant will be given not less than 48 hours to provide the specified information.
Shirrell Consulting Services will notify the claimant of the benefit determination as soon as possible but not later than the earlier of:
the date the requested information is received; or
the end of the period given to the claimant to provide the specified additional information.
The required notice may be provided to the claimant orally within the required time frame provided that a written or electronic
notification is furnished to the claimant not later than 3 days after the oral notification.
Pre-Service Claims. Shirrell Consulting Services will provide a benefit determination not later than 15 days after receipt of a preservice claim. If a claimant fails to provide all information needed to make a benefit determination, Shirrell Consulting Services
14
will notify the claimant of the specific information that is needed as soon as possible but no later than 5 days after receipt of the
claim. A notification of a failure to follow proper procedures for pre-service claims may be oral, unless a written notification is
requested by the claimant. The time period for providing a benefit determination may be extended by up to 15 days if Shirrell
Consulting Services determines that an extension is necessary due to matters beyond the control of the plan, and so notifies the
claimant before the end of the initial 15-day period.
If Shirrell Consulting Services extends the time period for making a benefit determination due to a claimant’s failure to submit
information necessary to decide the claim, the claimant will be given at least 45 days to provide the requested information.
The extension period will begin on the date on which the claimant responds to the request for additional information.
Post-Service Claims. Shirrell Consulting Services will provide a benefit determination not later than 30 days after receipt of a
post-service claim. If a claimant fails to provide all information needed to make a benefit determination, Shirrell Consulting
Services will notify the claimant of the specific information that is needed as soon as possible but no later than 30 days after receipt
of the claim.
The time period for completing a benefit determination may be extended by up to 15 days if Shirrell Consulting Services
determines that an extension is necessary due to matters beyond the control of the plan, and so notifies the claimant before the end
of the initial 30-day period.
If Shirrell Consulting Services extends the time period for making a benefit determination due to a claimant’s failure to submit
information necessary to decide the claim, the claimant will be given at least 45 days to provide the requested information.
The extension period will begin on the date on which the claimant responds to the request for additional information.
Concurrent Care Decisions. A reduction or termination of an approved ongoing course of treatment (other than by plan
amendment or termination) will be regarded as an adverse benefit determination. This is true whether the treatment is to be
provided(a) over a period of time; (b) for a certain number of treatments; or (c) without a finite end date. Shirrell Consulting
Services will notify a claimant at a time sufficiently in advance of the reduction or termination to allow the claimant to appeal.
In the case of a request by a claimant to extend an ongoing course of treatment involving urgent care, Shirrell Consulting Services
will make a benefit determination as soon as possible but no later than 24 hours after receipt of the claim.
Adverse Benefit Determination
If a claim is denied, Shirrell Consulting Services will provide a notice that will set forth:
the specific reason(s) for the adverse determination; reference to the specific plan provision(s) on which the determination is based;
a description of any additional material or information necessary to make the claim valid and an explanation of why such material
or information is needed;
a description of the plan’s claim review procedures and the time limits applicable to such procedures, including a statement
indicating that the claimant has the right to bring a civil action under ERISA Section 502(a) following an adverse benefit
determination;
identification and description of any specific internal rule, guideline or protocol that was relied upon in making an adverse benefit
determination, or a statement that a copy of such information will be provided to the claimant free of charge upon request; in the
case of an adverse benefit determination based on medical necessity or experimental treatment, notice will either include an
explanation of the scientific or clinical basis for the determination, or a statement that such explanation will be provided free of
charge upon request; and in the case of an urgent care adverse determination, a description of the expedited review process.
Appeal of Adverse Benefit Determinations
If a claim is wholly or partially denied, the claimant will have up to 180 days to make an appeal.
A request for an appeal of an adverse benefit determination involving an urgent care claim may be submitted orally or in writing.
Necessary information and communication regarding an urgent care claim may be sent to Shirrell Consulting Services by
telephone, facsimile or similar expeditious manner.
Shirrell Consulting Services will conduct a full and fair review of an appeal which includes providing to claimants the following:
the opportunity to submit written comments, documents, records and other information relating to the claim;
the opportunity, upon request and free of charge, for reasonable access to, and copies of, all documents, records and other
information relating to the claim; and a review that takes into account all comments, documents, records and other information
submitted by the claimant relating to the claim, without regard to whether such information was submitted or considered in the
initial benefit determination.
In reviewing an appeal, Shirrell Consulting Services will:
provide for a review conducted by a named fiduciary who is neither the person who made the initial adverse determination nor that
person’s subordinate;
in deciding an appeal based upon a medical judgment, consult with a health care professional who has appropriate training and
experience in the field of medicine involved in the medical judgment;
identify medical or vocational experts whose advice was obtained in connection with an adverse benefit determination; and ensure
that a health care professional engaged for consultation regarding an appeal based upon a medical judgment shall be neither the
person who was consulted in connection with the adverse benefit determination, nor that person’s subordinate.
Shirrell Consulting Services will notify the claimant of its decision regarding review of an appeal as follows:
Urgent Care Claims. Shirrell Consulting Services will notify the claimant of its decision as soon as possible but not later than 72
hours after receipt of the request for review of the adverse determination.
Pre-Service Claims. Shirrell Consulting Services will notify the claimant of its decision not later than 30 days after receipt of the
request for review of the adverse determination.
Post-Service Claims. Shirrell Consulting Services will notify the claimant of its decision not later than 60 days after receipt of the
request for review of the adverse determination.
15
Alternative Dispute Options
The claimant and the plan may have other voluntary alternative dispute resolution options, such as mediation. One way to find out
what may be available is to contact the local U.S Department of Labor Office and the State insurance regulatory agency.
Termination of This Group Plan
Santa Rosa City Schools may terminate this group plan at any time. When this plan ends, you may be eligible to continue your
coverage. Your rights, if any, upon termination of the plan are explained in this benefit booklet.
320 College Avenue, Suite 340
P.O. Box 329
707-544-1801
800-479-8479
16
!"#$%&'()*+%,-%./0)1'2/)*+%34*)(5(%
-,0%.6/*(%789'*'(54048%:;
ARROW BENEFITS GROUP
<='(% 6'()*+% '(% 1,00415% /(% ,-% 7>+>(5% !?@% !"#$A% % .64/(4% *,54% 5=/5% 5=404% 9/;% =/B4% C44*% 1=/*+4(%
('*14%5=4%8/54%5='(%6'()*+%D/(%>26,/848A%%<=404-,04@%D4%(>++4(5%;,>%/(E%;,>0%84*)(5%/5%5=4%)94%
,-%;,>0%B'('5%/(%5,%='(%,0%=40%1>004*5%(5/5>(%D'5=%700,D%:4*4F5(%G0,>2A!
"#$!%&'()*!+,)-.&)'!-#$!)./$'!,0!./0)1'2/)*+%34*)(5(%0,1!-#$!'$%02&)'31$4!5%.)'!.4/&)&'-$1$4!67!
811,9!:$)$;-'!<1,35=!
8!5$1',)!$%&*&6%$!0,1!6$)$;-'!/.7!'$%$+-!-#$!'$1>&+$'!,0!.)7!%&+$)'$4!4$)('-=! ?,9$>$1@!&0!-#$!
4$)('-!>&'&-$4!&'!.!./0)1'2/)*+%.0,B'840%,0!811,9!:$)$;-'!<1,35A'!)$-9,1B@!-#$!4$)('-'!#.>$!
'36/&C$4!-#$&1!0$$'!.)4!#.>$!6$$)!.551,>$4!0,1!DEEF!1$&/631'$/$)-!%$''!.)7!.55%&+.6%$!+,2!
5.7/$)-'!.)4G,1!4$43+(6%$'=!
H0! 7,3! '$%$+-! .! H,*I./0)1'2/)*+% 34*)(5@! -#$! .4/&)&'-1.-,1! 9&%%! 5.7! .%%,9.6%$! +#.1*$'! ,)! .)!
.>$1.*$! 0$$! '+#$43%$! &)! .++,14.)+$! 9&-#! -#$! 51,>&'&,)'! ,0! 7,31! 51,*1./@! .'! ,3-%&)$4! &)! 7,31!
61,+#31$=! H0!-#$1$!&'!.!6.%.)+$!43$@!#,9$>$1@!&-!&'!7,31!1$'5,)'&6&%&-7=!
"#&'!%&'()*!&'!&)!.%5#.6$(+!,14$1!67!+&-7=! I5$+&.%-7!+,4$'!.1$!%&'-$4!67!-#$!4$)('-'A!)./$'!0,1!
$.'7!1$0$1$)+$!-,!.!'5$+&.%&'-!&)!7,31!.1$.=!
I5$+&.%-7!+,4$'!0,1!4$)('-!.1$!.'!0,%%,9'J!
G3%I%G4*40/6%34*)(5(%51,>&4$!.!03%%!1.)*$!,0!'$1>&+$'!0,1!-#$!$)(1$!0./&%7=!
JH%I%J*8,8,*)(5(%'5$+&.%&K$!&)!4&'$.'$'!,0!-#$!-,,-#!53%5@!5$10,1/&)*!'3+#!'$1>&+$'!.'!
1,,-!+.).%'=!
KL%I%K0/6%L>0+4,*(%1$/,>$!&/5.+-$4!-$$-#@!1$5.&1!01.+-31$'!,0!-#$!L.9!.)4!,-#$1!
4./.*$!-,!-#$!6,)$!'-13+-31$!.1,3)4!-#$!/,3-#=!
.3%I%.48'/50'1%34*)(5(%*$)$1.%%7!%&/&-!-#$&1!51.+(+$!-,!+#&%41$)!.)4!-$$).*$1'=!
.M%I%.40',8,*)(5(%-1$.-!4&'$.'$'!,0!-#$!*3/'=!
.L%I%.0,(5=,8,*)(5(%*$)$1.%%7!'5$+&.%&K$!&)!9.7'!-,!1$5%.+$!/&''&)*!).-31.%!-$$-#!9&-#!
Arrow Benefits Group
61&4*$'!,1!4$)-31$'=!
A-6 Envelope 6.5"x4.75"
P.O. Box 750004 Petaluma, CA 94975
Specialty
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
PR
GD
GD
PS
GD
GD
PD
GD
GD
GD
GD
GD
GD
OS
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
In-‐Network Provider
Williams
Perkins
Gong
Nelson
Jelmini
Kim
Sagarian
Tarango
Meade
Roetzer
Shafer
Hochstein
Koppel
Barientos
Bustamante
Lange
Cooper
Lee
Ringrose
Richard
Mark
Simon
Ringrose
Cooper
Lee
Hewlett
Thomas
Hewlett
Garvin
Hufnagel
Nicholls
Wood
Armel
Garrett
Schmotter
Simon
Young
Carlsmith
Seely
Shaw
Varlakova
Baroudi
Thomas
Wallace
Fong
Bajwa
Carter
Pieroni
Schaller
Williams
Zaeni
Scheiner
Victor
Charles
Roderick
Harold
Lee
James
Gin
Ken
Robert
Robert
Jeff
Sandra
Elizabeth
Randy
Peter
Mike
Anthony
Dennis
Patrick
David
Ted
Roger
Bryan
Miguel
Kenneth
Mark
Simon
Richard
Ringrose
Cooper
Lee
Richard
Mark
Simon
Thomas
Hewlett
Thomas
Kevin
Ric
Richard
James
Joe
Cameron
Richard
Ira
Julie
Annaliese
Patrick
Kenneth
Ralitza
Rana
Bruce
Kim
Lawrence
Mohan
Harris
Nadine
Lee
John
Yasmine
Karol
Mueller
Harrison
Mcmillen
Lambeth
Baker
Hooper
Kremen
Baumgartner
Bruce
Address
41 Angwin Plaza
9061 Soquel Drive
101 Comanche Drive
3113 Professional Drive, Ste 3
4801 Wilson Road
2520 H. Street
505 W. Columbus Street
4698 American Ave., Ste B
1440 Military W., Ste 102
142 E. D Street
142 E. D Street
3031 Telegraph Ave., Ste 212
1760 Solano Ave., Ste 309
79 Wharf Road
24 Wharf Road
650 Rio Lindo Ave., Ste 5
3560 Old Hwy. 53
15130 Lakeshore Drive
15322 Lakeshore Drive, Ste 104
15322 LAKESHORE DRIVE, STE 104
3560 OLD HWY. 53
15130 LAKESHORE DRIVE
15322 Lakeshore Drive, Ste 104
3560 Old Hwy. 53
15130 Lakeshore Drive
3560 Old Hwy. 53
3560 OLD HWY. 53
3560 Old Hwy. 53
118 E. Second Street
5 Tarman Drive
114 N. Main Street
102 S. Main Street
770 Tamalpais Drive, Ste 304
81 Casa Buena Drive
770 Tamalpais Drive, Ste 304
770 Tamalpais Drive #317
81 Casa Buena Drive
8125 La Plaza
421 E. Cotati Ave.
8125 La Plaza
8125 La Plaza
2171 Junipero Serra #660
1920 Sycamore Lane
635 Anderson Road, Ste 17
61-‐A Broadway
5041 Business Center Drive
1325 Travis Blvd.
1325 Travis Blvd.
1325 Travis Blvd.
1325 Travis Blvd.
1325 Travis Blvd. Ste D
P.O. Box 249
25620 WARD AVE
528 N. HARRISON STREET
825 SEQUOIA CIRCLE
552 N. FRANKLIN STREET
890 RIVER DRIVE
203 E. PINE STREET
552 N. FRANKLIN STREET
18175 N. HIGHWAY ONE
801 RIVER DRIVE
City
Angwin
Aptos
Arvin
Auburn
Bakersfield
Bakersfield
Bakersfield
Bakersfield
Benicia
Benicia
Benicia
Berkeley
Berkeley
Bolinas
Bolinas
Chico
Clearlake
Clearlake
Clearlake
Clearlake
Clearlake
Clearlake
Clearlake
Clearlake
Clearlake
Clearlake Hlnds.
Clearlake Hlnds.
Clearlake Hlnds.
Cloverdale
Cloverdale
Cloverdale
Cloverdale
Corte Madera
Corte Madera
Corte Madera
Corte Madera
Corte Madera
Cotati
Cotati
Cotati
Cotati
Daly City
Davis
Davis
Fairfax
Fairfield
Fairfield
Fairfield
Fairfield
Fairfield
Fairfield
Forestville
Fort Bragg
Fort Bragg
Fort Bragg
Fort Bragg
Fort Bragg
Fort Bragg
Fort Bragg
Fort Bragg
Fort Bragg
Phone Number
(707) 965-‐2479
(831) 688-‐3633
(661) 854-‐5558
(530) 885-‐8152
(661) 832-‐1877
(661) 324-‐1200
(661) 322-‐1300
(661) 834-‐5660
(707) 745-‐2121
(707) 745-‐8002
(707) 745-‐8002
(510) 841-‐5801
(510) 527-‐9564
(415) 868-‐0168
(415) 868-‐0911
(530) 345-‐5111
(707) 994-‐9414
(707) 994-‐6000
(707) 994-‐6050
(707)994-‐6050
(707)994-‐9414
(707)994-‐6000
(707)994-‐6050
(707)994-‐9414
(707)994-‐6000
(707) 994-‐7271
(707)994-‐7271
(707)994-‐7271
(707) 894-‐2514
(707) 894-‐3394
(707) 894-‐3986
(707) 894-‐2464
(415) 927-‐4000
(415) 924-‐4772
(415) 927-‐4000
(415) 924-‐2501
(415) 924-‐5300
(707) 795-‐6424
(707) 664-‐8800
(707) 795-‐6424
(707) 795-‐6424
(650) 992-‐0440
(530) 756-‐1424
(530) 757-‐6453
(415) 457-‐3377
(707) 863-‐9950
(707) 427-‐2222
(707) 427-‐2222
(707) 427-‐2222
(707) 427-‐2222
(707) 427-‐2222
(707) 887-‐2140
(707)964-‐0255
(707)964-‐4759
(707)964-‐0242
(707)964-‐6489
(707)964-‐0255
(707)964-‐2618
(707)964-‐6489
(707)964-‐0440
(707)964-‐8080
GD
GD
OR
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
OS
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
PR
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
OS
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
James
Neil
Tsau
Prince
Geissberger
Lerner
Mac Donald
Michna
Pancoska
Preovolos
Cox
Cox
Salmon
Skryja
Alexander
Bartels
Boettger
Bozeman
Brunner
Chadburn
Cleland
Costanza
Everson
Fiorentino
Herzberg
Jarvis
Lane
Leach
Martin
Mazhar
Neal
Neal
Nichols
Rodriguez-‐Mccann
Schulze
Tom
Whitely
Whitely
Widick
Yee
Iamsurey
Prasong
Iamsurey
Herschleb
Johnson
Boxerman
Dunbar
Johnson
Long
Milani
Sun
Don
Randolph
James
Keith
Johnson
Sun, Apc
Milani
Long
Truitt
Barnard
Cunningham
Mattson
Wilensky
James
Richard
Louis
Michael
Gordon
Mark
Roger
Theodore
Allen
Allen
Eric
Raymond
Marc
Roger
Steven
Brian
Michael
Ashby
Thomas
Victor
Pamela
Elvira
Thomas
Stephen
Andrew
Robert
Steven
Raafia
Michael
Michael
George
Guillermo
George
William
Jesse
Jesse
Shawn
Dana
Prasong
Iamsurey
Prasong
John
John
Keith
Eric
Don
Keith
James
Randolph
Johnson
Sun
Milani
Long
Don
Randolph
James
Keith
Harold
John
John
499 CHESTNUT ST. STE C
895 RIVER DRIVE
4803 Fremont Blvd.
13692 Arnold Drive
1341 S. Eliseo Drive
599 Sir Francis Drake Blvd Ste 306
481 Via Hidalgo, Ste 100
38460 S. Highway 1
38460 S. Highway 1
14001 Old Cazadero Road
14001 Old Cazadero Road
125 Grant Street
138 Matheson Street
445 March Ave., Ste B
704-‐C Healdsburg Ave.
606 Center Street
1310 Prentice Dr. Suite C
1381 University Ave.
1526 Healdsburg Ave.
217 Matheson Street
606 Center Street
1260 Healdsburg Ave., Ste 101
1310 Prentice Drive, Ste C
1310 Prentice Drive Suite A
441 March Ave Suite B
224 Matheson Street
1310 Prentice Drive, Ste A
704 Healdsburg Ave., Ste A
445 March Ave., Ste B
125 Grant Street
704 Healdsburg Ave., Ste A
4150 Main Street (Info Only)
4150 MAIN STREET (INFO ONLY)
4150 Main Street (Info Only)
1036 Sir Francis Drake Blvd. Suite 9
1036 Sir Francis Drake Blvd.
P.O. Box 717
401 Pennisula Drive, Ste B
1053 -‐ 11Th Street
818 Lakeport Blvd.
800 11Th Street
800 S. Main Street
1053 -‐ 11TH STREET
800 S. MAIN STREET
800 11TH STREET
818 LAKEPORT BLVD.
800 S. Main Street
800 11Th Street
818 Lakeport Blvd.
43713 N. 20Th Street W.
428 Magnolia Ave.
426 Magnolia Ave.
Fort Bragg
Fort Bragg
Fremont
Glen Ellen
Greenbrae
Greenbrae
Greenbrae
Greenbrae
Greenbrae
Greenbrae
Gualala
Gualala
Guerneville
Guerneville
Healdsburg
Healdsburg
Healdsburg
Healdsburg
Healdsburg
Healdsburg
Healdsburg
Healdsburg
Healdsburg
Healdsburg
Healdsburg
Healdsburg
Healdsburg
Healdsburg
Healdsburg
Healdsburg
Healdsburg
Healdsburg
Healdsburg
Healdsburg
Healdsburg
Healdsburg
Healdsburg
Healdsburg
Healdsburg
Healdsburg
Kelseyville
Kelseyville
Kelseyville
Kentfield
Kentfield
Kenwood
Lake Alamor
Lakeport
Lakeport
Lakeport
Lakeport
Lakeport
Lakeport
Lakeport
Lakeport
Lakeport
Lakeport
Lakeport
Lakeport
Lanscaster
Larkspur
Larkspur
(707)964-‐5616
(707)961-‐4270
(510) 651-‐7700
(707) 996-‐8471
(415) 461-‐1341
(415) 461-‐1337
(415) 461-‐9393
(415) 461-‐4614
(415) 461-‐1830
(415) 461-‐4614
(707) 884-‐3738
(707)884-‐3738
(707) 869-‐2623
(707) 869-‐2623
(707) 433-‐2425
(707) 433-‐8888
(707) 433-‐0231
(707) 433-‐2464
(707) 433-‐1881
(707) 433-‐5557
(707) 433-‐8161
(707) 433-‐8161
(707) 433-‐0210
(707) 433-‐8161
(707) 433-‐5557
(707) 433-‐1455
(707) 433-‐8161
(707) 433-‐5052
(707) 433-‐5496
(707) 433-‐5052
(707) 433-‐6910
(707) 433-‐6910
(707) 433-‐9477
(707) 433-‐6925
(707) 433-‐6907
(707) 433-‐0231
(707) 433-‐5052
(707) 433-‐2425
(707) 433-‐6907
(707) 433-‐8161
(707) 279-‐4251
(707)279-‐4251
(707)279-‐4251
(415) 456-‐5402
(415) 453-‐5750
(707) 833-‐2643
(530) 596-‐3993
(707) 263-‐6108
(707) 263-‐7023
(707) 263-‐9992
(707) 263-‐3030
(707)263-‐6108
(707)263-‐3030
(707)263-‐9992
(707)263-‐7023
(707)263-‐6108
(707)263-‐3030
(707)263-‐9992
(707)263-‐7023
(661) 945-‐4132
(415) 924-‐7900
(415) 924-‐4244
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
PS
PS
GD
PS
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
OR
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
OS
GD
PR
GD
PR
GD
GD
GD
GD
GD
GD
GD
GD
GD
Koppe
Gregory
Browning
Cooper
Cooper
Herman
Herman
Joseph
Joseph
Kalia
Kalia
Manaloto
Manaloto
Nguyen
Nguyen
Petersen
Petersen
Szmyd
Patrick
Chris
Konopka
Van Zyl
Ian
Ewa
Van Zyl
Konopka
Carlos
Disick
Garcia
Gates
Kessler
Nebenzahl
Patel
Safapour
Stock
Wilson
Yang
Wu
Fenderson
Fisher
Newberry
Wong
Wong
Montes
Anand
Causey
Derham
Donesky
Elder
Elloway
Grill
Hansen
Hollander
Huang
Huffman
Lampert
Landa
Maclean
Mcconnell
Menjivar-‐Gray
Patel
Perry
Michael
Kocher
Donovan
Christopher
Christopher
Timothy
Timothy
Martine
Martine
Guneeta
Guneeta
Abdon
Abdon
Kayla
Kayla
Flaviane
Flaviane
Paul
Carney
Martin
Ewa
Ian
Van Zyl
Konopka
Ian
Ewa
Julieta
Evan
Richard
Robert
Terry
Jeffrey
Amitesh
Negar
Dawn
Robert Mark
Leo
Eric
Adrian
R. Scott
Justin
Cherise
Aaron
Jorge
Rajiv
Jeff
Nancy
Myron
Mahr
Norman
Gary
Mark
Brian
Samuel
Leahn
H. Scott
Richard
Jon
Steven
Myrna
Neal
Lynn
5 Bon Air Road, Ste 114
PO BOX 1758 825 Twelve Bridges Drive, Ste 55
685 Twelve Bridges Drive, Ste #E
945 Orchard Creek Lane
685 Twelve Bridges Dr. Suite E
691 North L Street
PO BOX 2477
45160 MAIN STREET
P.O. Box 1124
P.O. Box 1124
P.O. BOX 1124
P.O. BOX 1124
P.O. Box 1124
P.O. Box 1124
163 Miller Ave.
591 Redwood Hwy Bldg 2000
655 Redwood Hwy.
316 Miller Ave.
163 Miller Ave.
7 N. Knoll Road, Ste 7
316 Miller Ave.
316 Miller Ave.
141 Camino Alto, Ste 4
147 Lomita Drive, Ste D-‐1
163 Miller Ave.
142 Ranch Drive
3416 Valle Verde Drive
1600 Trancas Street Ste C
3260 Beard Rd., Ste 2
390 West Napa St., Ste B
390 West Napa Street Suite B
6631 Laurel Canyon Blvd, 2Nd Floor
1805 Novato Blvd., Ste 5
7595 Redwood Blvd., Ste 107
1316 Grant Ave.
1805 Novato Blvd. #1
1316 Grant Ave.
208 Vintage Way, Ste K-‐23
1730 Novato Blvd., Ste H
1615 Hill Road, Ste 4
7460 Redwood Blvd.
208 Vintage Way, Ste K-‐23
1730 Novato Blvd., Ste A
208 Vintage Way, Ste K23
190 San Marin Drive
Larkspur
Laytonville
Lincoln
Lincoln
Lincoln
Lincoln
Lincoln
Lincoln
Lincoln
Lincoln
Lincoln
Lincoln
Lincoln
Lincoln
Lincoln
Lincoln
Lincoln
Livermore
Mendocino
Mendocino
Middletown
Middletown
Middletown
Middletown
Middletown
Middletown
Mill Valley
Mill Valley
Mill Valley
Mill Valley
Mill Valley
Mill Valley
Mill Valley
Mill Valley
Mill Valley
Mill Valley
Mill Valley
Milpitas
Napa
Napa
Napa
Napa
Napa
North Hollywood
Novato
Novato
Novato
Novato
Novato
Novato
Novato
Novato
Novato
Novato
Novato
Novato
Novato
Novato
Novato
Novato
Novato
Novato
(415) 924-‐2585
(707)984-‐8463
(916) 543-‐4400
(916) 408-‐5136
(916) 408-‐5557
(916) 408-‐5136
(916) 408-‐5557
(916) 408-‐5136
(916) 408-‐5557
(916) 408-‐5136
(916) 408-‐5557
(916) 408-‐5136
(916) 408-‐5557
(916) 408-‐5136
(916) 408-‐5557
(916) 408-‐5136
(916) 408-‐5557
(925) 447-‐7892
(707)937-‐0255
(707)937-‐1790
(707) 987-‐2773
(707) 987-‐2773
(707)987-‐2773
(707)987-‐2773
(707)987-‐2773
(707)987-‐2773
(415) 383-‐1737
(415) 381-‐4381
(415) 383-‐2256
(415) 388-‐1726
(415) 383-‐1737
(415) 383-‐0350
(707) 763-‐0962
(707) 763-‐0962
(415) 389-‐8520
(415) 388-‐9495
(415) 383-‐1737
(408) 262-‐4434
(707) 258-‐8700
(707) 226-‐2399
(707) 255-‐2832
(707) 938-‐5322
(707) 938-‐5322
(818) 765-‐6671
(415) 892-‐6901
(415) 892-‐0109
(415) 892-‐4721
(415) 897-‐9642
(415) 892-‐1190
(415) 897-‐8338
(415) 898-‐5100
(415) 897-‐5070
(415) 898-‐6660
(415) 897-‐3914
(415) 897-‐3411
(415) 897-‐6453
(415) 897-‐7777
(415) 898-‐5100
(415) 897-‐4149
(415) 898-‐5100
(415) 897-‐7777
(415) 897-‐6877
GD
GD
GD
PR
EN
GD
GD
GD
GD
PD
OS
PD
OS
GD
GD
GD
GD
GD
GD
OS
GD
OS
GD
EN
OS
EN
GD
GD
GD
OS
GD
GD
GD
OS
GD
GD
GD
GD
PD
GD
PR
GD
GD
GD
GD
GD
GD
OR
GD
PR
GD
GD
GD
GD
GD
GD
OS
GD
EN
GD
GD
GD
Purvis
Rasmussen
Rosenthal
Simon
Vafaie
Wutzke
Lavorini
Mc Neal
Shevchuk
Alcaide
Bae
Baroudi
Duffy
Edwards
Fathi
Glerum
Komenaka
Lotfi
Nguyen
Reddy
Salkola
Allen
Anderson
Ashtiani
Bae
Balytsky
Barnts
Barton
Brown
Chavez
Christensen
Crawford
Dembski
Duffy
Edwards
Elias
Gardner
Gilbert
Golinveaux
Graham
Grill
Haglund
Heggli
Himmelstein
Husein
Johns
Jonas
Karkia
Koenitzer
Koffler
Komenaka
Korman
Kundra
Lane
Lee
Long
Mogannam
Murdock
Nguyen
Nizibian
Patel
Permalla
James
Lance
Michael
Ira
Nader
Gerhard
Ernie
Steven
Andriy
Jeff
Richard
Rana
Patrick
Cameron
Marjan
John
Gary
Pouyan
Huong
Raju
Mimi
Robert
Heather
Andy
Richard
Orest
Kelcie
Alan
Samuel
Vicente
David
F.C.
Thomas
Patrick
Cameron
Rami
Paula
Robert
Megan
B. Hudson
Gary
Michael
F. Charles
Louis
Firas
Ronald
Lawrence
Claudia
Bob
Michael
Gary
Richard
Darpan
George
Tinna
Greg
Jiries
Emmy
Brian
Mark
Amitesh
Praveena
7460 Redwood Blvd.
460 Ignacio Blvd.
1730 Novato Blvd. Suite G
1730 Novato Blvd.
P.O. Box 310
P.O. Box 310
3920 Middlefield Road
101 Lynch Creek Way, Ste B
1301 Southpoint Blvd. Suite A
30 West El Rose Drive
249 N. Mcdowell Blvd.
1301 Southpoint Blvd Suite A
216 Howard Street
10 W. El Rose Drive
101 Lynch Creek Way Suite B
245 Kentucky Street
123 Washington Street
1301 Southpoint Blvd., Ste A
3835 Cypress Drive, Ste 101
1580 E. Washington Street, Ste 105
1126 B Street
515 Hayes Lane, Ste 1
765 Baywood Drive, Ste 101
135 Keller Street, Ste B
701 Sonoma Mountain Pky, E-‐1
1126 B Street
135 Keller Street, Ste. E
101 Lynch Creek Way
131 Lynch Creek Way, Ste A
249 N. Mcdowell Blvd
1301 S. Point Blvd, Ste A
9 W. El Rose Drive
10 W. El Rose Drive
101 Lynch Creek Way Suite B
1430 E. Washington Street
3835 Cypress Drive
1122 -‐ B Street
515 Hayes Lane
Novato
Novato
Novato
Novato
Novato
Novato
Oakland
Occidental
Occidental
Palo Alto
Palo Alto
Palo Alto
Palo Alto
Palo Alto
Palo Alto
Palo Alto
Palo Alto
Palo Alto
Palo Alto
Palo Alto
Palo Alto
Petaluma
Petaluma
Petaluma
Petaluma
Petaluma
Petaluma
Petaluma
Petaluma
Petaluma
Petaluma
Petaluma
Petaluma
Petaluma
Petaluma
Petaluma
Petaluma
Petaluma
Petaluma
Petaluma
Petaluma
Petaluma
Petaluma
Petaluma
Petaluma
Petaluma
Petaluma
Petaluma
Petaluma
Petaluma
Petaluma
Petaluma
Petaluma
Petaluma
Petaluma
Petaluma
Petaluma
Petaluma
Petaluma
Petaluma
Petaluma
Petaluma
(415) 897-‐3914
(415) 883-‐4631
(415) 892-‐6901
(415) 897-‐7770
(415) 209-‐6000
(415) 897-‐5070
(510) 444-‐4334
(707) 874-‐2447
(707) 874-‐2447
(650) 813-‐9800
(650) 813-‐9800
(650) 813-‐9800
(650) 813-‐9800
(650) 813-‐9800
(650) 813-‐9800
(650) 813-‐9800
(650) 813-‐9800
(650) 813-‐9800
(650) 813-‐9800
(209) 476-‐4700
(650) 813-‐9800
(707) 769-‐1414
(707) 762-‐0067
(707) 789-‐9399
(707) 765-‐9262
(707) 763-‐2170
(707) 762-‐0067
(707) 763-‐8088
(707) 762-‐9784
(707) 769-‐1414
(707) 763-‐4142
(707) 762-‐2415
(707) 762-‐0067
(707) 765-‐9262
(707) 765-‐9262
(707) 765-‐9262
(707) 766-‐8268
(707) 763-‐1959
(707) 765-‐9262
(707) 762-‐7183
(707) 762-‐7183
(707) 762-‐5561
(707) 765-‐1838
(707) 763-‐0949
(707) 782-‐0789
(707) 763-‐1959
(707) 762-‐7183
(707) 789-‐9399
(707) 762-‐6715
(707) 763-‐1951
(707) 765-‐9262
(707) 762-‐0067
(707) 778-‐9000
(707) 762-‐7381
(707) 765-‐9262
(707) 762-‐9784
(707) 769-‐1414
(707) 762-‐0067
(707) 241-‐9289
(707) 763-‐1688
(707) 763-‐0962
(707) 765-‐9262
GD
GD
GD
EN
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
PR
PR
GD
OS
GD
GD
GD
PD
PR
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
PR
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
OS
GD
GD
GD
GD
GD
GD
Permalla
Quarles
Radtke
Roper
Rosenthal
Safapour
Schultz
Shapira
Sibbald
Sinclair
Smida
Szyperski
Tran
Ventanilla
Wyatt
Zatto
Oliver
Choi
Chung
Duffy
Edwards
Ford
Komenaka
Liaw
Liu
Ocampo
Shiao
Zhao
Bonura
Dague
Lyons
Gonzalez
Mannion
William
Maryann
Mannion
Gonzalez
Geoghegan
Nguyen
Nguyen
Porteous
Daniel
Daniel
Grau
Grill
Henley
Henley
Huynh Costa
Kupelian
Lieu
Malkemus
Mann
Ostrowski
Owen
Romero
Scarr
Steffy
Terribilini
Terribilini
Unguren
Wheeler
Yee
Praveena
Larry
Klaus
Mark
Christopher
Negar
Clyde
Eric
Brian
John
Jurina
Yvonne
Lynda
Oscar
Cherilynn
Michael
Gilbert
James
Christopher
Patrick
Cameron
Dustin
Gary
Christine
Nelson
Michael
George
Shirley
Jack
Robert
William
Maryann
William
Mannion
Gonzalez
William
Maryann
Timothy
Thanh-‐Truc
Minh
Lawrence
Christopher
Christopher
Waltraut
Gary
James
George
Lora
Armen
Anthony
George
John
Douglas
Steven
Geronimo
Jon
Donald
Philip
David
John
Soonmyo
Lyle
855 Lakeville Street, Ste 101
1126 -‐ B Street
3835 Cypress Drive., #203
765 Baywood Drive, Ste 233
515 Hayes Lane
10 W. El Rose Drive
1301 Southpoint Blvd Suite A
8 W. El Rose Drive, Ste B
One Bodega Avenue Suite B
26 -‐ 4Th Street
1580 E. Washington Street #101
1430 East Washington Street
1580 E. Washington, #105
1430 E. Washington Street
1500 Tara Hills Drive, Ste 202
5540 Springdale Ave., Ste B
6280 W. Las Positas, Ste 215
6280 W. Las Positas Blvd Suite 215
1931 Canby Road
2081 Victor Ave.
2695 Bechelli Lane
6991 North State Street
6991 NORTH STATE STREET
6991 NORTH STATE STREET
3048 Hilltop Mall Road
2221 Sunset Blvd., Ste 119
2221 Sunset Blvd., Ste 119
665 Parker Ave.
1350 Medical Center Drive
5755 Redwood Drive
5755 Redwood Drive
5200 Snyder Lane Suite 3
5200 Snyder Lane
1331 Medical Center Drive, Ste H
40 Arlen Drive
6420 Commerce Blvd.
2 Padre Pkwy., Ste 200
5200 Snyder Lane, Ste 3
50 Enterprise Drive, Ste A
6585 Commerce Blvd., Ste E-‐275
5200 Snyder Lane, Ste 1
1331 Medical Center Drive, Ste H
1331 Medical Center Drive, Ste G
1331 Medical Center Drive, Ste G
1440 Medical Center Drive, Ste 1
455 Rohnert Park Expy. W.
5445 Snyder Lane
Petaluma
Petaluma
Petaluma
Petaluma
Petaluma
Petaluma
Petaluma
Petaluma
Petaluma
Petaluma
Petaluma
Petaluma
Petaluma
Petaluma
Petaluma
Petaluma
Pinole
Pleasanton
Pleasanton
Pleasanton
Pleasanton
Pleasanton
Pleasanton
Pleasanton
Pleasanton
Pleasanton
Pleasanton
Pleasanton
Redding
Redding
Redding
Redwood Valley
Redwood Valley
Redwood Valley
Redwood Valley
Redwood Valley
Redwood Valley
Richmond
Rocklin
Rocklin
Rodeo
Rohnert Park
Rohnert Park
Rohnert Park
Rohnert Park
Rohnert Park
Rohnert Park
Rohnert Park
Rohnert Park
Rohnert Park
Rohnert Park
Rohnert Park
Rohnert Park
Rohnert Park
Rohnert Park
Rohnert Park
Rohnert Park
Rohnert Park
Rohnert Park
Rohnert Park
Rohnert Park
Rohnert Park
(707) 773-‐1234
(707) 763-‐4611
(707) 766-‐7373
(707) 766-‐7668
(707) 763-‐9841
(707) 763-‐0962
(707) 762-‐9784
(707) 762-‐0067
(707) 762-‐5363
(707) 763-‐4116
(707) 789-‐9151
(707) 763-‐4122
(707) 762-‐0067
(707) 763-‐1959
(707) 762-‐0067
(707) 765-‐9630
(510) 724-‐3666
(925) 225-‐1011
(925) 225-‐1011
(925) 225-‐1011
(925) 225-‐1011
(925) 225-‐1011
(925) 225-‐1011
(925) 225-‐1011
(925) 225-‐1011
(925) 462-‐7117
(925) 225-‐1011
(925) 462-‐7117
(530) 222-‐1000
(530) 222-‐0939
(530) 222-‐4900
(707) 485-‐5115
(707) 485-‐5115
(707)485-‐5115
(707)4855-‐115
(707)485-‐5115
(707)485-‐5115
(510) 222-‐3322
(916) 435-‐1155
(916) 435-‐1155
(510) 799-‐0194
(707) 584-‐1360
(707) 584-‐1630
(707) 584-‐1000
(707) 584-‐1000
(707) 584-‐9589
(707) 584-‐9589
(707) 585-‐8599
(707) 795-‐5419
(707) 795-‐4523
(707) 585-‐8595
(707) 584-‐9589
(707) 585-‐0946
(707) 575-‐8700
(707) 585-‐3160
(707) 584-‐1630
(707) 585-‐8599
(707) 585-‐2525
(707) 585-‐2525
(707) 585-‐6000
(707) 206-‐0700
(707) 794-‐9995
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
PS
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
OS
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
EN
GD
GD
GD
GD
GD
PR
GD
GD
GD
GD
Yock
Cooper
Cooper
Herman
Herman
Joseph
Joseph
Kalia
Kalia
Kelly
Manaloto
Manaloto
Nguyen
Nguyen
Petersen
Petersen
Woo
Ward
Smith
Arevalo Marcos
Arevalo Marcos
Ayoub
Bacha
Baronia
Bennett
Brewster
Carlos
Castaneda
Ceniceros
Chan
Chan
Chavez
Cole
Conroy
Cox
Crandall
Creese
Debbane
Dumas
Eakle
Edwards
El Natour
Ellerhorst
Floresca
Fong
Fong
Freeman
Gee
Glick
Gonzalez Iii
Gregory
Grenn
Growney
Hom
Hom
Hoo
Hurowitz
Itokazu
Jang
Jang
Jew
Jue
Donna
Christopher
Christopher
Timothy
Timothy
Martine
Martine
Guneeta
Guneeta
Randall
Abdon
Abdon
Kayla
Kayla
Flaviane
Flaviane
Corrine
Michael
John
Carliza
Alicia
Samir
Jihad
Hipolito
Jeff
James
Julieta
Rebecca
Robert
Ricci
Derrick
Marco
Michael
Peter
Jeffery
Jennifer
Richard
Eric
Michael
W. Stephan
Cameron
Aref
Thomas
Romeo
Melvin
Brian
Kenneth
Patrick
Paul
Bernardo
James
Joseph
Maurice
William
Harry
Baldwin
Donna
Harold
Gail Chan
Corey
Ronald
Vincent
5300 Snyder Lane, Ste D
1258 Coloma Way
4000 Foothills Blvd., Ste #126
1258 Coloma Way
1258 Coloma Way
1258 Coloma Way
700 Sunrise Ave., Ste E
1258 Coloma Way
1258 Coloma Way
1258 Coloma Way
225 Spruce Ave.
905 Secret River Drive, Ste C
915 Sir Francis Drake Blvd.
3998 Mission Street
3998 Mission Street
500 Sutter Street, Ste 302
1569 Sloat Blvd., Ste 332
2460 Mission Street, Ste 211
490 Post Street, Ste 1450
2345 Ocean Ave.
2572 Noriega Street
2440 Mission Street
2001 Union Street, Ste 240
5300 Geary Blvd., Ste 210
2460 Mission, Ste 201
2595 Mission, Ste 308
1044 Taraval Street
187 Pine Street
2001 Union Street,Ste 666
450 Sutter, Ste 2031
2780 Mission Street
595 Buckingham Way #208
707 Parnassus Ave., Box 760
2364 Geary Blvd.
9 Silliman Street, Ste 1
2409 Taraval Street
2364 Geary Blvd.
690 Market Street, Ste 1500
2634 Geary Blvd.
500 Spruce Street, Ste 200
790 Ulloa Street
890 Jackson Street, Ste 301
3927 Sacramento Street
490 Post Street, Ste 1620
2305 Van Ness Ave.
490 Post Street Suite 1004
838 Grant Ave., Ste 309
Rohnert Park
Roseville
Roseville
Roseville
Roseville
Roseville
Roseville
Roseville
Roseville
Roseville
Roseville
Roseville
Roseville
Roseville
Roseville
Roseville
S. San Francisco
Sacramento
San Anselmo
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
(707) 586-‐1549
(916) 784-‐1144
(916) 771-‐7200
(916) 784-‐1144
(916) 771-‐7200
(916) 784-‐1144
(916) 771-‐7200
(916) 784-‐1144
(916) 771-‐7200
(916) 773-‐1122
(916) 784-‐1144
(916) 771-‐7200
(916) 784-‐1144
(916) 771-‐7200
(916) 784-‐1144
(916) 771-‐7200
(650) 588-‐2466
(916) 391-‐4848
(415) 453-‐1666
(415) 239-‐8511
(415) 239-‐8511
(415) 781-‐2227
(415) 664-‐6622
(415) 821-‐7847
(415) 421-‐6390
(415) 333-‐2308
(415) 337-‐7222
(415) 986-‐1616
(415) 285-‐9900
(415) 931-‐8795
(415) 221-‐5200
(415) 821-‐0101
(415) 647-‐9191
(415) 665-‐4300
(415) 397-‐4433
(415) 921-‐1726
(415) 986-‐5886
(415) 641-‐1001
(415) 664-‐5060
(415) 476-‐3028
(415) 921-‐6722
(415) 398-‐1345
(415) 921-‐0434
(415) 468-‐1777
(415) 564-‐6170
(415) 921-‐6722
(415) 398-‐6344
(415) 362-‐8287
(415) 921-‐6722
(415) 282-‐4566
(415) 986-‐1020
(415) 221-‐2900
(415) 566-‐8500
(415) 982-‐3053
(415) 362-‐0830
(415) 668-‐2200
(415) 391-‐7525
(415) 776-‐2010
(415) 982-‐4015
(415) 982-‐4015
(415) 398-‐4964
(415) 982-‐8434
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
PD
PD
GD
GD
PR
GD
PR
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
PR
GD
GD
GD
GD
GD
PR
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
PR
GD
GD
PD
GD
GD
GD
GD
GD
GD
GD
GD
GD
Keery
Kessler
Kiisk
Kinney
Kir
Komenaka
Konopaski
Lee
Lee
Leung
Liu
Look
Mack
Mazza
Mcfaul
Min
Nathan
Nguyen
Nguyen
Ochev
Pearl
Pollick
Relos
Rengstorff
Riaboff
Rodriguez
Roytman
Roytman
Sander
Schiller
Schulz
Sebastian
Shepard
Sidi
Silvestri
St. James
Staninec
Stonum
Szeto
Vaisman
Valdez
Velada
Vo
Vu
Woelfle
Woo
Yabu
Yep
Young
Nguyen
Kundra
Bennett
Canihan
Chase
Collard
Covin
Creaghe
Dab
Dalton
Deer
Foehr
Giusti
Joseph
Terry
Mat
Barry
Chun Pang
Gary
Ronald
Linda
Clara
Gayla
Peter
Lawrence
Ronald
John
Joel
Michael
Paul
Phuong
Binh
Igor
Richard
Howard
Apolinar
Peter
Peter
Ivan
Eugene
Eugene
Michael
Lary
John
Cecile
Bradley
Claude
Ann Marie
Stephen
Michael
Walter
K. Sam
Lilya
Hilaria
Mario
Sam Thi
Christine
Andrew
Wallace
Eric
William
Matthew
Binh
Darpan
Timothy
William
Steven
Anthony
Pamela
Richard
Michael
Bernard
Edwin
Robert
Lola
632 Taraval Street
129 Sacramento
3100 -‐ 19Th Ave.
814 Broadway
2364 Geary Blvd.
120 Battery Street
2411 Ocean Ave., Ste 203
2243 Van Ness Ave., Ste 102
1030 Clement Street
950 Stockton Street, Ste 400
632 Taraval Street
2364 Geary Blvd.
595 Buckingham Way, Ste 437
9 Silliman Street, Ste 2
3938 Geary Blvd.
2494 Mission Street
3003 Fillmore Street
350 Parnassus Ave., Ste 603
2440 Mission Street
403 -‐ 25Th Ave.
2494 Mission Street
4585 Mission Street
132 The Embarcadero
345 W. Portal Ave.
595 Buckingham Way, Ste 331
3003 Fillmore Street
22 Battery Street
2364 Geary Blvd.
3580 California Street, Ste 204
595 Buckingham Way
4318 Geary Blvd., Ste 202
760 La Playa
5865 Mission Street
3085 -‐ 24Th Street, Ste 2
825 Van Ness Ave., Ste 301
926 Irving Street
2 Embarcadero Center Podium
225 Columbus Ave.
2001 Union Street, Ste 240
2364 Geary Blvd.
450 Sutter Street Suite 1808
2351 B. Mckee Road
70 N. El Camino Real
411 -‐ 4Th Street
920 Northgate Drive, Ste 7
4050 Redwood Hwy.
880 Las Gallinas Ave.
411 4Th Street Suite B
1099 D Street, Ste 206
750 Las Gallinas, Ste 111
912 Grand Ave.
11 Greenfield Ave.
1721 -‐ 5Th Ave.
630 Pt. San Pedro Road
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Francisco
San Jose
San Mateo
San Rafael
San Rafael
San Rafael
San Rafael
San Rafael
San Rafael
San Rafael
San Rafael
San Rafael
San Rafael
San Rafael
(415) 661-‐5133
(415) 362-‐1850
(415) 584-‐2537
(415) 647-‐7077
(415) 392-‐0788
(415) 921-‐6722
(415) 391-‐4466
(415) 337-‐7222
(415) 771-‐2127
(415) 387-‐0963
(415) 392-‐2020
(415) 956-‐3317
(415) 661-‐5133
(415) 641-‐5200
(415) 921-‐0434
(415) 921-‐6722
(415) 681-‐0402
(415) 467-‐4726
(415) 386-‐8790
(415) 821-‐1200
(415) 346-‐9173
(415) 731-‐2757
(415) 821-‐2332
(415) 285-‐9900
(415) 668-‐1930
(415) 642-‐6777
(415) 821-‐1200
(415) 584-‐8500
(415) 777-‐5115
(415) 664-‐4532
(415) 731-‐4058
(415) 346-‐9173
(415) 982-‐4277
(415) 391-‐9748
(415) 921-‐0434
(415) 921-‐6722
(415) 563-‐2022
(415) 564-‐0160
(415) 751-‐1955
(415) 221-‐5592
(415) 334-‐2584
(415) 824-‐0395
(415) 441-‐7588
(415) 564-‐9888
(415) 398-‐4400
(415) 989-‐2729
(415) 447-‐6868
(415) 921-‐6722
(415) 392-‐8611
(408) 259-‐6394
(650) 685-‐1400
(415) 453-‐1927
(415) 479-‐4640
(415) 499-‐7700
(415) 479-‐8747
(415) 453-‐1927
(415) 453-‐0744
(415) 472-‐5211
(415) 456-‐8735
(415) 453-‐7501
(415) 453-‐4720
(415) 453-‐9470
GD
GD
GD
GD
GD
GD
EN
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
EN
GD
GD
GD
GD
GD
GD
GD
PS
GD
PD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
EN
EN
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
OS
GD
GD
GD
GD
GD
GD
OS
GD
GD
GD
GD
Grablin
Hakimi
Jaffe
Jarvis
Kirby
Lanphier
Levine
Lew
Lin
Nguyen
Rajkovic
Redfern
Rinck
Uelk
Varin
Christie
Coffey
Abbott
Abel
Achyuta
Aikawa
Albers
Alford
Amiri
Anderson
Anderson
Anderson
Apostle
Azmoudeh
Baird
Barbieri
Barnts
Bauer
Baum
Bean
Block
Bloom
Bornstein
Bozeman
Buoncristiani
Burrell
Butrica, Jr.
Buzza
Catalon
Cayco
Chamberlain
Chase
Chase
Chera
Chin
Chu
Collins
Costanza
Couture
Cox
Crandall
Danford
Daniel
Davis
Davis
Degolia
Delwiche
Gary
Farideh
Stephen
Thomas
John
Rita
Lawrence
Michael
Ben
Christine
Ana
James
Melissa
Thom
Thomas
William
John
James
Erin
Suryamanga
Charles
Harry
Kenneth
Hamid
Richard
Matthew
Heather
Gregory
Kamran
Gregory
Allen
Kelcie
Kenneth
Barry
Jeffrey
Conrad
Howard
Daniel
T. Brian
Mindi
E. Ronald
William
John
Phillip
Mirabel
Jeffrey
Douglas
Douglas
Alin
James B.K.
Tony
Frederic
Victor
Albert
Ronald
Jennifer
Michael
Christopher
Stephen
Richard
Ted
Amanda
1001 -‐ D Street
1721 -‐ 5Th Ave.
1531 -‐ 5Th Ave.
908 E Street
750 Las Gallinas Ave., Ste 108
662 Las Gallinas Ave.
911 Mission Ave.
411-‐4Th Street, Ste B
1530 -‐ 5Th Ave.
1534 -‐ 5Th Ave.
1118 Irwin Street
918 Center Street
1505 Soquel Drive, Ste 6
4655 Hoen Ave., Ste 2
1100 Sonoma Ave., Ste C3
4100 Montgomery Drive
397 Aviation Blvd., Ste L
1100 Sonoma Ave. Suite E-‐1
233 Farmers Lane
1421 Guerneville Road, Ste 102
90 Doctors Park Road, Ste A
90 Doctors Park Dr. Suite 90B
2305-‐A Mendocino Avenue
95 Montgomery Drive, Ste 210
1200 Farmers Lane
55 Mission Circle, Ste 106
1820 Sonoma Ave.,#76
301 College Ave.
4527 Montgomery Drive, Ste B
1144 Sonoma Ave., Ste 102
70 Doctors Park Drive
1421 Guerneville Rd., Ste 102
90 A Doctors Park Drive
990 Sonoma Ave., Ste. 22
2448 Guerneville Road Suite 1200
3080-‐A7 Marlow Road
2448 Guerneville Rd, Ste 1000
2801 Yulupa Ave., Ste D
6575 Oakmont Drive, Ste 5
838 Second Street
1100 Farmers Lane
4982 Sonoma Hwy.
1100 Sonoma Ave., Ste E-‐1
4757 Hoen Ave.
6574 Oakmont Drive, Ste B
1820 Sonoma Ave.# 80
2801 Yulupa Ave., Ste D
San Rafael
San Rafael
San Rafael
San Rafael
San Rafael
San Rafael
San Rafael
San Rafael
San Rafael
San Rafael
San Rafael
San Rafael
San Rafael
San Rafael
San Rafael
Santa Cruz
Santa Cruz
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
(415) 454-‐3222
(415) 479-‐4640
(415) 457-‐9366
(415) 479-‐1840
(415) 456-‐6366
(415) 454-‐8640
(415) 479-‐6444
(415) 479-‐6540
(415) 453-‐7188
(415) 479-‐6560
(715) 453-‐1927
(415) 457-‐2077
(415) 479-‐4977
(415) 453-‐8589
(415) 456-‐6729
(408) 429-‐8419
(831) 476-‐8724
(707) 523-‐3636
(707) 546-‐2235
(707) 537-‐2020
(707) 579-‐1201
(707) 575-‐1190
(707) 575-‐1900
(707) 528-‐7000
(707) 545-‐0944
(707) 526-‐3303
(707) 525-‐1502
(707) 542-‐4746
(707) 576-‐1416
(707) 537-‐1904
(707) 544-‐3287
(707) 546-‐0429
(707) 538-‐1086
(707) 538-‐8000
(707) 542-‐4414
(707) 545-‐1213
(707) 528-‐7000
(707) 546-‐4989
(707) 546-‐2887
(707) 528-‐7000
(707) 545-‐0944
(707) 528-‐8400
(707) 573-‐0600
(707) 578-‐2000
(707) 595-‐3615
(707) 526-‐6165
(707) 578-‐7701
(707) 539-‐8956
(707) 542-‐2676
(707) 523-‐3028
(707) 545-‐4625
(707) 539-‐4321
(707) 545-‐7575
(707) 526-‐6160
(707) 528-‐2420
(707) 575-‐1190
(707) 575-‐9944
(707) 545-‐4625
(707) 575-‐9595
(707) 539-‐0336
(707) 542-‐5125
(707) 526-‐6165
GD
PR
GD
GD
GD
OS
GD
GD
GD
GD
GD
EN
GD
GD
GD
GD
GD
GD
GD
GD
PR
PD
GD
EN
GD
GD
GD
GD
GD
PR
PR
GD
GD
GD
GD
PR
PR
EN
GD
GD
GD
GD
GD
PD
OS
EN
GD
GD
GD
OS
GD
GD
PR
PR
EN
GD
GD
GD
GD
GD
OR
GD
Desalvo
Dickinson
Didier
Downs
Du
Duffy
Edwards
Elliott
Elward
Erlach
Etchell
Factor
Fan
Farhang-‐Azad
Fernandez
Ferrick
Field
Foehl
Fontana
Ford
Ford
Forni
Forni
Fortman
Francis
Franke
Frey
Gabriel
Gaeta-‐Wilson
Gasper
Gee
Gilbaugh
Gock
Gonzalez
Gray
Grill
Grill
Grove Jr
Hamblin
Hamblin
Hammer
Harris
Hawkins
Hodges
Hoey
Holifield
Hurley
Husein
Jang
Jarvis
Jeffers
Jeffers
Jenderseck
Johansen
Johl
Jue
Kang
Kang
Katzoff
Kellam
Khalifa
Kim
Stephen
W. Reed
Robert
Simone
Katelyn
Patrick
Cameron
Jeffrey
Kelly
Robert
David
Thomas
Yunfei
Leila
Anthony
Reed
Eugene
Charles
Gina
Jason
Christine
Maryanne
James
Jared
Warren
Frederick
Mark
Sandy
Laura
Christina
Justin
Robert
Lorraine
Darren
Dinu
Gary
Gary
Robert
Michael
Michael
Joshua
David
William
Frank
Michael
Stephen
Patrick
Firas
Eun Sub
Robert
Robert
Kevin
Richard
Niels
Tej
Leslie
John (Yo-‐Hoon)
John (Yo-‐Hoon)
Richard
Wayne
El-‐Rasheed
Daniel
1416 Townview Lane
2305-‐A Mendocino Ave.
1206 Farmers Lane
140-‐A Stony Point Road
1421 Guerneville Road #102
301 College Ave.
2305-‐A Mendocino Ave.
3536 Mendocino Ave., Ste 350
2360 Mendocino Ave A6
170 Sotoyome Street
101 Brookwood Ave., Ste 203
515 Farmers Lane
4655 Hoen Ave, Ste 5
1100 Sonoma Ave., Ste B
90 Doctors Park Circle, Ste B
301 College Ave
4850 Glencannon Street
55 Elaine Drive
1100 Sonoma Ave., Ste C-‐2
3910 Princeton Drive
2360 Mendocino Ave. A-‐6
1421 Guerneville Road, #102
305 Farmers Lane
6575 Oakmont Drive, Ste 5
1100 Sonoma Ave.
1100 Sonoma Ave., Ste E
1331 Guerneville Road, Ste-‐G
42 Doctors Park Dr.
1416 Townview Lane
4527 Montgomery Drive, Ste B
1260 N. Dutton Ave., Ste 295
1260 N. Dutton Ave, Ste 295
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
(707) 573-‐9747
(707) 578-‐3010
(707) 525-‐1501
(707) 575-‐4450
(707) 528-‐7000
(707) 578-‐3118
(707) 528-‐7000
(707) 546-‐0429
(707) 539-‐4646
(707) 525-‐1502
(707) 575-‐1400
(707) 545-‐0944
(707) 537-‐2020
(707) 528-‐7000
(707) 546-‐1166
(707) 542-‐6772
(707) 568-‐1436
(707) 545-‐7811
(707) 579-‐0843
(707) 528-‐2420
(707) 568-‐7633
(707) 527-‐8509
(707) 544-‐2696
(707) 527-‐9170
(707) 545-‐0944
(707) 526-‐3303
(707) 545-‐4125
(707) 546-‐0429
(707) 571-‐8152
(707) 523-‐7423
(707) 537-‐0550
(707) 575-‐1194
(707) 546-‐9882
(707) 542-‐1532
(707) 568-‐1436
(707) 528-‐7000
(707) 571-‐1480
(707) 569-‐9706
(707) 544-‐6280
(707) 539-‐8956
(707) 526-‐6160
(707) 544-‐2811
(707) 578-‐3118
(707) 544-‐4611
(707) 545-‐4625
(707) 528-‐7730
(707) 546-‐3791
(707) 526-‐3900
(707) 545-‐3368
(707) 575-‐1198
(707) 545-‐2299
(707) 528-‐6343
(707) 578-‐3010
(707) 537-‐0550
(707) 544-‐1838
(707) 546-‐1680
(707) 538-‐8000
(707) 578-‐4700
(707) 578-‐7701
(707) 528-‐6343
(707) 578-‐3118
(707) 578-‐4700
GD
GD
GD
GD
GD
GD
OS
GD
PD
GD
GD
GD
GD
GD
EN
GD
PD
EN
OS
GD
GD
PR
GD
GD
GD
GD
GD
OS
EN
GD
GD
PR
GD
GD
GD
EN
GD
GD
EN
GD
GD
GD
GD
GD
GD
PR
OS
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
EN
GD
GD
GD
Komenaka
Kroncke
Latham
Lawrence
Lawson
Le
Le
Lee
Lee
Lee
Lee
Lehman
Leisen
Levin
Levine
Lieu
Lo
Loxley
Lyu
Machado
Mallory
Martin
Mayelzadeh
Meckstroth
Minye
Mjelde
Mlynarczyk
Mogannam
Morton
Mozafam
Murolo
Murray
Nelson
Nguyen
Nguyen
Nguyen
Nijjar
Niles
Nuwey
O'Brien
Osendorf
Ostad
Pascual
Petersen
Petersen
Phamduong
Phan
Plack
Pouradib
Poxon
Quock
Rice
Rice
Rice
Rich
Richards
Robinson
Ruo
Rush
Sandhu
Sandhu
Savko
Gary
Mark
Gary
Valeria
Scott
Nicole
Hung
Virginia
Tinna
Thomas
Thomas
Jason
Corrie
Howard
Lawrence
Anthony
Jennifer
Emine
Peter
Asterita
Marie
Michael
Behzad
Robert
John
Christopher
Gregory
Jiries
Nicklaus
Maryum
Christopher
Patricia
Alec
Randy T-‐Q
Harrison
Brian
Harit
Diane
Donald
Jason
Gerret
Naser
Anna Lynn
Susan
Jeffrey
Sharon
The
Les
Hassan
Mary
Stanley
Michael
Lara
Elden
John
Leonard
John
Hiko
Randolph
Kamaldeep
Jagdeep
John
1420 Townview Lane
1408 Townview Lane
1421 Guernville Road #102
3536 Mendocino Ave Suite 330
301 College Ave.
1331 Guerneville Road, Ste G
1408 Townview Lane
4527 Montgomery Drive Suite B
70 Stony Point Rd, Ste #E
170 Farmers Lane, Ste 1
1100 Sonoma Ave., Ste A-‐2
1111 Sonoma Ave Suite 220
1421 Guernville Road, Ste 102
1100 Sonoma Ave., Ste D
855 Fountaingrove Pkwy., Ste 100
526 College Ave.
526 College Ave.
90 A. Doctors Park Drive
2285 Cleveland Ave.
1820 Sonoma Ave., #76
301 College Avenue
55 Elaine Street
2801 Yulupa Ave., Ste A
2801 Yulupa Ave., Ste A
1206 Farmers Lane
98 Montgomery Drive
55 Elaine Drive
988 Sonoma Ave.
95 Montgomery Drive, #212
3536 Mendocino Ave., Ste 330
4757 Hoen Ave.
4757 Hoen Ave.
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
(707) 528-‐7000
(707) 578-‐3721
(707) 527-‐7400
(707) 546-‐7699
(707) 542-‐1532
(707) 539-‐3999
(707) 528-‐7000
(707) 539-‐3503
(800) 922-‐3132
(707) 545-‐3368
(707) 578-‐4700
(707) 544-‐1836
(707) 546-‐2129
(707) 544-‐6280
(707) 545-‐0944
(707) 528-‐7000
(707) 528-‐7000
(707) 545-‐4104
(707) 546-‐0429
(707) 526-‐6800
(707) 542-‐7800
(707) 546-‐7699
(707) 623-‐9913
(707) 575-‐9200
(707) 539-‐8762
(707) 542-‐7800
(707) 527-‐0363
(707) 566-‐7300
(707) 575-‐1190
(707) 528-‐7000
(707) 528-‐7000
(707) 525-‐1600
(707) 546-‐2829
(707) 527-‐8700
(707) 527-‐8700
(707) 545-‐0944
(707) 545-‐3338
(707) 542-‐7577
(707) 575-‐1190
(707) 546-‐0429
(707) 523-‐7423
(707) 544-‐8338
(707) 528-‐6797
(707) 579-‐2808
(707) 579-‐2808
(707) 528-‐7000
(707) 528-‐7000
(707) 575-‐1190
(707) 544-‐8338
(707) 575-‐4450
(707) 578-‐7424
(804) 318-‐0135
(707) 539-‐8956
(707) 542-‐9380
(707) 575-‐1190
(707) 542-‐8104
(707) 537-‐1002
(707) 528-‐3412
(707) 545-‐4104
(707) 575-‐9595
(707) 575-‐9595
(707) 539-‐3998
GD
GD
GD
GD
OS
GD
GD
PR
GD
PR
PR
GD
GD
GD
GD
GD
OS
OS
GD
GD
PD
OS
GD
OS
PR
PR
PR
PR
GD
GD
GD
EN
EN
GD
GD
GD
PR
GD
GD
GD
GD
GD
GD
EN
EN
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
PD
GD
GD
GD
GD
GD
Schettler
Schneider
Schwartz
Scott
Sejud
Sellman
Sharma
Simonds
Skabelund
Steigerwald
Steiner
Streutker
Streutker
Sullivan
Sullivan
Templin
Tiernan
Tolin
Tomaszewski
Tomaszewski
Tornabene
Trent
Trent
Tyko
Uemura
Uemura
Uemura
Veber
Vu
Waggener
Wallace
Waterman
Weaver
Westerberg
Wilburn
Wilson
Wilson
Wiseman
Wyatt
Wyatt
Xiao
Yeager
Yount
Zahedi
Zoufan
Davey
Smith
Benstock
Dixon
Dixon
Ford
Hetler
Jang
Kahle
Lucchese
Nakashima
Oliver
Tharp
Thielen
Webb
Dacio
Perez
Darin
George
Simeon
Michael
Paul
Richard
Sandeep
James
Todd
Paul
Gregory
Donald
Dawne
Scott
Daniel
Jeff
Paul
Jack
Christine
Art
Ann
David
Brigid
Leonard
Jay
Jay
Jay
Yuri
Han
Kelly
Christopher
Phillip
Clinton
Linnea
Steven
Sean
Craig
Richard
Cherylin
Cherylin
Wanlan
Paul
Ben
Leila
Keivan
Bruce
Delman
Scott
Scott
Gerald
Larry
Bryce
Eun Sub
Stephanie
Rose
Larry
Robert
David
Paul
Patricia
Rudy
Lutgarda
1432 Townview Lane
479 Stony Point Road
418 Aviation Blvd., Ste A
1544 Sebastopol Road
2213 Mendocino Ave., Ste A
2321 Bethards Drive
868 -‐ 2Nd Street
6543 Montecito Blvd.
6543 Montecito Blvd., Ste 1
65 St. James Drive
2135 Armory Drive, Ste 200
2135 Armory Drive, Ste 200
1421 Guerneville Road #102
515 Farmers Lane
2213 Mendocino Ave., Ste A
868 -‐ 2Nd Street
526 College Ave.
1400 Townview Lane
1202 Farmers Lane
4755 Hoen Ave.
98 Montgomery Drive
2321 Bethards Drive, Ste A-‐1
2798 Yulupa Ave., Ste B
301 College Ave.
30 Caledonia Street, Ste B
107 Caledonia Street, Ste 1
652 Petaluma Ave., Ste A
6800 Palm Avenue Ste. E
6800 Palm Ave., Ste E
120 Pleasant Hill Ave. N., Ste 110
7138 Willow Street
6800 Palm Ave., Ste F
568 Petaluma Ave.
7164 Keating Ave.
8901 Barnett Valley Road
568 Petaluma Ave.
318 S. Main Street
410 James Street
410 James Street
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Santa Rosa
Sausalito
Sausalito
Sebastopol
Sebastopol
Sebastopol
Sebastopol
Sebastopol
Sebastopol
Sebastopol
Sebastopol
Sebastopol
Sebastopol
Sebastopol
Sebastopol
Sebastopol
Shafter
Shafter
(707) 576-‐1595
(707) 542-‐4692
(707) 575-‐9200
(707) 542-‐7223
(707) 566-‐7300
(707) 575-‐3105
(707) 000-‐0000
(707) 525-‐0555
(707) 527-‐9280
(707) 525-‐1228
(707) 545-‐0944
(707) 539-‐2176
(707) 539-‐2176
(707) 546-‐6367
(707) 545-‐5260
(707) 545-‐8191
(707) 546-‐4727
(707) 545-‐4625
(707) 544-‐5700
(707) 544-‐5700
(707) 528-‐7000
(707) 545-‐4625
(707) 527-‐8509
(707) 545-‐4625
(707) 525-‐0555
(707) 544-‐1836
(707) 575-‐1190
(707) 525-‐1228
(707) 527-‐8700
(707) 544-‐1836
(707) 578-‐8100
(707) 546-‐7905
(707) 526-‐7036
(707) 571-‐7890
(707) 542-‐2881
(707) 579-‐1555
(707) 544-‐4922
(707) 527-‐9280
(707) 545-‐0944
(707) 546-‐3791
(707) 546-‐1680
(707) 542-‐7299
(707) 546-‐0429
(707) 575-‐1190
(707) 575-‐1190
(415) 332-‐4011
(415) 332-‐2438
(707) 823-‐5339
(707) 823-‐8529
(707) 823-‐8529
(707) 823-‐6481
(707) 824-‐5454
(707) 823-‐5308
(707) 823-‐7417
(707) 829-‐0692
(707) 823-‐1211
(707) 823-‐5207
(707) 829-‐0692
(707) 823-‐3654
(707) 823-‐6010
(661) 746-‐4067
(661) 746-‐4067
GD
EN
GD
GD
GD
GD
GD
GD
OS
GD
PD
OS
OS
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
OS
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
PR
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
OS
PR
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
Daffurn
Holifield
Ivanoff
Kittleson
Lopes
Marcus
Meyerhof
Neale
Schaller
Wong
Avula
Bae
Chung
Edwards
Fernandez
Gotamco
Gotamco
Komenaka
Reed
Turner
Vassilian
Waters
Smida
Ballard
Boettger
Cizek
Dutro
Howe
Lee
Limbird
Mannion, Jr.
Ortega
Pasternak
Phillips
Powell
Scoggins
Steigerwald
Tom
Dan
Stephen
Robert
Richard
Alan
Robert
Daryl
William
Virginia
Sara
Wonseok
John
Steven
Paul
William
Robert
Lily
Shelly
Dutro
Pasternak
Ortega
Phillips
Limbird
Howe
Richard
Stephen
Alex
Daniel
Jeffrey
Dena
Peter
Christopher
Lee
Richard
Shilpa
Richard
Francis
Cameron
Cristian
Vincent John
Vincent
Gary
Duff
Lance
Jenny
Randall
Branko
Daryl
Steven
Sara
Dan
Robert
Wonseok
Alan
William
Robert
Stephen
Richard
Virginia
John
Paul
William
Dutro
Pasternak
Ortega
Phillips
Limbird
Howe
Ballard
Mannion,Jr.
Powell
Cizek
Lee
Scoggins
Boettger
Steigerwald
Tom
Barrington
Brinckhaus
Cheneweth
Dan
Stephen
Robert
Richard
Alan
Robert
181 Andrieux Street, Ste 104
375 Perkins Street
17776 Sonoma Hwy.
548 Third Street West
399 W. Napa Street
644 Third Street West Suite A
684 W. Napa Street
644 Third Street West, Ste A
378 Perkins Street
390 W Napa
555 W. Benjamin Holt Drive, Ste 100
555 W. Benjamin Holt Drive, Ste B
3453 Brookside Road, Ste B
1545 St. Marks Plaza, Ste 11
1565 Hollenbeck Ave., Ste 110
1690 Tiburon Blvd.
413 W. Standley Street
620 S. Dora Street, Ste 205
660 N State Street
715 S. Dora Street
715 South Dora Street
1096 S. Dora Street
1119 S. State Street
1091 S. Dora Street
1377 S. Dora Street
303 Luce Ave.
307 Luce Ave.
1091 S. Dora Street
1252 Airport Park Blvd., Ste D1
765 S. Dora Street
715 S. DORA STREET
303 LUCE AVE.
1377 S. DORA STREET
307 LUCE AVE.
1119 S. STATE STREET
715 SOUTH DORA STREET
413 W. STANDLEY STREET
1091 S. DORA STREET
1091 S. DORA STREET
660 N STATE STREET
1096 S. DORA STREET
1252 AIRPORT PARK BLVD., STE D1
620 S. DORA STREET, STE 205
765 S. DORA STREET
620 S. DORA STREET, STE 205
660 NO. STATE 415 W. STANDLEY STREET
236-‐A HOSPITAL DRIVE
715 S. Dora Street
303 Luce Ave.
1377 S. Dora Street
307 Luce Ave.
1119 S. State Street
715 South Dora Street
Sonoma
Sonoma
Sonoma
Sonoma
Sonoma
Sonoma
Sonoma
Sonoma
Sonoma
Sonoma
Stockton
Stockton
Stockton
Stockton
Stockton
Stockton
Stockton
Stockton
Stockton
Stockton
Stockton
Sunnyvale
Tiburon
Ukiah
Ukiah
Ukiah
Ukiah
Ukiah
Ukiah
Ukiah
Ukiah
Ukiah
Ukiah
Ukiah
Ukiah
Ukiah
Ukiah
Ukiah
Ukiah
Ukiah
Ukiah
Ukiah
Ukiah
Ukiah
Ukiah
Ukiah
Ukiah
Ukiah
Ukiah
Ukiah
Ukiah
Ukiah
Ukiah
Ukiah
Ukiah
Ukiah
Ukiah
Ukiah
Ukiah
Ukiah
Ukiah
Ukiah
(707) 996-‐4585
(707) 933-‐9700
(707) 935-‐8200
(707) 938-‐3077
(707) 996-‐6704
(707) 996-‐7775
(707) 996-‐8833
(707) 996-‐7775
(707) 996-‐4519
(707) 938-‐5322
(209) 473-‐7888
(209) 473-‐7888
(209) 473-‐7888
(209) 473-‐7888
(209) 473-‐7888
(209) 473-‐8884
(209) 473-‐7888
(209) 473-‐7888
(209) 473-‐7888
(209) 957-‐1244
(209) 473-‐7888
(408) 730-‐4444
(415) 789-‐5899
(707) 462-‐2022
(707) 462-‐6983
(707) 462-‐2022
(707) 462-‐6052
(707) 462-‐6052
(707) 462-‐5706
(707) 462-‐2993
(707) 462-‐1540
(707) 462-‐3875
(707) 462-‐5071
(707) 462-‐1881
(707) 462-‐1540
(707) 462-‐8719
(707) 462-‐0880
(707) 462-‐6983
(707)462-‐6052
(707)462-‐5071
(707)462-‐3875
(707)462-‐1881
(707)462-‐2993
(707)462-‐6052
(707)462-‐2022
(707)462-‐1540
(707)462-‐1540
(707)462-‐2022
(707)462-‐5706
(707)462-‐8719
(707)462-‐6983
(707)462-‐0880
(707)462-‐6983
(707)462-‐4751
(707)462-‐2170
(707)468-‐0444
(707)462-‐6052
(707)462-‐5071
(707)462-‐3875
(707)462-‐1881
(707)462-‐2993
(707)462-‐6052
GD
GD
GD
GD
GD
GD
OS
PR
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
GD
OS
GD
GD
PD
EN
GD
GD
Ballard
Mannion, Jr.
Powell
Cizek
Lee
Scoggins
Boettger
Steigerwald
Tom
Pederson
Aquino
Chua
Dacasin
Ho
Ho
Porteous
Te-‐San Gabriel
Wong
Green
Sagarian
Rued
Henry
Alfred
Rued
Chun
Jarvis
Mc Naughton
Monraz
Oliver
Scheiner
Scott
Scott
Daryl
William
Virginia
Sara
Wonseok
John
Steven
Paul
William
Wayne
Editha
Marie
Steve
Violeta
Gordon
Lawrence
Jeannie
Darren
James
Mike
Henry
Rued
Kerr
Henry
Tedmund
Robert
John
Sergio
Robert
David
Steve
Steve
413 W. Standley Street
1091 S. Dora Street
1091 S. Dora Street
660 N State Street
1096 S. Dora Street
1252 Airport Park Blvd., Ste D1
765 S. Dora Street
1010 Nut Tree Road, Ste 280
2600 Springs Road, Ste A
96 -‐ A Springstowne Center
96 -‐ A Springstown Center
2600 Springs Road
2600 Springs Road
972 Admiral Callaghan Lane
2600 Springs Road
2254 Tennessee Street
13 Main Street
1229 7Th Street
361 S. Main Street
361 S. MAIN STREET
12 W. VALLEY STREET
361 S. Main Street
8260 Old Redwood Hwy Ste 101
8741 Brooks Road South, Ste 101
8012 Creekside Drive
8741 Brooks Road South, Ste 201
8911 Lakewood Dr, #15
8741 Brooks Road, Ste 100
8908 Lakewood Drive
173 Johnson Street
Ukiah
Ukiah
Ukiah
Ukiah
Ukiah
Ukiah
Ukiah
Ukiah
Ukiah
Vacaville
Vallejo
Vallejo
Vallejo
Vallejo
Vallejo
Vallejo
Vallejo
Vallejo
Valley Springs
Wasco
Willits
Willits
Willits
Willits
Windsor
Windsor
Windsor
Windsor
Windsor
Windsor
Windsor
Windsor
(707)462-‐2022
(707)462-‐1540
(707)462-‐1540
(707)462-‐2022
(707)462-‐5706
(707)462-‐8719
(707)462-‐6983
(707)462-‐0880
(707)462-‐6983
(707) 447-‐1010
(707) 642-‐3711
(707) 642-‐2938
(707) 644-‐5528
(707) 642-‐3711
(707) 642-‐3711
(707) 648-‐3384
(707) 642-‐3711
(707) 643-‐8399
(209) 772-‐8662
(661) 758-‐5338
(707) 459-‐6103
(707)459-‐6103
(707)459-‐2163
(707)459-‐6103
(707) 838-‐6697
(707) 838-‐8836
(707) 544-‐9519
(707) 838-‐0444
(707) 838-‐7207
(707) 837-‐8311
(707) 838-‐2559
(707) 838-‐2559
Get the best in eyecare and
eyewear with
SANTA ROSA CITY ELEMENTARY &
HIGH SCHOOL DISTRICT and VSP®
Vision Care.
At VSP, we invest in the things you value most—the best
care at the lowest out-of-pocket costs. Because we’re
the only national not-for-profit vision care company, you
can trust that we’ll always put your wellness over profit.
You’ll like what you see with VSP.
• Value and Savings. You’ll enjoy more value and the lowest out-ofpocket costs.
• High Quality Vision Care. You’ll get the best care from a VSP doctor
including a WellVision Exam®—the most comprehensive exam
designed to detect eye and health conditions.
• Choice of Providers. The decision is yours to make—choose a VSP
doctor, retail chain affiliate, or any other provider.
• Great Eyewear. It’s easy to find the perfect frame at a price that fits
your budget.
Using your VSP benefit is easy.
• Find an eyecare provider who’s right for you.
To find a VSP doctor or retail chain affiliate, visit vsp.com or call
800.877.7195.
• Review your benefit information. Once your benefit is effective, visit
vsp.com to review your plan coverage before your appointment.
• At your appointment, tell them you have VSP.
There’s no ID card necessary.
That’s it! We’ll handle the rest—there are no claim forms to complete
when you see a VSP doctor or retail chain affiliate.
Choice in Eyewear
From classic styles to the latest designer frames, you’ll find hundreds of
options. Choose from great brands, like bebe®, ck Calvin Klein, Flexon®,
Lacoste, Michael Kors, Nike, Nine West, and more. Visit vsp.com to find a
doctor who carries these brands.
See why we’re
consumers’ #1
choice in vision care.
Contact us.
vsp.com | 800.877.7195
Your VSP Vision Benefits Summary
Santa Rosa City Elementary & High School District and VSP provide you with an affordable eyecare plan.
VSP Coverage Effective Date: 07/01/2014
VSP Doctor Network: VSP Signature
Benefit
Visit vsp.com for more details on your
vision benefit and for exclusive savings
and promotions for VSP members.
Description
Copay
Frequency
Your Coverage with VSP Doctors and Affiliate Providers*
WellVision Exam
• Focuses on your eyes and overall wellness
$0
Every 12 months
$25
See frame and lenses
Frame
• $150 allowance for a wide selection of frames
• $170 allowance for featured frame brands like bebe®, ck Calvin
Klein, Flexon®, Lacoste, Michael Kors, Nike, Nine West, and more
• 20% off amount over your allowance
• $80 allowance for Costco frames
Included in
Prescription
Glasses
Every 24 months
Lenses
• Single vision, lined bifocal, and lined trifocal lenses
• * Interim Benefits: Lenses every 12 months with a prescription
change of .50 diopter or more
• Polycarbonate lenses for dependent children
Included in
Prescription
Glasses
Every 24 months*
Lens Options
•
•
•
•
Contacts
(instead of glasses)
Primary Eyecare
Prescription Glasses
Standard progressive lenses
Premium progressive lenses
Custom progressive lenses
Average 35-40% off other lens options
$50
$80 - $90
$120 - $160
Every 24 months
• $150 allowance for contacts lenses
Contact lens exam (fitting & evaluation)
• 15% off contact lens exam (fitting and evaluation)
$60
Every 24 months
• Treatment and diagnosis of eye conditions like pink eye, vision loss
and monitoring of cataracts, glaucoma and diabetic retinopathy.
Limitations and coordination with medical coverage may apply. Ask
your VSP doctor for details.
$20
As needed
Glasses and Sunglasses
• 30% off additional glasses and sunglasses, including lens options, from the same VSP doctor on the same day as
your WellVision Exam. Or get 20% off from any VSP doctor within 12 months of your last WellVision Exam.
Extra Savings
and Discounts
Retinal Screening
• Guaranteed pricing on retinal screening as an enhancement to your WellVision Exam.
Laser Vision Correction
• Average 15% off the regular price or 5% off the promotional price; discounts only available from contracted facilities
• After surgery, use your frame allowance (if eligible) for sunglasses from any VSP doctor
Your Coverage with Other Providers
Visit vsp.com for details, if you plan to see a provider other than a VSP doctor.
Exam............................................up to $50
Frame..........................................up to $70
Single Vision Lenses............up to $50
Lined Bifocal Lenses...........up to $75
Lined Trifocal Lenses..........up to $100
Progressive Lenses..............up to $75
Contacts....................................up to $105
*Coverage with a retail chain affiliate may be different. Once your benefit is effective, visit vsp.com for details.
Coverage information is subject to change. In the event of a conflict between this information and your organization’s contract with VSP, the terms of the contract will prevail.
See why we’re consumers’ #1
choice in vision care.
Contact us. vsp.com | 800.877.7195
©2010 Vision Service Plan. All rights reserved.
VSP and WellVision Exam are registered trademarks of Vision
Service Plan. All other company names and brands are
trademarks or registered trademarks of their respective owners.
Flexible Spending Plan
Administered by:
Plan Year: 2012-2013
Santa Rosa City Schools - Flexible Spending Plan
Plan Administrator: Shirrell Consulting Services
2012-2013 Plan Year
Thank you for your interest in the Santa Rosa City Schools Flexible Spending Plan. This
brochure has been created to educate you in the benefits of a Flexible Spending Account. If
after reading this brochure, you have any questions please do not hesitate to contact our
office:
Phone: (707) 544-1801
What is a Flexible Spending Plan (FSA)?
A Flexible Spending Plan is an IRS plan offered by Santa Rosa City Schools to help reduce
your taxable income. The Flexible Spending Plan consists of three separate programs:
• The “Premium Payment Plan”
• The “Medical Expense Account”
• The “Dependent Care Account”
The Premium Payment Plan allows for your medical, dental and vision premiums
(district sponsored plans only) to be deducted from your paycheck on a pre-tax basis.
PLEASE NOTE: IRS regulations do not permit the reimbursement of your premiums
as a medical expense.
The Medical Expense Account allows you to be reimbursed for eligible out-of-pocket
medical/dental/vision and over-the-counter expenses (See List) that were incurred during
the plan year using pre-tax dollars.
The Dependent Care Account allows you to be reimbursed for eligible dependent care
expenses for children under the age of 13 or for expenses paid for the care of a dependent
who is physically or mentally incapable of caring for him/her self that were incurred during
the plan year using pre-tax dollars.
Flexible Spending Plan Eligibility
All employees who are eligible for benefits through Santa Rosa City Schools are eligible to
participate in the Flexible Spending Plan.
Santa Rosa City Schools Plan Year
The plan year 2012-2013 runs from July 1, 2012 through June 30, 2013.
Flexible Spending Plan
You will need to enroll to the Premium Payment Plan annually, but your
medical/dental/vision premiums will automatically be deducted from your paycheck on a
pre-tax basis.
For the Medical Expense Account and the Dependent Care Account you will first need to
estimate your medical/dependent care expenses for the plan year. Make sure you take care
with this first step, as there is an IRS “use-it-or-lose-it” rule in effect for the Flexible
Spending Account where any unused funds remaining in your account(s) at the end of the
plan year/grace period are forfeited. Once you have determined your annual election, it will
be divided by the number of paychecks you receive in the plan year. These monthly
contributions are deducted from your paycheck on a pre-tax basis and are submitted to our
office. When you submit a claim for reimbursement, your check will be processed using the
funds contributed to your Medical Expense Account and/or Dependent Care Account.
Contribution Maximums
Medical Expense Account - A maximum election of $2,500 can be tax deferred for
approved out-of-pocket expenses for each plan year as determined by Santa Rosa City
Schools.
Dependent Care Account - A maximum election of $5,000 can be tax deferred for
approved out-of-pocket expenses for each plan year as determined by the IRS.
• The $5,000 maximum must be reduced to $2,500 if you are married and file a
separate federal income tax return (unless you are legally separated.) If your spouse
contributes to a separate Dependent Care Account through his/her employer the
$5,000 maximum must be reduced by their annual election.
• If you or your spouse earns less than $5,000/year, the maximum is then reduced to
the lesser of the two incomes.
• If your spouse is a full-time student at an educational institution during at least five
months of the plan year, or if your spouse is incapable of self-care during any month,
your maximum contribution is $250/month if you have one dependent or
$500/month if you have two or more dependents.
• If your child will turn 13 during the plan year, your Dependent Care maximum
should only be calculated for the time your child is under 13.
“Use-it-or-lose-it” Rule
IRS regulations require that any unused balance remaining in your Medical
Expense/Dependent Care Account(s) be forfeited if not used by the end of the plan year and
subsequent grace period. If you over estimate your expenses for the year and are unable to
request full balance reimbursement you will permanently forfeit the balance of your
account(s) for that plan year. Any forfeited balance remains in the Santa Rosa City Schools
Account (A non-interest bearing account) and accumulates there. Santa Rosa City Schools
can request disbursement of the accumulated balance at any time and is permitted by the
IRS to use the money for administrative costs.
Grace Periods
For the Medical Expense Account only, there is a grace period that begins after the end of
the plan year. This grace period is two and a half months long and runs from July 1, 2013September 15, 2013. During this time you are allowed to incur expenses and apply them to
any remaining balance in your 2012 account before the difference is “rolled over” to your
2012-2013 account if you elected to re-enroll.
EXAMPLE: As of June 30, 2013 (The end of the plan year) you still have $300.00
remaining in your Medical Expense Account you may incur expenses from July 1, 2013
through September 15, 2013, those expenses would first be applied to your 2012 remaining
balance before the expenses are applied to your new 2013 account. This eases the “use-itor-lose-it” rule.
Unfortunately, this grace period is not available for the Dependent Care Account. All claims
for reimbursement for the Dependent Care Account must be for expenses incurred within
the plan year (July 1, 2012 - June 30, 2013.)
Claims Run-Out Period
For both the Medical Expense Account as well as the Dependent Care Account you have 90
days from the last day of the plan year in which to submit claims for expenses incurred
within the plan year. This means you are allowed to submit claims for expenses incurred
from July 1, 2012 - June 30, 2013 until September 30, 2013. Claims submitted for
reimbursement of your 2012-2013 plan year after September 30, 2013 will not be processed
and any remaining balance will be forfeited.
Claim Reimbursement Procedures
In order to receive reimbursement for eligible health care from your Medical Expense
Account, you will need to complete and submit a Santa Rosa City Schools Claim Form for
Reimbursement along with legitimate documentation of your expenses:
• On the Claim Form for Reimbursement, you will need to provide your name, social
security number, home and work phone number as well as your signature and the
date.
• You will also need to complete the appropriate section of the claim form based on the
account(s) in which you are participating. Provide the date(s) of service, the service
provider, a brief service expense description, patient name as well as the net amount.
• You will need to attach a copy of the Explanation of Benefits from your insurance
carrier (Medical, dental and/or vision) or you may submit the printed receipt or
billing statement as long as they provide the amount charged for each service/item
and the date or service.
• PLEASE NOTE: Per IRS regulations, all medical/dental/vision expenses must be
submitted to your appropriate insurance carrier regardless of whether or not it is a
covered benefit. If you do not have insurance, please make a note on your Claim
Form for Reimbursement each time you submit for reimbursement.
In order to receive reimbursement for eligible health care from your Dependent Care
Account, you will need to complete and submit a Claim Form for Reimbursement along
with legitimate documentation of your expenses:
•
•
On the Claim Form for Reimbursement, you will need to provide your name, social
security number, home and work phone number as well as your signature and the
date.
You will also need to complete the appropriate section of the claim form based on the
account(s) in which you are participating. Provide the date(s) of service, the name of
your dependent care service provider, their address and tax i.d./ social security
number and/or license number, the name of your dependent(s) and the amount
charged.
Claim Submittal
Claims can be submitted at any time and claim submittal is decided by the employee.
Claims received by Wednesday are prepared for the weekly check run on Thursday and
payments are mailed out on Fridays. There is no minimum reimbursement request, we will
process a check for any amount.
Claim Reimbursement
Medical Expense Account - You are eligible to receive your full annual election amount
day one of the plan year regardless of the actual current balance of your account.
Dependent Care Account - You are only eligible to receive your current account balance
under your Dependent Care Account. If you submit a claim requesting more than the
current balance of your account you will receive a check for a partial payment, the
remainder of your claim will be carried over to the next month for payment until further
funds are contributed.
Claim Rejection
If a claim submitted for reimbursement from your Medical Expense/Dependent Care
Account(s) is received and part of the claim cannot be processed, you will receive a letter
with your partial check explaining what specifically was denied, the reason for denial and if
applicable, what is needed to receive reimbursement if the item/service was an eligible
expense. You may then follow the directions in the letter to obtain the necessary
documentation/information to re-submit your request.
If a claim is submitted for reimbursement from your Medical Expense/Dependent Care
Account(s) is received and the expense(s) are ineligible for reimbursement you will receive a
letter explaining what specifically was denied and the reason for denial.
Employee Statements
Employee Statements are provided automatically by mail to you every quarter. These
statements show your monthly contributions, payments and remaining funds to date. Your
Employee Statement reflects both your Medical Expense Account activity as well as your
Dependent Care Account activity.
If at any time during the year you wish to request your balance or inquire on your account,
you may contact:
angela@shirrellconsulting.com
Phone: (707) 544-1801
Fax: (707) 544-1804
Eligible Dependent Care Expenses
The Dependent Care Account can be used for expenses related to the care of your
dependent(s) preformed in or outside of your home while you or your spouse is at work or if
you or your spouse, attend school full-time. (See IRS publication 503 for further examples
of covered expenses: http://www.irs.gov/pub/irs-pdf/p503.pdf)
•
Day Care Center - Licensed day care centers, preschools, nursery schools, and day
camps (Expenses paid for over night camps are not a reimbursable expense.) In
order to be classified as an eligible dependent care provider, these centers must:
 Not be for the primary purpose of education
 Comply with all applicable laws and regulations of the state, city or
town in which it is located
 Receive a payment, fee or grant from the individuals for whom it
provides services
•
Caregiver - An individual providing dependent care services. This could be anyone
but:
 You or your spouse
 Anyone you claim as a dependent on your taxes
 You or your spouses child, unless he/she is 19 years or older
•
Eligible Dependent - You may receive reimbursement for any dependent whom
you claim on your tax return as long as they:
 are you or your spouses child (son, daughter, step-son, step-daughter)
under the age of 13
 Physically or mentally incapable of caring for him/herself. This could
be a handicapped child (regardless of age) or family member who lives
with you for more than half of the plan year.
Eligible Medical Expenses
The Medical Expense Account can be used for out-of-pocket expenses not covered by
insurance incurred by yourself or eligible family member. (See IRS publication 502 for
further examples of covered expenses: http://www.irs.gov/pub/irs-pdf/p502.pdf)
•
Eligible Family Member - You may receive reimbursement for expenses incurred
by any person who is included as a dependent on your federal tax return:
 Yourself


•
Your spouse or a domestic partner who qualifies as a tax dependent
You or your spouses child (son, daughter, step-son, step-daughter)
Eligible Expenses - Must be incurred for an eligible medical, dental or vision
service.
 Medically necessary
 Not covered or reimbursable by your insurance
 Acceptable under IRS publication 502
 Many over-the-counter items
QUALIFYING MEDICAL EXPENSES
*Acupuncture
*Ambulance
*Artificial limbs
*Artificial teeth & eyes
*Auto modifications (hand controls, etc.)
*Birth control
*Blood donor
*Braille books & magazines
*Chiropractic
*Co-insurance
*Contact lens solution
*Cost of physical or mental illness confinement
*Crutches
*Deductibles
*Dental care, orthodontic treatment
*Diagnostic fees
*Doctor’s fees
*Drugs (legal prescriptions only & insulin)
*Elastic hosiery, medically necessary
*Eyeglasses/contacts
*Eye examination fees
SERVICES NOT REIMBURSABLE:
*Cosmetic surgery
*Dance lessons
*Dental bleaching or teeth whitening
*Diapers or diaper services
*Fitness expenses
*Funeral expenses
*Hair transplant
*Health club dues
*Maternity clothes
*Medical, dental, vision or COBRA premiums
*Swimming Lessons
*Special tooth cleaning systems ex: Sonicare
*Homeopathic medicine
*Hospital
*Laboratory
*Laser eye surgery
*Massages only for stress relief or to treat
illness
*Nursing care
*Oculist
*Ophthalmologist
*Optician therapy treatment
*Over the counter drugs that are
medically necessary
*Oxygen equipment
*Physicians fees
*Prescribed medicines
*Psychiatric care
*Psychologist fees
*Seeing-eye dogs
*Transportation
*Wheelchair
*Wigs (for medical reasons only)
*X-rays
REQUIRES DOCTOR LETTER:
Must be reviewed for approval
*Acne Medication
*Dental Flouride
*Exercise programs
*Herbs
*Hormone therapy and treatment
*Orthopedic shoes and inserts
*Minerals
*Supplements
*Vitamins
The treasury department and the IRS decided that certain over-the counter (OTC) drugs can
be reimbursed through your Flexible Spending Plan. This means that reimbursements for
over-the-counter drugs under your FSA plan can be claimed tax free.
Allowed FSA medical care expenses include amounts paid for diagnosing, curing mitigating
or treatment of disease.
Please note that this is not a complete list, but is intended to provide Plan
participants with examples of OTC items that may be eligible.
Eligible OTC Medical Supplies
Itemized receipt required with claim request.
· Adult incontinence
products
(e.g. Depends)
· Birth control products
(e.g.
prophylactics)
· Contact lens solution
· Denture adhesives
· Ear supplies (e.g. ear
plugs)
· First aid supplies (e.g.
band-aids)
· Health monitors (e.g.
blood pressure,
cholesterol, HIV,
thermometers)
· Hearing aid batteries
· Heat wraps (e.g.
ThermaCare)
· Heating pads, hot water
bottles
· Insulin & diabetic
supplies
· Medicine
dropper/spoon
· Motion sickness devices
· Supports/braces (e.g.
ankle, knee,
wrist, therapeutic glove)
OTC Drugs and Medicines Requiring a Prescription
· Acne medications
· Allergy and sinus
medications (e.g.
Benadryl, Claritin,
Sudafed)
· Anti-fungal medications
(e.g.
Lotramin AF)
· Anti-itch medications
(e.g. Caladryl,
Cortizone)
· Cold sore medications
· Cough, cold & flu
remedies
· Decongestants
· Diaper rash ointments
· First aid creams
· Gastrointestinal aids
(antacids,
antidiarrhea medicines,
laxatives –
nonfiber, nausea
medications)
· Lactose intolerance pills
· Motion sickness pills
· Nasal sprays for
congestion (e.g.
Afrin)
· Pain relievers (e.g.
aspirin, Excedrin,
Tylenol, Advil, Motrin)
· Pre-natal vitamins
· Sleeping aids
· Smoking cessation
medications (e.g.
nicotine gum or
patches)
· Suppositories
· Toothache relievers (e.g.
Orajel)
· Topical ointments for
gingivitis
· Wart remover
medications
· Yeast infection creams
(e.g. Monistat)
Dual-purpose Items
Itemized receipt and Certification of Medical Necessity form required with claim request.
· Calcium supplements
· Fiber supplements
· Foot insoles
· Herbal medicines
· Homeopathic remedies
· Hormone therapy
· Joint supplements
· Nasal strips & snore
relief (e.g.
Breathe Right)
· Vaporizers/humidifiers
·Vitamins/minerals/supp
lements
Ineligible OTC Items
Do not submit for
reimbursement.
· Baby diapers
· Cosmetics
· Deodorants
· Face creams
· Feminine hygiene
products
· Hair removal products
· Insect repellants
· Lip balms (e.g.
Chapstick, Blistex)
· Lotions/Moisteners
· Mouthwashes
· Shampoos
· Soaps
· Sport energy liquids,
bars, etc.
· Stay awake aids (e.g. No
Doz)
· Suntan lotions
· Teeth whitening
products
· Toiletries
· Toothpaste
· Tooth brush
· Wrinkle reducer
Mid-Year Changes/”Qualifying Events”
In order to make a change to your original elected election(s), you must have a “qualifying
event”. “Qualifying events” allow you to increase or decrease your annual election(s),
terminate your contributions or enroll mid-year.
Medical Expense Account “Qualifying Events” - A change in status that makes you
eligible to change your elections to your Medical Expense Account are as follows:
• Becoming a new eligible employee with Santa Rosa City Schools
• Marriage, divorce or annulment
• Birth or adoption of a child
• Returning from a leave of absence
• Death of a spouse or child
Dependent Care Account “Qualifying Events” - A change in status that makes you
eligible to change your elections to your Dependent Care Account are as follows:
• Ineligibility of a dependent
• Birth or adoption of a child
• Death of a spouse or child
• Marriage, divorce or annulment
• Start or termination of employment for you or your spouse
For both the Medical Expense Account as well as the Dependent Care Account regarding a
mid-year change you must notify your employer or Shirrell Consulting Services within 30
days of “qualifying event” and be able to provide proper documentation. You will need to
revise your open enrollment form so the proper adjustments can be made to your payroll
deductions as well as your account(s).
Termination of Employment/Leave of Absence
If you decide to take a Leave of Absence or if your employment through Santa Rosa City
Schools is terminated and you wish to keep your full annual election you may choose to have
the remainder of your election taken from your last pay-check on a pre-tax basis. In order
to be reimbursed for the balance remaining in your account(s), you must submit your claim
with receipts for expenses incurred during the time of employment to Shirrell Consulting
Services within 90 days of the last day of employment.
To make this easier for you, once Shirrell Consulting Services, is notified by Santa Rosa City
Schools of your leave of absence or termination of employment our office will adjust your
annual election(s) appropriately, send you a letter informing you of the balance remaining
and give you a deadline to submit claims for the disbursement of your account balance(s).
If at the time of your leave of absence or employment termination you have been
reimbursed more than your total adjusted annual contribution, our office will send you a
letter requesting the money that was over-reimbursed to you be returned.
320 College Ave., Ste 340
Phone: (707) 544-1801
Fax: (707) 544-1804
Email: angela@shirrellconsulting.com
1
General Notice of COBRA Continuation Coverage Rights
(California Employees)
Date: __________
Dear: ________________________________________
Name or Status of Qualified Beneficiary(ies)
Introduction
You are receiving this notice because you have recently become covered under a group health plan (the Plan). This
notice contains important information about your right to COBRA continuation coverage, which is a temporary extension of
coverage under the Plan. This notice generally explains COBRA continuation coverage, when it may become
available to you and your family, and what you need to do to protect the right to receive it.
The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget
Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you when you would
otherwise lose your group health coverage. It can also become available to other members of your family who are
covered under the Plan when they would otherwise lose their group health coverage. For additional information about
your rights and obligations under the Plan and under federal law, you should review the Plan’s Summary Plan Description
or see the contact information below..
What is COBRA Continuation Coverage?
COBRA continuation coverage is a continuation of Plan coverage when coverage would otherwise end because of a life
event known as a “qualifying event.” Specific qualifying events are listed later in this notice. After a qualifying event,
COBRA continuation coverage must be offered to each person who is a “qualified beneficiary.” You, your spouse, and
your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying
event.
Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation
coverage. If you are an employee, you will become a qualified beneficiary if you lose your coverage under the Plan
because either one of the following qualifying events happens:
• Your hours of employment are reduced, or
• Your employment ends for any reason other than your gross misconduct.
If you are the spouse of an employee, you will become a qualified beneficiary if you lose your coverage under the Plan
because any of the following qualifying events happens:
• Your spouse dies;
• Your spouse’s hours of employment are reduced;
• Your spouse’s employment ends for any reason other than his or her gross misconduct;
• Your spouse becomes entitled to Medicare* benefits (under Part A, Part B, or both); or
• You become divorced or legally separated from your spouse.
Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because any of the
following qualifying events happens:
• The parent-employee dies;
• The parent-employee’s hours of employment are reduced;
• The parent-employee’s employment ends for any reason other than his or her gross misconduct;
• The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both);
• The parents become divorced or legally separated; or
• The child stops being eligible for coverage under the plan as a “dependent child.”
* The interaction of Medicare and receipt of COBRA benefits is a complex area of the law. Please consult with
your legal counsel or a benefits specialist to ensure proper compliance with applicable legal requirements.
This Plan provides retiree health coverage, so you should read the following paragraph:
Sometimes, filing a proceeding in bankruptcy under title 11 of the United States Code can be a qualifying event. If a
proceeding in bankruptcy is filed with respect to this company, and that bankruptcy results in the loss of coverage of any
retired employee covered under the Plan, the retired employee will become a qualified beneficiary with respect to the
bankruptcy. The retired employee’s spouse, surviving spouse, and dependent children will also become qualified
beneficiaries if bankruptcy results in the loss of their coverage under the Plan.
When is COBRA Coverage Available?
The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Human Resources Technician
has been notified that a qualifying event has occurred. When the qualifying event is the end of employment or reduction of
hours of employment, death of the employee or the employee's becoming entitled to Medicare benefits (under Part A, Part
B, or both), the employer must notify their Human Resources Technician of the qualifying event.
You Must Give Notice of Some Qualifying Events
For the other qualifying events (divorce or legal separation of the employee and spouse or a dependent child’s
losing eligibility for coverage as a dependent child), you must notify you Human Resources Technician within 30
days of the qualifying event.
How is COBRA Coverage Provided?
Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be
offered to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA
continuation coverage. Covered employees may elect COBRA continuation coverage on behalf of their spouses, and
parents may elect COBRA continuation coverage on behalf of their children.
How Long will Continuation Coverage Last?
COBRA continuation coverage is a temporary continuation of coverage:
• When the qualifying event is the death of the employee, the employee's becoming entitled to Medicare benefits
(under Part A, Part B, or both), your divorce or legal separation, or a dependent child's losing eligibility as a
dependent child, COBRA continuation coverage lasts for up to a total of 36 months.
When the qualifying event is the end of employment or reduction of the employee's hours of employment, and
•
the employee became entitled to Medicare benefits less than 18 months before the qualifying event, COBRA
continuation coverage for qualified beneficiaries other than the employee lasts until 36 months after the date of
Medicare entitlement. For example, if a covered employee becomes entitled to Medicare 8 months before the
date on which his employment terminates, COBRA continuation coverage for his spouse and children can last up
to 36 months after the date of Medicare entitlement, which is equal to 28 months after the date of the qualifying
event (36 months minus 8 months).
• Otherwise, when the qualifying event is the end of employment or reduction of the employee’s hours of
employment, COBRA continuation coverage generally lasts for only up to a total of 18 months.
There are two ways in which this 18-month period of COBRA continuation coverage can be extended:
1. Disability extension of 18-month period of continuation coverage
If you or anyone in your family covered under the Plan is determined by the Social Security Administration (SSA) to be
disabled and you notify Shirrell Consulting or CVT in a timely fashion, you and your entire family may be entitled to
receive up to an additional 11 months of COBRA continuation coverage, for a total maximum of 29 months. The disability
would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until
the end of the 18-month period of continuation coverage. Notice of an SSA disability determination should be given to:
Shirrell Consulting Services (For Certificated, Confidential, Supervisory and Management Employees)
Santa Rosa, CA. 95405 (707) 544-1801
CVT (For Classified Employees)
(800) 288-9870
2. Second qualifying event extension of 18-month period of continuation coverage
If your family experiences another qualifying event while receiving 18 months of COBRA continuation coverage, the
spouse and dependent children in your family can get up to 18 additional months of COBRA continuation coverage, for a
maximum of 36 months, if notice of the second qualifying event is properly given to the Plan. This extension may be
available to the spouse and any dependent children receiving continuation coverage if the employee or former employee
dies, becomes entitled to Medicare benefits (under Part A, Part B, or both), or gets divorced or legally separated, or if the
dependent child stops being eligible under the Plan as a dependent child, but only if the event would have caused the
spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred.
Extended Cal-COBRA Coverage for California Employees
The Plan must offer any qualified beneficiary who is entitled to less than 36 months of continuation coverage under
COBRA and has exhausted such coverage the opportunity to extend coverage under Cal-COBRA to a total of 36 months
from the date the qualified beneficiary’s continuation coverage began. A qualified beneficiary electing such further
continuation coverage must pay to the group plan, on or before the due date of each payment but not more frequently
than on a monthly basis, not more than 110 percent of the applicable rate charged for a covered employee or, in the case
of dependent coverage, not more than 110 percent of the applicable rate charged to a similarly situated individual under
the group benefit plan being continued under the group contract. In the case of a qualified beneficiary who is determined
to be disabled by SSA (see “Disability” above), the qualified beneficiary shall be required to pay to the group health plan
an amount no greater than 150 percent of the group rate after the first 18 months of continuation coverage.
If You Have Questions
Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or
contacts identified below. For more information about your rights under ERISA, including COBRA, the Health Insurance
Portability and Accountability Act (HIPAA), and other laws affecting group health plans, contact the nearest Regional or
District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit
the EBSA website at www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are
available through EBSA’s website.)
Keep Your Plan Informed of Address Changes
In order to protect your family’s rights, you should keep the Plan Contacts informed of any changes in the addresses of
family members. You should also keep a copy, for your records, of any notices you send to the Plan Contacts.
Plan Contact Information
For information about COBRA continuation coverage, contact:
Shirrell Consulting Services (For Certificated, Confidential, Supervisory and Management Employees)
Santa Rosa, CA. 95405
(707) 544-1801
CVT (For Classified Employees)
(800) 288-9870
I acknowledge that I have received a copy of my Initial COBRA Continuation Coverage Rights
____________________________________
Employee Signature
___________________________
Date
____________________________________
Human Resources Technician Signature
___________________________
Date
Section 125 and Retirement
Savings Options
Certificated
Plan Type
Administered
By
Classified 75, 367
and Supervisory
Notes
Section 125 Shirrell
Consulting
Pre-tax
benefits, FSA,
Dependent
Care
STRS
Retirement
8% employee
contribution.
8.24% District
Contribution
CalSTRS
403(b)
CalPERS
457 Plan
STRS
CalSTRS—
Tax Sheltered
1-800-892-7494, Annuity—pays
www.CalSTRS40 out over time.
3bComply.com
CalPERS—
1-800-260-0659
https://
calpers.ingplans.
com
Mutual Funds,
etc. pay out
when person
wants it.
Plan Type
Administered
By
Notes
Section 125 American Fidelity Pre-tax
benefits, FSA,
Dependent
Care and other
optional
benefits
PERS
Retirement
Plan
CalSTRS
403(b)
CalPERS
457 Plan
PERS
7% employee
contribution.
10.9% District
Contribution
CalSTRS—
Tax Sheltered
1-800-892-7494, Annuity—pays
3bComply.com
CalPERS—
1-800-260-0659
https://
calpers.ingplans.
com
Mutual Funds,
etc. pay out
when person
wants it.
Classified Management and
Confidential
Plan Type
Administered
By
Section 125 Shirrell
Consulting
Notes
Pre-tax
benefits, FSA,
Dependent
Care
PERS
Retirement
Plan
PERS
7% employee
contribution.
10.9% District
Contribution
CalSTRS
403(b)
CalSTRS—
Tax Sheltered
1-800-892-7494, Annuity—pays
3bComply.com
CalPERS
457 Plan
CalPERS—
1-800-260-0659
https://
calpers.ingplans.
com
Optional
Benefits
American Fidelity Life, Disability,
Accident.
Mutual Funds,
etc. pay out
when person
wants it.
Business Services
(707)528-5382
______________________________________________________________________________
DATE:
January 30, 2015
TO:
All Employees of Santa Rosa City Schools
FROM:
Steve Eichman, Assistant Superintendent
SUBJECT:
Notice of Eligibility for 403(b) or 457 Plan Participation and
2015 Contribution Limits
One of the voluntary benefits that Santa Rosa City Schools offers its employees is the ability to
participate in a 403(b) and/or a 457 (often called a “tax sheltered annuity” or TSA) plan. These
plans allow you to defer a portion of your paycheck to a retirement plan on a pre-tax basis.
Under federal law, you do not have to pay federal or state income taxes on your contributions or
account earnings until you take the money out of the plan.
The IRS has established an annual limit for contributions to a TSA plan. For 2015, the annual
limit is $18,000 per plan. Employees age 50 and over can invest an additional $6,000 per year as
a “catch-up” contribution.
All employees of the District are eligible to participate in these plans. You can sign up at any
time during the year. The deadline to complete enrollment information is:


403(b): Fill out the forms online no later than the 10th of the month, in order to have
your contribution deducted at the end of the month. See instructions below to
access the CalSTRS 403(b) website.
457: Turn forms in to Reyna Gonzalez, no later than the 10th of the month, in order
to have your contribution deducted at the end of the month. See instructions below
to obtain forms for the 457 plan.
The 457 plan is administered by CalPERS. If you are interested in enrolling or would like more
information, you may do one of the following:
1. Obtain an enrollment packet from the District Office: Reyna Gonzalez at 528-5332.
2. Visit the CalPERS website at https://calpers.ingplans.com to download forms.
3. Call the CalPERS 457 Plan Information Line at 1-800-260-0659.
211 RIDGWAY AVENUE ◊ SANTA ROSA, CA 95401
The 403(b) plan is administered by CalSTRS 403bComply, in partnership with JEM Resource
Partners. If you are interested in enrolling or would like more information, follow the
instructions below.
1.
2.
3.
4.
Go to www.CalSTRS403bComply.com.
Click on “Login” on the left side of the screen.
Choose the Status that applies to you.
Carefully read the Login Instructions and click on “Login”
a. Login according to the instructions
b. The Plan password can also be found on your Employer’s Summary Plan
Description under the Plan Descriptions tab on the homepage.
5. If you do not have access to a computer or need assistance, please call JEM Customer
Service at (888) 892-7494.
In Partnership with JEM Resource Partners
Toll Free: 888.892.7494 Fax: 888.989.9247
Email: 403b@CalSTRS403bComply.com
Website: www.CalSTRS403bComply.com
403bComply
Compliance & Administration Solutions
ANNUAL 403(b) PLAN NOTICE
TO ALL SCHOOL DISTRICT EMPLOYEES:
WHY DO I NEED TO
SAVE IF I HAVE CalSTRS
OR CalPERS
RETIREMENT?
Your pension may not replace
all of your income in retirement. The average retiree
receives 60-65 percent of
their income at retirement.
For example, if your current
salary is $5,000 per month
and your retirement benefit
equals 65 percent of your
current salary, you will receive
$3,250 each month. However,
CalSTRS research indicates
that retirees must receive
90-95 percent of their income
in retirement to maintain their
current standard of living. In
the above example the
member has a shortfall of
$1,750 per month.
WHY SHOULD I
CONTRIBUTE TO A
403(b) PLAN
The new school year is an ideal time to make you aware of your eligibility to
participate in your employer’s 403(b) retirement plan. The 403(b) plan (often called
a “tax-sheltered annuity” or TSA) is a voluntary plan that allows you to defer a
portion of your paycheck to a retirement plan.
This is a great benefit offered by your employer to help you bridge your retirement
income gap and lower your current taxes. Under federal tax law, you do not have to
pay income taxes on your contributions or account earnings until you take the
money out of the plan.
Please continue reading for details on how to enroll and how easy it is to start
saving now. Also explore why it is a good idea to invest for retirement.
IMPORTANT POINTS ABOUT YOUR 403(b) PLAN:
A. You may start, stop or change your payroll deduction contribution to the Plan
at any time. The deadline for doing this for each pay period is on the CalSTRS
403bComply website. Go to www.CalSTRS403bComply.com,* click on PLAN
DESCRIPTIONS on the left side of the page and then scroll down to the material
for your employer. This will include a simple Summary Plan Description and a
payroll schedule.
B. You may contribute 100% of your compensation up to $18,000 for 2016 if you
are under age 50. Employees who are age 50 or over at the end of the calendar
year can also make catch-up contributions of up to $6,000 in 2016 beyond the
basic limit on elective deferrals. There are no other restrictions on your right to
make contributions to the Plan.
C. To see other Plan features for your employer, such as whether your Plan allows
Roth 403(b) contributions, go to the Summary Plan Description as described in
item A. above.
To make a 403(b) salary reduction election or changes online please:
1. Go to www.CalSTRS403bComply.com.*
• Bridge your retirement
income gap
• Lower your taxes
• Automatic saving; payroll
deducted
• Easy to start saving now
CALSTRS 403(b) PLAN LIMITS 2/2016
2. Click on LOGIN on the left side of the screen.
3. To make a change to your current salary deferral, click LOGIN and enter your
credentials to access your account
4. To enroll in the Plan, click LOGIN next to “I have never been in a plan”, enter the
plan password listed on the summary plan description for your employer and
select BEGIN.
Ifyouhaveanyproblems,pleasecallCalSTRS403bComplyCustomerServiceat888.892.7494.
*If you do not have Internet access or need assistance, please call us at (800) 943-9179 and we can
assist you with these services by phone.
Santa Rosa City Schools Memo of Acknowledgment of Board Policies and Administrative Regulations 2015-2016
TO:
All Staff
FROM:
Jason A. Lea, Assistant Superintendent, Human Resources
RE:
Acknowledgment of Board Policies and Administrative Regulations 2015-2016
The Human Resources Department of the Santa Rosa City Schools is required by Federal
and State law, education code and board policy to provide employees with the following
notifications and requires signed acknowledgment that such notifications were received and
read. (AR 4112.9 Employee Notifications)
Please be sure to sign the acknowledgment form with your school secretary, office manager or
department supervisor. ~ Thank you ~
The following are provided for your information:
PUBLIC NOTICE – SANTA ROSA CITY SCHOOLS NONDISCRIMINATION COMPLIANCE
1. Complaints Concerning District Employees; Board Policy & Administrative Regulation
1312.1
(06/08).
2. Uniform Complaint Procedures; Board Policy & Administrative Regulation 1312.3 (03/13).
Uniform complaint procedures for students, parents, and guardians are included for your
review.
3. Tobacco-Free Schools; Board Policy & Administrative Regulations 3513.3 (10/13)
4. Drug and Alcohol-Free Workplace; Board Policy 4020 (04/12)
5. Nondiscrimination in Employment; Board Policy & Administrative Regulation 4030
(02/08). General compliance notice for your review which is to be posted in a visible
location for employees, students, parents, and guardians at all district site locations.
6. Complaints Concerning Discrimination in Employment; Administrative Regulation 4031
(02/08).
7. Employee Use of Technology; Board Policy & Administrative Regulation 4040 (02/08)
8. Oath of affirmation of allegiance required of public employees Administrative Regulation
4112.3/4212.3/4312.3 (2/08)
9. Sexual Harassment; Board Policies & Administrative Regulations 4119.11 (05/13)
1
All Staff Memo of Acknowledgment with BP and AR Attached 2015-2016
10. Employees with Infectious Disease; Board Policies 4119.41 (02/08)
11. Exposure Control Plan for Bloodborne Pathogens; Board Policy & Administrative
Regulations 4119.42 (02/08). This portion includes Exposure Control Plan for Bloodborne
Pathogens Exhibit Hepatitis “B” Vaccine Declination4112.3
12. Universal Precautions; Board Policy & Administrative Regulations 4119.43 (02/08)
13. Appointment and Conditions of Employment Administrative Regulations 4212 (04/08)
14. Demotion/Reassignment Board Policy & Administrative Regulations 4313.2 (04/12)
15. Student Conduct; Board Policy 5131 (06/12), Administrative Regulation & Exhibit (06/11)
16. Child Abuse Prevention and Reporting; Board Policy & Administrative Regulation 5141.4
(01/16)
For additional Board Policies, follow these steps to access our updated policies and
regulations:
1.
2.
3.
4.
Go to our district website at www.srcs.k12.ca.us.
At the bottom of the page, under Quick Links, choose Board Policies and Regulations.
Click on the GAMUT Online link in the middle of the screen.
Search the Santa Rosa City Schools for key words or policy/code numbers.
If further clarification is needed, please call me at (707)-528-5352.
Sincerely,
Jason A. Lea
Assistant Superintendent
Human Resources
Santa Rosa City Schools – 211 Ridgeway Avenue – Santa Rosa, CA 95401 – (707) 528-5352 - Fax (707) 528-5487
2
PUBLIC NOTICE
SANTA ROSA CITY SCHOOLS NONDISCRIMINATION COMPLIANCE
The Governing Board is committed to equal opportunity for all individuals in education. District programs,
activities, and practices shall be free from discrimination based on race, color, ancestry, national origin, ethnic group
identification, age, religion, marital or parental status, physical or mental disability, sex, sexual orientation, gender,
gender identity or expression, or genetic information; the perception of one or more of such characteristics; or
association with a person or group with one or more of these actual or perceived characteristics.
The Board shall promote programs which ensure that discriminatory practices are eliminated in all district activities.
(BP 0410, Nondiscrimination in District Programs and Activities)
The Superintendent or designee shall provide multiple opportunities for members of the public to give input on district
and school issues and operations. Community members are encouraged to become involved in school activities,
participate on district and school committees, provide input at Board meetings, submit suggestions to district staff,
and use the district's complaint procedures as appropriate. (BP 1100, Communication with the Public)

See Board Policies and Administrative Regulations:
1312.1 - Complaints Concerning District Employees
1312.3 - Uniform Complaint Procedures
3555 – Nutrition Program Compliance
4119.11/4219.11/4319.11/5145.7 – Sexual Harassment
1312.2 - Complaints Concerning Instructional Materials
1312.4 - Williams Uniform Complaint Procedures
4030 – Nondiscrimination in Employment
4144/4244/4344 - Complaints
Office responsible for overall district compliance with all nondiscrimination provisions:
Santa Rosa City Schools Child Welfare and Attendance
211 Ridgway Ave., Santa Rosa, CA 95401  528-5137
Students, parents or guardians, or any other individual having questions or concerns regarding the nondiscrimination
policy of the Santa Rosa City Schools or the filing of discrimination complaints should contact the appropriate district
office:
Complaint
Individual
District Office
Telephone
Gender Equity
K-6 Students
7-12 Students
Anna Guzman, C&I K-6
Diann Kitamura, C&I 7-12
528-5272
528-5284
Sexual Harassment
K-12 Students
Employees
Mary Ann Ayala, CWA
Jason Lea, Human Resources
528-5137
528-5352
Section 504
Handicapped Students
Handicapped Employees
Steve Mizera, Special Services
528-5322
528-5352
K-6 Students
7-12 Students
Employees
Students or Employees
Students or Employees
Anna Guzman, C&I K-6
Diann Kitamura, C&I 7-12
Steve Eichman, Business Services
Anna Guzman, State and Federal Programs
528-5272
528-5284
528-5352
528-5381
528-5788
Title IX and
Other*
CCR Title 5
Title II
e.g. race, national origin, ancestry, ethnic group identification, religion, creed, age, sex, color, physical or mental disability, marital or parental
status.
For assistance in determining the application of the District’s policies on nondiscrimination, and in pursuing informal resolution of
complaints, you may contact Human Resources at 528-5352.
When requested, Human Resources will provide referrals to outside agencies such as *EEOC or DFEH (as to employment) or OCR
(as to students or employees).
Public Notice Nondiscrimination Compliance
3
Board Policy
Complaints Concerning District Employees
BP 1312.1
Community Relations
The Board of Education accepts responsibility for providing a means by which the public can
hold employees accountable for their actions. The Board desires that complaints be resolved
expeditiously without disrupting the educational process.
The Superintendent or designee shall develop regulations which permit the public to submit
complaints against district employees in an appropriate way. These regulations shall protect the
rights of involved parties. The Board may serve as an appeals body if the complaint is not
resolved.
(cf. 1312.2 - Complaints Concerning Instructional Materials)
(cf. 1312.3 - Uniform Complaint Procedures)
(cf. 3515.2 - Disruptions)
The Board prohibits retaliation against complainants. The Superintendent or designee at his/her
discretion may keep a complainant's identity confidential, except to the extent necessary to
investigate the complaint. The district will not investigate anonymous complaints unless it so
desires.
Legal Reference:
EDUCATION CODE
33308.1 Guidelines on procedure for filing child abuse complaints
35146 Closed sessions
44031 Personnel file contents and inspection
44811 Disruption of public school activities
44932-44949 Resignation, dismissal and leaves of absence (rights of employee; procedures to
follow)
48987 Child abuse guidelines
GOVERNMENT CODE
54957 Closed session; complaints re employees
54957.6 Closed session; salaries or fringe benefits
PENAL CODE
273 Cruelty or unjustifiable punishment of child
11164-11174.3 Child Abuse and Neglect Reporting Act
WELFARE AND INSTITUTIONS CODE
300 Minors subject to jurisdiction of juvenile court
Management Resources:
CDE LEGAL ADVISORIES
0910.93 Guidelines for parents to report suspected child abuse by school district employees or
other persons against a pupil at school site (LO:4-93)
Policy
adopted: June 25, 2008
4
Santa Rosa, California
Administrative Regulation
Complaints Concerning District Employees
AR 1312.1
Community Relations
AR 1312.1(a)
The Superintendent or designee shall determine whether a complaint should be considered a
complaint against the district and/or an individual employee, and whether it should be resolved
by the district's process for complaints concerning personnel and/or other district procedures.
(cf. 4144/4244/4344 - Complaints)
To promote prompt and fair resolution of the complaint, the following procedures shall govern
the resolution of complaints against district employees:
1.
Every effort should be made to resolve a complaint at the earliest possible stage.
Whenever
possible, the complainant should communicate directly to the employee in order
to resolve
concerns.
2.
If a complainant is unable or unwilling to resolve the complaint directly with the
employee,
he/she may submit an oral or written complaint to the employee's immediate
supervisor or the principal. Complaints must be submitted within a reasonable period of time
not to exceed three months from the event giving rise to the complaint.
3.
filed
All complaints related to district personnel other than administrators shall be submitted in
writing to the principal or immediate supervisor. If the complainant is unable to prepare
complaint in writing, administrative staff shall help him/her to do so. Complaints related
principal or central office administrator shall be initially filed in writing with the
Superintendent or designee. Complaints related to the Superintendent shall be initially
in writing with the Board.
4.
in
When a written complaint is received, the employee shall be notified within five days or
accordance with collective bargaining agreements.
5.
A written complaint shall include:
a.
b.
c.
The full name of each employee involved
A brief but specific summary of the complaint and the facts surrounding it
A specific description of any prior attempt to discuss the complaint with the employee
and the failure to resolve the matter
6.
Staff responsible for investigating complaints shall attempt to resolve the complaint to the
satisfaction of the parties involved within 30 days.
the
to a
5
Complaints Concerning District Employees (continued)
AR 1312.1(b)
7.
Both the complainant and the employee against whom the complaint was made may
appeal a decision by the principal or immediate supervisor to the Superintendent or designee,
who shall attempt to resolve the complaint to the satisfaction of the person involved within 30
days. Parties should consider and accept the Superintendent or designee's decision as
final. However, the complainant, the employee, or the Superintendent or designee may ask to
address the Board regarding the complaint.
8.
Before any Board consideration of a complaint, the Superintendent or designee shall
submit to the Board a written report concerning the complaint, including but not limited to:
a.
The full name of each employee involved
b.
A brief but specific summary of the complaint and the facts surrounding it, sufficient to
inform the Board and the parties as to the precise nature of the complaint and to allow the
parties to prepare a response
c.
A copy of the signed original complaint
d.
A summary of the action taken by the Superintendent or designee, together with his/her
specific finding that the problem has not been resolved and the reasons
9.
The Board may uphold the Superintendent's decision without hearing the complaint.
10.
All parties to a complaint may be asked to attend a Board meeting in order to clarify the
issue and present all available evidence.
11.
A closed session may be held to hear the complaint in accordance with law.
(cf. 9321 - Closed Session Purposes and Agendas)
(cf. 9323 - Meeting Conduct)
12.
The decision of the Board shall be final.
Any complaint of child abuse or neglect alleged against a district employee shall be reported to
the appropriate local agencies in accordance with law, Board policy and administrative
regulation.
(cf. 5141.4 - Child Abuse Prevention and Reporting)
Regulation
approved: June 25, 2008
6
Board Policy
Uniform Complaint Procedures
BP 1312.3
Community Relations
The Governing Board recognizes that the district has the primary responsibility to ensure
compliance with applicable state and federal laws and regulations governing educational
programs. The district shall investigate and seek to resolve any complaints alleging failure to
comply with such laws and/or alleging unlawful discrimination, harassment, intimidation, or
bullying in accordance with the uniform complaint procedures.
The district shall use the uniform complaint procedures to resolve any complaint alleging
unlawful discrimination, harassment, intimidation, or bullying in district programs and activities
based on actual or perceived characteristics of race or ethnicity, color, ancestry, nationality,
national origin, ethnic group identification, age, religion, marital or parental status, physical or
mental disability, sex, sexual orientation, gender, gender identity, gender expression, or genetic
information, or any other characteristic identified in Education Code 200 or 220, Penal Code
422.55, or Government Code 11135, or based on association with a person or group with one or
more of these actual or perceived characteristics.
(cf. 0410 - Nondiscrimination in District Programs and Activities)
(cf. 4030 - Nondiscrimination in Employment)
(cf. 4031 - Complaints Concerning Discrimination in Employment)
(cf. 5131.2 - Bullying)
(cf. 5145.3 - Nondiscrimination/Harassment)
(cf. 5145.7 - Sexual Harassment)
Uniform complaint procedures shall also be used to address any complaint alleging the district's
failure to comply with the prohibition against requiring students to pay fees, deposits, or other
charges for participation in educational activities, the requirements for the development and
adoption of a school safety plan, and state and/or federal laws in adult education programs,
consolidated categorical aid programs, migrant education, career technical and technical
education and training programs, child care and development programs, child nutrition programs,
and special education programs.
(cf. 0450 - Comprehensive Safety Plan)
(cf. 1312.1 - Complaints Concerning District Employees)
(cf. 3260 - Fees and Charges)
(cf. 3320 - Claims and Actions Against the District)
(cf. 3553 - Free and Reduced Price Meals)
(cf. 3555 - Nutrition Program Compliance)
(cf. 5141.4 - Child Abuse Prevention and Reporting)
(cf. 5148 - Child Care and Development)
(cf. 6159 - Individualized Education Program)
(cf. 6171 - Title I Programs)
7
(cf. 6174 - Education for English Language Learners)
(cf. 6175 - Migrant Education Program)
(cf. 6178 - Career Technical Education)
(cf. 6178.1 - Work-Based Learning)
(cf. 6178.2 - Regional Occupational Center/Program)
(cf. 6200 - Adult Education)
The Board prohibits any form of retaliation against any complainant in the complaint process.
Participation in the complaint process shall not in any way affect the status, grades, or work
assignments of the complainant.
The Board encourages the early, informal resolution of complaints at the site level whenever
possible.
The Board recognizes that a neutral mediator can often suggest a compromise that is agreeable to
all parties in a dispute. In accordance with the uniform complaint procedures, whenever all
parties to a complaint agree to try resolving the problem through mediation, the Superintendent
or designee shall initiate that process. The Superintendent or designee shall ensure that the
results are consistent with state and federal laws and regulations.
In investigating complaints, the confidentiality of the parties involved and the integrity of the
process shall be protected. As appropriate for any complaint alleging discrimination,
harassment, intimidation, or bullying, the Superintendent or designee may keep the identity of a
complainant confidential to the extent that the investigation of the complaint is not obstructed.
(cf. 4119.23/4219.23/4319.23 - Unauthorized Release of Confidential/Privileged Information)
(cf. 5125 - Student Records)
(cf. 9011 - Disclosure of Confidential/Privileged Information)
The district's Williams uniform complaint procedures, AR 1312.4, shall be used to investigate
and resolve any complaint related to the following:
1.
Sufficiency of textbooks or instructional materials
2.
Emergency or urgent facilities conditions that pose a threat to the health or safety of
students or staff
3.
Teacher vacancies and misassignments
4.
Deficiency in the district's provision of instruction and/or services to any student who,
by the completion of grade 12, has not passed one or both parts of the high
school exit
examination
(cf. 1312.4 - Williams Uniform Complaint Procedures)
Legal Reference:
EDUCATION CODE
200-262.4 Prohibition of discrimination
8200-8498 Child care and development programs
8
8500-8538 Adult basic education
18100-18203 School libraries
32289 School safety plan, uniform complaint procedures
35186 Williams uniform complaint procedures
37254 Intensive instruction and services for students who have not passed exit exam
41500-41513 Categorical education block grants
48985 Notices in language other than English
49010-49013 Student fees
49060-49079 Student records
49490-49590 Child nutrition programs
52160-52178 Bilingual education programs
52300-52490 Career technical education
52500-52616.24 Adult schools
52800-52870 School-based program coordination
54000-54028 Economic impact aid programs
54100-54145 Miller-Unruh Basic Reading Act
54400-54425 Compensatory education programs
54440-54445 Migrant education
54460-54529 Compensatory education programs
56000-56867 Special education programs
59000-59300 Special schools and centers
64000-64001 Consolidated application process
GOVERNMENT CODE
11135 Nondiscrimination in programs or activities funded by state
12900-12996 Fair Employment and Housing Act
PENAL CODE
422.55 Hate crime; definition
422.6 Interference with constitutional right or privilege
CODE OF REGULATIONS, TITLE 5
3080 Application of section
4600-4687 Uniform complaint procedures
4900-4965 Nondiscrimination in elementary and secondary education programs
UNITED STATES CODE, TITLE 20
6301-6577 Title I basic programs
6601-6777 Title II preparing and recruiting high quality teachers and principals
6801-6871 Title III language instruction for limited English proficient and immigrant students
7101-7184 Safe and Drug-Free Schools and Communities Act
7201-7283g Title V promoting informed parental choice and innovative programs
7301-7372 Title V rural and low-income school programs
WEB SITES
CSBA: http://www.csba.org
California Department of Education: http://www.cde.ca.gov
U.S. Department of Education, Office for Civil Rights: http://www.ed.gov/about/offices/list/ocr
Policy SANTA ROSA CITY SCHOOLS
adopted: March 13, 2013
(1/06 3/12 1/13) 3/13
9
Uniform Complaint Procedures
AR 1312.3
Community Relations
Except as the Governing Board may otherwise specifically provide in other Board policies, the
uniform complaint procedures shall be used only to investigate and resolve complaints alleging
violations of federal or state laws or regulations governing specific educational programs, the
prohibition against requiring students to pay fees, deposits, or other charges for participating in
educational activities, and unlawful discrimination, harassment, intimidation, or bullying, as
specified in accompanying Board policy.
(cf. 1312.4 - Williams Uniform Complaint Procedures)
The district's uniform complaint procedures policy and administrative regulation shall be posted
in all district schools and offices, including staff lounges and student government meeting rooms.
If 15 percent or more of students enrolled in a particular district school speak a single primary
language other than English, the district's policy, regulation, forms, and notices concerning
uniform complaint procedures shall be translated into that language. (Education Code 234.1,
48985)
(cf. 5145.6 - Parental Notifications)
Compliance Officers
The following compliance officer(s) shall receive and investigate complaints and shall ensure
district compliance with law:
Child Welfare and Attendance
Santa Rosa School District
211 Ridgeway Avenue
(707) 528-5137
The Superintendent or designee shall ensure that employees designated to investigate complaints
are knowledgeable about the laws and programs for which they are responsible. Designated
employees may have access to legal counsel as determined by the Superintendent or designee.
(cf. 9124 - Attorney)
10
Notifications
The Superintendent or designee shall annually provide written notification of the district's
uniform complaint procedures to students, employees, parents/guardians, the district advisory
committee, school advisory committees, appropriate private school officials or representatives,
and other interested parties. (Education Code 262.3, 49013; 5 CCR 4622)
(cf. 0420 - School Plans/Site Councils)
(cf. 1220 - Citizen Advisory Committees)
(cf. 3260 - Fees and Charges)
(cf. 4112.9/4212.9/4312.9 - Employee Notifications)
(cf. 5145.6 - Parental Notifications)
The notice shall:
1.
Identify the person(s), position(s), or unit(s) responsible for receiving complaints
2.
Advise the complainant of any civil law remedies that may be available to him/her under
state or federal discrimination laws, if applicable
3.
Advise the complainant of the appeal process, including, if applicable, the complainant's
right to take a complaint directly to the California Department of Education (CDE) or to
pursue remedies before civil courts or other public agencies
4.
Include statements that:
a.
The district has the primary responsibility to ensure compliance with applicable state
and federal laws and regulations governing educational programs.
b.
The complaint review shall be completed within 60 calendar days from the date of receipt
of the complaint unless the complainant agrees in writing to an extension of the timeline.
c.
A complaint alleging unlawful discrimination, harassment, intimidation, or bullying
must be filed not later than six months from the date it occurred, or six months from the
date the complainant first obtained knowledge of the facts of the alleged discrimination,
harassment, intimidation, or bullying.
d.
The complainant has a right to appeal the district's decision to the CDE by filing a written
appeal within 15 calendar days of receiving the district's decision.
e.
The appeal to the CDE must include a copy of the complaint filed with the district and a
copy of the district's decision.
f.
Copies of the district's uniform complaint procedures are available free of charge.
Procedures
All complaints shall be investigated and resolved within 60 calendar days of the district's receipt
of the complaint. (5 CCR 4631)
11
Compliance officers shall maintain a record of each complaint and subsequent related actions,
including all information required for compliance with 5 CCR 4631 and 4633.
All parties involved in allegations shall be notified when a complaint is filed, when a complaint
meeting or hearing is scheduled, and when a decision or ruling is made.
Step 1: Filing of Complaint
Any individual, public agency or organization may file a written complaint of the district's
alleged noncompliance with federal or state laws or regulations governing educational programs.
(5 CCR 4630)
A complaint concerning unlawful discrimination, harassment, intimidation, or bullying may be
filed only by a person who alleges that he/she personally suffered unlawful discrimination,
harassment, intimidation, or bullying or by a person who believes that an individual or any
specific class of individuals has been subjected to it. The complaint shall be initiated no later
than six months from the date when the alleged discrimination, harassment, intimidation, or
bullying occurred, or six months from the date when the complainant first obtained knowledge of
the facts of the alleged discrimination, harassment, intimidation, or bullying. However, upon
written request by the complainant, the Superintendent or designee may extend the filing period
for up to 90 calendar days. (5 CCR 4630)
A complaint alleging noncompliance with the law regarding the prohibition against requiring
students to pay student fees, deposits, and charges may be filed anonymously if the complaint
provides evidence or information leading to evidence to support an allegation of noncompliance.
(Education Code 49013)
The complaint shall be presented to the compliance officer who shall maintain a log of
complaints received, providing each with a code number and a date stamp.
If a complainant is unable to put a complaint in writing due to conditions such as a disability or
illiteracy, district staff shall assist him/her in the filing of the complaint. (5 CCR 4600)
Step 2: Mediation
Within three business days of receiving the complaint, the compliance officer may informally
discuss with all the parties the possibility of using mediation. If the parties agree to mediation,
the compliance officer shall make all arrangements for this process.
Before initiating the mediation of a complaint alleging discrimination, harassment, intimidation,
or bullying, the compliance officer shall ensure that all parties agree to make the mediator a party
to related confidential information.
If the mediation process does not resolve the problem within the parameters of law, the
compliance officer shall proceed with his/her investigation of the complaint.
The use of mediation shall not extend the district's timelines for investigating and resolving the
complaint unless the complainant agrees in writing to such an extension of time. (5 CCR 4631)
12
Step 3: Investigation of Complaint
Within 10 calendar days of receiving the complaint, the compliance officer shall provide the
complainant and/or his/her representative an opportunity to present the complaint and any
evidence, or information leading to evidence, to support the allegations in the complaint. The
compliance officer also shall collect all documents and interview all witnesses with information
pertinent to the complaint.
A complainant's refusal to provide the district's investigator with documents or other evidence
related to the allegations in the complaint, failure or refusal to cooperate in the investigation, or
engagement in any other obstruction of the investigation may result in the dismissal of the
complaint because of a lack of evidence to support the allegation. (5 CCR 4631)
In accordance with law, the district shall provide the investigator with access to records and other
information related to the allegation in the complaint and shall not in any way obstruct the
investigation. Failure or refusal of the district to cooperate in the investigation may result in a
finding based on evidence collected that a violation has occurred and in the imposition of a
remedy in favor of the complainant. (5 CCR 4631)
Step 4: Response
Within 30 calendar days of receiving the complaint, the compliance officer shall prepare and
send to the complainant a written report of the district's investigation and decision, as described
in Step #5 below. If the complainant is dissatisfied with the compliance officer's decision, he/she
may, within five business days, file his/her complaint in writing with the Board.
The Board may consider the matter at its next regular Board meeting or at a special Board
meeting convened in order to meet the 60-day time limit within which the complaint must be
answered. The Board may decide not to hear the complaint, in which case the compliance
officer's decision shall be final.
If the Board hears the complaint, the compliance officer shall send the Board's decision to the
complainant within 60 calendar days of the district's initial receipt of the complaint or within the
time period that has been specified in a written agreement with the complainant. (5 CCR 4631)
Step 5: Final Written Decision
The district's decision shall be in writing and sent to the complainant. (5 CCR 4631)
The district's decision shall be written in English and, when required by Education Code 48985,
in the complainant's primary language.
For all complaints, the decision shall include: (5 CCR 4631)
1.
The findings of fact based on the evidence gathered
2.
The conclusion(s) of law
3.
Disposition of the complaint
13
4.
Rationale for such disposition
5.
Corrective actions, if any are warranted
6.
Notice of the complainant's right to appeal the district's decision within 15 calendar days
to the CDE and procedures to be followed for initiating such an appeal
In addition, any decision concerning a discrimination, harassment, intimidation, or bullying
complaint based on state law shall include a notice that the complainant must wait until 60
calendar days have elapsed from the filing of an appeal with the CDE before pursuing civil law
remedies. (Education Code 262.3)
If investigation of a complaint results in discipline to a student or an employee, the decision shall
simply state that effective action was taken and that the student or employee was informed of
district expectations. The report shall not give any further information as to the nature of the
disciplinary action.
If a complaint alleging noncompliance with the laws regarding student fees, deposits, and other
charges is found to have merit, the district shall provide a remedy to all affected students and
parents/guardians, which, where applicable, shall include reasonable efforts to ensure full
reimbursement to them. (Education Code 49013)
Appeals to the California Department of Education
If dissatisfied with the district's decision, the complainant may appeal in writing to the CDE.
(Education Code 49013; 5 CCR 4632)
The complainant shall file his/her appeal within 15 calendar days of receiving the district's
decision and the appeal shall specify the basis for the appeal of the decision and whether the
facts are incorrect and/or the law has been misapplied. The appeal shall be accompanied by a
copy of the locally filed complaint and a copy of the district's decision. (5 CCR 4632)
Upon notification by the CDE that the complainant has appealed the district's decision, the
Superintendent or designee shall forward the following documents to the CDE: (5 CCR 4633)
1.
A copy of the original complaint
2.
A copy of the decision
3.
A summary of the nature and extent of the investigation conducted by the district, if not
covered by the decision
4.
A copy of the investigation file including, but not limited to, all notes, interviews, and
documents submitted by the parties and gathered by the investigator
5.
A report of any action taken to resolve the complaint
6.
A copy of the district's uniform complaint procedures
7.
Other relevant information requested by the CDE
14
The CDE may directly intervene in a complaint without waiting for action by the district when
one of the conditions listed in 5 CCR 4650 exists, including when the district has not taken
action within 60 calendar days of the date the complaint was filed with the district. (5 CCR
4650)
Civil Law Remedies
A complainant may pursue available civil law remedies outside of the district's complaint
procedures. Complainants may seek assistance from mediation centers or public/private interest
attorneys. Civil law remedies that may be imposed by a court include, but are not limited to,
injunctions and restraining orders.
For complaints alleging discrimination, harassment, intimidation, and bullying based on state
law, a complainant shall wait until 60 calendar days have elapsed from the filing of an appeal
with the CDE before pursuing civil law remedies, provided the district has appropriately and in a
timely manner apprised the complainant of his/her right to file a complaint in accordance with 5
CCR 4622. The moratorium does not apply to injunctive relief and to discrimination complaints
based on federal law. (Education Code 262.3)
Regulation
adopted: March 13, 2013
(1/06 3/12 1/13) 3/13
15
Board Policy
Tobacco-Free Schools
BP 3513.3
Business and Noninstructional Operations
The Governing recognizes that the health hazards associated with smoking and the use of
tobacco products, including the breathing of second-hand smoke, are inconsistent with its goal to
provide a healthy environment for students and staff.
(cf. 3514 - Environmental Safety)
(cf. 4159/4259/4359 - Employee Assistance Programs)
(cf. 5030 - Student Wellness)
(cf. 5131.62 - Tobacco)
(cf. 5141.23 - Asthma Management)
(cf. 6142.8 - Comprehensive Health Education)
(cf. 6143 - Courses of Study)
The Board prohibits the use of tobacco products containing tobacco and/or nicotine, including,
but not limited to, smokeless tobacco, snuff, chew, clove cigarettes, and electronic nicotine
delivery systems, such as electronic cigarettes, any time, in charter school or school districtowned or leased buildings, on school or district property, and in school or district vehicles.
However, this section does not prohibit the use or possession of prescription products, or other
cessation aids such as nicotine patches or nicotine gum. Student use or possession of such
products must conform to laws governing student use and possession of medications on school
property. Other vapor emitting electronic devices, such as electronic hookah, with or without
nicotine content, that mimic the use of tobacco products, are also prohibited, at any time in
district-owned or leased buildings, on district property, and in district vehicles. (Health and
Safety Code 104420; Labor Code 6404.5; 20 USC 6083)
This prohibition applies to all employees, students, and visitors at any school-sponsored
instructional program, activity, or athletic held on or off district property. Any written joint use
agreement governing community use of district facilities or grounds shall include notice of the
district's tobacco-free schools policy and consequences for violations of the policy.
(cf. 1330 - Use of School Facilities)
(cf. 1330.1 - Joint Use Agreements)
Prohibited products include any product containing tobacco or nicotine, including, but not
limited to, cigarettes, cigars, miniature cigars, smokeless tobacco, snuff, chew, clove cigarettes,
betel, and nicotine delivery devices such as electronic cigarettes. Exceptions may be made for the
use or possession of prescription nicotine products.
Smoking or use of any tobacco-related products and disposal of any tobacco-related waste are
prohibited within 25 feet of any playground, except on a public sidewalk located within 25 feet
of the playground. (Health and Safety Code 104495)
16
Legal Reference:
EDUCATION CODE
48900 Grounds for suspension/expulsion
48901 Prohibition against tobacco use by students
HEALTH AND SAFETY CODE
39002 Control of air pollution from nonvehicular sources
104350-104495 Tobacco use prevention, especially:
104495 Prohibition of smoking and tobacco waste on playgrounds
119405 Unlawful to sell or furnish electronic cigarettes to minors
LABOR CODE
3300 Employer, definition
6304 Safe and healthful workplace
6404.5 Occupational safety and health; use of tobacco products
6083 Nonsmoking policy for children's services
7100-7117 Safe and Drug Free Schools and Communities Act
CODE OF FEDERAL REGULATIONS, TITLE 21
1140.1-1140.34 Unlawful sale of cigarettes and smokeless tobacco to minors
PERB RULINGS
Eureka Teachers Assn. v. Eureka City School District (1992) PERB Order #955 (16 PERC
23168)
CSEA #506 and Associated Teachers of Metropolitan Riverside v. Riverside Unified School
District (1989) PERB Order #750 (13 PERC 20147)
WEB SITES
California Department of Education, Alcohol, Tobacco and Other Drug Prevention:
http://www.cde.ca.gov/ls/he/at
California Department of Education, Tobacco-Free School District Certification:
http://www.cde.ca.gov/ls/he/at/tobaccofreecert.asp
California Department of Public Health, Tobacco Control:
http://www.cdph.ca.gov/programs/tobacco
Occupational Safety and Health Standards Board: http://www.dir.ca.gov/OSHSB/oshsb.html
U.S. Environmental Protection Agency: http://www.epa.gov
Adopted: October 23, 2013, Santa Rosa, California
17
Tobacco-Free Schools
AR 3513.3
Business and Noninstructional Operations
Notifications
Information about the district's tobacco-free schools policy and enforcement procedures shall be
communicated clearly to employees, parents/guardians, students, and the community. (Health
and Safety Code 104420)
The Superintendent or designee may disseminate this information through annual written
notifications, district and school web sites, student and parent handbooks, and/or other
appropriate methods of communication.
(cf. 1113 - District and School Web Sites)
Signs stating "Tobacco use is prohibited" shall be prominently displayed at all entrances to
school property. (Health and Safety Code 104420)
Enforcement/Discipline
Any employee or student who violates the district's tobacco-free schools policy shall be asked to
refrain from smoking and shall be subject to disciplinary action as appropriate.
(cf. 4118 - Suspension/Disciplinary Action)
(cf. 4218 - Dismissal/Suspension/Disciplinary Action)
(cf. 5144 - Discipline)
(cf. 5144.1 - Suspension and Expulsion/Due Process)
Any other person who violates the district's policy on tobacco-free schools shall be informed of
the district's policy and asked to refrain from smoking. If the person fails to comply with this
request, the Superintendent or designee may:
1.
Direct the person to leave school property
2.
Request local law enforcement assistance in removing the person from school premises
3.
If the person repeatedly violates the tobacco-free schools policy, prohibit him/her from
entering district property for a specified period of time
(cf. 1250 - Visitors/Outsiders)
(cf. 3515.2 - Disruptions)
18
The Superintendent or designee shall not be required to physically eject a nonemployee who is
smoking or to request that the nonemployee refrain from smoking under circumstances involving
a risk of physical harm to the district or any employee. (Labor Code 6404.5)
Regulation
Adopted: October 23, 2013, Santa Rosa, California
19
Board Policy
Drug And Alcohol-Free Workplace
BP 4020
Personnel
The Board of Education believes that the maintenance of a drug- and alcohol-free workplace is
essential to staff and student safety and to help ensure a productive and safe work and learning
environment.
(cf. 4112.41/4212.41/4312.41 - Employee Drug Testing)
(cf. 4112.42/4212.42/4312.42 - Drug and Alcohol Testing for School Bus Drivers)
An employee shall not unlawfully manufacture, distribute, dispense, possess, or use any
controlled substance in the workplace. (Government Code 8355; 41 USC 701)
Employees are prohibited from being under the influence of controlled substances or alcohol
while on duty. For purposes of this policy, on duty means while an employee is on duty during
both instructional and noninstructional time in the classroom or workplace, at extracurricular or
cocurricular activities, or while transporting students or otherwise supervising them. Under the
influence means that the employee's capabilities are adversely or negatively affected, impaired,
or diminished to an extent that impacts the employee's ability to safely and effectively perform
his/her job.
(cf. 4032 - Reasonable Accommodation)
The Superintendent or designee shall notify employees of the district's prohibition against drug
use and the actions that will be taken for violation of such prohibition. (Government Code
8355; 41 USC 701)
An employee shall abide by the terms of this policy and shall notify the district, within five days,
of his/her conviction for violation in the workplace of any criminal drug statute. (Government
Code 8355; 41 USC 701)
The Superintendent or designee shall notify the appropriate federal granting or contracting
agency within 10 days after receiving notification, from an employee or otherwise, of any
conviction for a violation occurring in the workplace. (41 USC 701)
In accordance with law and the district's collective bargaining agreements, the Superintendent or
designee shall take appropriate disciplinary action, up to and including termination, against an
employee for violating the terms of this policy and/or shall require the employee to satisfactorily
participate in and complete a drug assistance or rehabilitation program approved by a federal,
state, or local public health or law enforcement agency or other appropriate agency.
(cf. 4112 - Appointment and Conditions of Employment)
(cf. 4117.4 - Dismissal)
(cf. 4212 - Appointment and Conditions of Employment)
20
Drug-Free Awareness Program
The Superintendent or designee shall establish a drug-free awareness program to inform
employees about: (Government Code 8355; 41 USC 701)
1.
The dangers of drug abuse in the workplace
2.
The district's policy of maintaining a drug-free workplace
3.
Available drug counseling, rehabilitation, and employee assistance programs
(cf. 4159/4259/4359 - Employee Assistance Programs)
4.
The penalties that may be imposed on employees for drug abuse violations occurring in
the workplace
Legal Reference:
EDUCATION CODE
44011 Controlled substance offense
44425 Conviction of controlled substance offenses as grounds for revocation of credential
44836 Employment of certificated persons convicted of controlled substance offenses
44940 Compulsory leave of absence for certificated persons
44940.5 Procedures when employees are placed on compulsory leave of absence
45123 Employment after conviction of controlled substance offense
45304 Compulsory leave of absence for classified persons
GOVERNMENT CODE
8350-8357 Drug-free workplace
7111-7117 Safe and Drug Free Schools and Communities Act
812 Schedule of controlled substances
701-707 Drug-Free Workplace Act
1308.01-1308.49 Schedule of controlled substances
COURT DECISIONS
Cahoon v. Governing Board of Ventura USD, (2009) 171 Cal.App.4th 381
Ross v. RagingWire Telecommunications, Inc., (2008) 42 Cal.4th 920
WEB SITES
California Department of Alcohol and Drug Programs: http://www.adp.ca.gov
U.S. Department of Labor: http://www.dol.gov
adopted: April 25, 2012
21
Board Policy
Nondiscrimination In Employment
BP 4030(a)
BP 4030
Personnel
The Board of Education prohibits unlawful discrimination against and/or harassment of district
employees and job applicants on the basis of actual or perceived race, color, national origin,
ancestry, religion, age, marital status, pregnancy, physical or mental disability, medical
condition, veteran status, gender, sex, sexual orientation or any other legally required category, at
any district site and/or activity. The Board also prohibits retaliation against any district
employee or job applicant who complains, testifies or in any way participates in the district's
complaint procedures instituted pursuant to this policy.
(cf. 4119.11/4219.11/4319.11 - Sexual Harassment)
(cf. 4119.41/4219.41/4319.41 - Employees with Infectious Disease)
Any district employee who engages or participates in unlawful discrimination, or who aids,
abets, incites, compels or coerces another to discriminate, is in violation of this policy and is
subject to disciplinary action, up to and including dismissal.
Any district employee who observes or has knowledge of an incident of unlawful discrimination
or harassment shall report the incident to the principal, district administrator or Superintendent as
soon as practical after the incident. Failure of a district employee to report discrimination or
harassment may result in disciplinary action.
The Superintendent or designee shall regularly publicize, within the district and in the
community, the district's nondiscrimination policy and the availability of complaint procedures.
Such publication shall be included in each announcement, bulletin or application form that is
used in employee recruitment. (34 CFR 100.6, 106.9)
The district's policy and administrative regulation shall be posted in all schools and offices
including staff lounges and student government meeting rooms. (5 CCR 4960)
The Board designates the following position as Coordinator for Nondiscrimination in
Employment:
22
(continued)
BP 4030(b)
Assistant Superintendent, Human Resources
211 Ridgeway Ave.
707-528-5352
Other Remedies
An employee may, in addition to filing a discrimination complaint with the district, file a
complaint with either the California Department of Fair Employment and Housing (DFEH) or
the Equal Employment Opportunity Commission (EEOC). The time limits for filing such
complaints are as follows:
1. To file a valid complaint with DFEH, the employee must file his/her complaint within one
year of the alleged discriminatory act(s), unless an exception exists pursuant to
Government Code 12960. (Government Code 12960)
2. To file a valid complaint directly with EEOC, the employee must file his/her complaint
within 180 days of the alleged discriminatory act(s). To file a valid complaint with EEOC
after filing a complaint with DFEH, the employee must file the complaint within
300
days of the alleged discriminatory act(s) or within 30 days after the termination of
proceedings by DFEH, whichever is earlier. (42 USC 2000e-5)
Employees wishing to file complaints with the DFEH and EEOC should contact the
nondiscrimination coordinator for more information.
Legal Reference:
CIVIL CODE
51.7 Freedom from violence or intimidation
GOVERNMENT CODE
11135 Unlawful discrimination
PENAL CODE
422.56 Definitions, hate crimes
7287.6 Terms, conditions and privileges of employment
4900-4965 Nondiscrimination in elementary and secondary education programs receiving state
financial assistance
1681-1688 Discrimination based on sex or blindness, Title IX
794 Section 504 of the Rehabilitation Act of 1973
2000d-2000d-7 Title VI, Civil Rights Act of 1964
2000e-2000e-17 Title VII, Civil Rights Act of 1964 as amended
23
(continued)
BP 4030(c)
2000h-2-2000h-6 Title IX, 1972 Education Act Amendments
12101-12213 Americans with Disabilities Act
35.101-35.190 Americans with Disabilities Act
100.6 Compliance information
104.8 Notice
106.8 Designation of responsible employee and adoption of grievance procedures
106.9 Dissemination of policy
COURT DECISIONS
Carter v. California Department of Veterans Affairs (2003) 2003 Cal.LEXIS 5694
Shephard v. Loyola Marymount (2002) 102 CalApp.4th 837
EQUAL EMPLOYMENT OPPORTUNITY COMMISSION
Enforcement Guidance: Vicarious Employer Liability for Unlawful Harassment by Supervisors,
June 1999
Enforcement Guidance: Reasonable Accommodation and Undue Hardship under the Americans
with Disabilities Act, March, 1999
U.S. DEPARTMENT OF EDUCATION, OFFICE OF CIVIL RIGHTS
Notice of Non-Discrimination, January, 1999
WEB SITES
EEOC: http://www.eeoc.gov
OCR: http://www.ed.gov/offices/OCR
DFEH: http://www.dfeh.ca.gov
Policy
adopted: February 13, 2008
24
AR 4030
Personnel
Unlawful discrimination or harassment of an individual includes:
1.
Slurs, epithets, threats or verbal abuse
2.
Derogatory or degrading comments, descriptions, drawings, pictures or gestures
3.
Unwelcome jokes, stories, teasing or taunting
4.
Any other verbal, written, visual or physical conduct against the individual which:
a.
Adversely affects his/her employment opportunities, or
b.
Has the purpose or effect of unreasonably interfering with his/her work performance or
creating an intimidating, hostile or offensive work environment
Any employee or job applicant who feels that he/she has been or is being unlawfully
discriminated against or harassed should immediately contact his/her supervisor, the
Superintendent or designee in order to obtain procedures for reporting a complaint. Such
complaints shall be filed in accordance with AR 4031 - Complaints Concerning Discrimination
in Employment. An employee may bypass his/her supervisor when the supervisor is the alleged
offender.
Any supervisor who receives a discrimination/harassment complaint shall immediately notify the
nondiscrimination coordinator or the Superintendent, who shall ensure that the complaint is
appropriately investigated in accordance with district policy and regulations.
The Superintendent or designee shall ensure that annual training is provided to all employees
regarding the issues of discrimination.
Regulation
approved: February 13, 2008
25
Complaints Concerning Discrimination In Employment
AR 4031(a)
AR 4031
Personnel
The following procedures shall be used when a district employee or job applicant has a
complaint alleging that a specific action, policy, procedure or practice discriminates against
him/her on any basis specified in the district's nondiscrimination policies.
1.
The complaint should be initiated promptly after a complainant knew, or should have
known, of the alleged discrimination.
2.
All parties involved in allegations of discrimination shall be notified when a complaint is
filed, when a complaint meeting or hearing is scheduled, and when a decision or ruling is
made. The parties also shall be notified of their right to appeal the decision to the next
level.
3.
When a complaint is brought against the individual responsible for the complaint process
at
any level, the complainant may address the complaint directly to the next
appropriate level.
4.
Meetings related to a complaint shall be held at times the district determines appropriate
to
the circumstances.
5.
For the protection of all the parties involved, complaint proceedings shall be kept
confidential insofar as appropriate.
6.
All documents, communications and records dealing with the investigation of the
complaint
shall be placed in a confidential district personnel complaint file and not in
employee's individual personnel file.
the
(cf. 1340 - Access to District Records)
(cf. 3580 - District Records)
(cf. 4112.6/4212.6/4312.6 - Personnel Files)
7.
Time limits specified in these procedures may be revised only by written agreement of all
parties involved. If the district fails to respond within a specified or adjusted time limit,
a
complainant may proceed to the next level. If a complainant fails to take the
complaint
26
Complaints Concerning Discrimination In Employment (continued)
AR 4031(b)
to the next step within the prescribed time, the complaint shall be considered settled at the
preceding step.
Level I
The complainant shall first meet informally with his/her supervisor or the administrator of the
school where the alleged discriminatory act occurred. A complaint regarding discrimination
away from the school site should be discussed informally with the complainant's supervisor. If
the complainant's concerns are not clear or cannot be resolved through informal discussion, the
supervisor or other administrator shall prepare, within 10 working days, a written summary of
his/her meeting(s) with the complainant. This report shall be made available to the
Superintendent or designee.
Level II
If a complaint cannot be resolved to the satisfaction of the complainant at Level I, he/she may
submit a formal written complaint to the coordinator within 10 working days of his/her attempt
to resolve the complaint informally. The written complaint shall include the following:
1.
The complainant's name, address and telephone number
2.
The name and work location of the district staff member who committed the alleged
violation
3.
A description of the alleged discriminatory act(s) or omission(s)
4.
The discriminatory basis alleged
5.
A specific description of the time, place, nature, participants in and witnesses to the
alleged violation
6.
Other pertinent information which may assist in investigating and resolving the complaint
7.
The complainant's signature or that of his/her representative
The coordinator shall assign a staff member to assist the complainant with this writing if such
help is needed. The coordinator shall respond to the complaint in writing within 10 working
days.
The coordinator shall conduct any investigation necessary to respond to the complaint, including
discussion with the complainant, person(s) involved, appropriate staff members and students, and
review of the Level I report and all other relevant documents. If a response from third parties is
necessary, the coordinator may designate up to 10 additional working days for investigation of
the complaint.
27
AR 4031(c)
Level III
If the complaint cannot be resolved at Level II, either party may present the complaint to the
Superintendent or designee within 10 working days. The Superintendent or designee shall
review the Level II investigation file, including the written complaint and all responses from
district staff. The Superintendent or designee shall respond to the complaint in writing within 10
working days.
If the Superintendent or designee finds it necessary to conduct further investigation, he/she may
designate up to 10 additional working days for such investigation and shall respond to the
complaint in writing within 10 working days of completing the investigation.
Level IV
If the matter is not resolved at Level III, either party may file a written appeal to the Board
within 10 working days after receiving the Level III response. The Superintendent or designee
shall provide the Board with all information presented at previous levels.
The Board shall grant the hearing request for the next regular Board meeting for which the
matter can be placed on the agenda. Any complaint against a district employee shall be
addressed in closed session in accordance with law. The Board shall render its decision within
10 working days.
(cf. 9321 - Closed Session Purposes and Agendas)
The Board may appoint a hearing panel to review the complaint and previous decisions and
make recommendations to the Board. The panel shall hear the appeal and render its decision
within 10 working days.
Other Remedies
Complainants may appeal the Board's action to the California Department of Education. The
Superintendent or designee shall ensure that complainants are informed that injunctions,
restraining orders and other civil law remedies may also be available to them. This information
shall be published with the district's nondiscrimination complaint procedures and included in any
related notices. (Education Code 262.3)
Legal Reference:
EDUCATION CODE
GOVERNMENT CODE
12920-12921 Nondiscrimination
12940-12948 Discrimination prohibited; unlawful practices, generally
28
AR 4031(d)
621-634 Age Discrimination in Employment Act
794 Section 504 of the Rehabilitation Act of 1973
2001e-2001e-17 Title VII, Civil Rights Act of 1964 as amended
12101-12213 Americans with Disabilities Act
35.101-35.190 Americans with Disabilities Act
EQUAL EMPLOYMENT OPPORTUNITY COMMISSION
Enforcement Guidance: Reasonable Accommodation and Undue Hardship under the Americans
with Disabilities Act, March, 1999
OFFICE OF CIVIL RIGHTS AND NATIONAL ASSOCIATION OF ATTORNEYS GENERAL
Protecting Students from Harassment and Hate Crime, January, 1999
WEB SITES
EEOC: http://www.eeoc.gov
OCR: http://www.ed.gov/offices/OCR
Regulation
29
Board Policy
Employee Use Of Technology
BP 4040(a)
BP 4040
Personnel
The Board of Education recognizes that technological resources can enhance employee
performance by improving access to and exchange of information, offering effective tools to
assist in providing a quality instructional program, and facilitating district and school operations.
The Board expects all employees to use the available technological resources that will assist
them in the performance of their job responsibilities, and use them according to established
policies and district guidelines.
(cf. 0440 - District Technology Plan)
(cf. 4131 - Staff Development)
(cf. 6163.4 - Student Use of Technology)
Employees shall be responsible for the appropriate use of technology and shall use the district's
technological resources only for purposes related to their employment. Such use is a privilege
which may be revoked at any time.
(cf. 4119.25/4219.25/4319.25 - Political Activities of Employees)
Employees should be aware that computer files and communications over electronic networks,
including email and voice mail, are not private. These technologies shall not be used to transmit
confidential information about students, employees or district operations unless necessary to
conduct the legal business of the district.
(cf. 5125 - Student Records)
(cf. 5125.1 - Release of Directory Information)
The Superintendent or designee shall ensure that Internet access for all computers has technology
protection measures that prevent access to visual depictions that are obscene or child
pornography, and that the operation of such measures is enforced. The Superintendent or
designee may disable the technology protection measure during use by an adult to enable access
for bona fide research or other lawful purpose. (20 USC 6777; 47 USC 254)
To ensure proper use, the Superintendent or designee may monitor the district's technological
resources, including email and voice mail systems, at any time without advance notice or
consent.
30
(continued)
BP 4040(b)
The Superintendent or designee shall establish administrative regulations which outline
employee obligations and responsibilities related to the use of district technology. He/she also
may establish guidelines and limits on the use of technological resources. Inappropriate use may
result in disciplinary action and/or legal action in accordance with law, Board policy and
administrative regulation.
The Superintendent or designee shall provide copies of related policies, regulations, and
guidelines to all employees who use the district's technological resources. Employees shall be
required to acknowledge in writing that they have read and understood these policies, regulations
and guidelines.
In the event that the use of an electronic resource affects the working conditions of one or more
employees, the Superintendent or designee shall notify the employees' exclusive representative.
Any employee that uses a cell phone or mobile communications device in violation of law,
Board policy, or administrative regulation shall be subject to discipline and may be referred to
law enforcement officials as appropriate.
Legal Reference:
EDUCATION CODE
51870-51874 Education technology
52270-52272 Education technology and professional development grants
52295.10-52295.55 Implementation of Enhancing Education Through Technology grant
program
GOVERNMENT CODE
3543.1 Rights of employee organizations
PENAL CODE
502 Computer crimes, remedies
632 Eavesdropping on or recording confidential communications
VEHICLE CODE
23123 Wireless telephones in vehicles
23123.5 Mobile communication devices; text messaging while driving
23125 Wireless telephones in school buses
6751-6777 Enhancing Education Through Technology Act, Title II, Part D, especially:
6777 Internet safety
254 Universal service discounts (E-rate)
54.520 Internet safety policy and technology protection measures, E-rate discounts
31
(continued)
BP 4040(c)
WEB SITES
American Library Association: http://www.ala.org
Federal Communications Commission: http://www.fcc.gov
U.S. Department of Education: http://www.ed.gov
Policy
32
AR 4040(a)
AR 4040
Personnel
Online/Internet Services: User Obligations and Responsibilities
Employees are authorized to use district equipment to access the Internet or other online services
in accordance with Board policy, the district's Acceptable Use Agreement, and the user
obligations and responsibilities specified below.
1.
The employee in whose name an online services account is issued is responsible for its
proper use at all times. Employees shall keep account information, home addresses, and
telephone numbers private. They shall use the system only under the account number to
which they have been assigned.
2.
Employees shall use the system safely, responsibly, and primarily for work-related
purposes.
3.
Employees shall not access, post, submit, publish, or display harmful or inappropriate
matter that is threatening, obscene, disruptive, or sexually explicit, or that could be
construed as harassment or disparagement of others based on their race, ethnicity,
national
origin, sex, gender, sexual orientation, age, disability, religion, or political
beliefs.
4.
Employees shall not use the system to promote unethical practices or any activity
prohibited
by law, Board policy, or administrative regulations.
(cf. 4119.25/4219.25/4319.25 - Political Activities of Employees)
5.
Employees shall not use the system to engage in commercial or other for-profit activities
without permission of the Superintendent or designee.
6.
Copyrighted material shall be posted online only in accordance with applicable copyright
laws.
(cf. 6162.6 - Use of Copyrighted Materials)
7.
33
Employees shall not attempt to interfere with other users' ability to send or receive email,
nor shall they attempt to read, delete, copy, modify, or forge other users' email.
(continued)
AR 4040(b)
8.
Employees shall not develop any classroom or work-related web sites, blogs, forums, or
similar online communications representing the district or using district equipment or
resources without permission of the Superintendent or designee. Such sites shall be
subject to rules and guidelines established for district online publishing activities
including,
but not limited to, copyright laws, privacy rights, and prohibitions against
obscene, libelous,
and slanderous content. Because of the unfiltered nature of blogs,
any such site shall
include a disclaimer that the district is not responsible for the content of
the messages. The district retains the right to delete material on any such online
communications.
9.
Users shall report any security problem or misuse of the services to the Superintendent or
designee.
Regulation
34
Oath Or Affirmation
AR 4112.3
Personnel
All district employees are declared by law to be disaster service workers and thus shall take the
oath or affirmation required for disaster service workers before beginning employment with the
district. In the event of natural, manmade or war-caused emergencies which result in conditions
of disaster or extreme peril to life, property and resources, all district employees are subject to
disaster service activities as assigned to them by their supervisors or by law. (Government Code
3100-3102)
(cf. 3516 - Emergencies and Disaster Preparedness Plan)
(cf. 9224 - Oath or Affirmation)
Legally employed noncitizens shall be exempt from taking this oath. (Government Code 3101)
At the advice of legal counsel, the Superintendent or designee may exempt an employee from
taking the oath if he/she raises a valid religious objection.
The Superintendent, deputy or assistant superintendent, principal or other person authorized in
Education Code 60 shall administer the oath or affirmation when a district employee is hired.
In the case of intermittent, temporary, emergency or successive employments, the Superintendent
or designee may determine that the oath shall be effective for all successive periods of
employment which begin within one calendar year from the date that the oath was subscribed.
(Government Code 3102)
(cf. 4121 - Temporary/Substitute Personnel)
The Superintendent or designee shall file the executed oath or affirmation within 30 days of the
date on which it is taken and subscribed. An employee's oath or affirmation may be destroyed
five years after the termination of employment. (Government Code 3105)
Reimbursement of Expenses for Disaster Service Workers
Whenever an employee seeks compensation or reimbursement of expenses as a disaster service
worker, the Superintendent or designee shall ascertain and certify that the employee has taken
the oath or affirmation. (Government Code 3107)
Legal Reference:
EDUCATION CODE
60 Persons authorized to administer and certify oaths
44334 Oath or affirmation required for credential
44354 Administration of oath required for credential
35
GOVERNMENT CODE
3100-3109 Oath or affirmation of allegiance
CALIFORNIA CONSTITUTION
Article 20, Section 3 Oath of office
COURT DECISIONS
Chilton v. Contra Costa Community College District 55 Cal. App. 3d 544 (1976)
Vogel v. County of Los Angeles (1967) 68 Cal. 2d 18, 22
Regulation
approved: February 13, 2008 Santa Rosa, California
36
Board Policy
Sexual Harassment
BP 4119.11, 4219.11, 4319.11
Personnel
The Governing Board prohibits sexual harassment of district employees and job applicants. The
Board also prohibits retaliatory behavior or action against district employees or other persons
who complain, testify or otherwise participate in the complaint process established pursuant to
this policy and administrative regulation.
The Superintendent or designee shall take all actions necessary to ensure the prevention,
investigation, and correction of sexual harassment, including but not limited to:
1.
Providing training to employees in accordance with law and administrative regulation
2.
Publicizing and disseminating the district's sexual harassment policy to staff
3.
Ensuring prompt, thorough, and fair investigation of complaints
4.
Taking timely and appropriate corrective/remedial action(s), which may require interim
separation of the complainant and the alleged harasser and subsequent monitoring of
developments
All complaints and allegations of sexual harassment shall be kept confidential to the extent
necessary to carry out the investigation or to take other subsequent necessary actions. (5 CCR
4964)
Any district employee or job applicant who feels that he/she has been sexually harassed or who
has knowledge of any incident of sexual harassment by or against another employee, a job
applicant or a student, shall immediately report the incident to his/her supervisor, the principal,
district administrator or Superintendent.
A supervisor, principal or other district administrator who receives a harassment complaint shall
promptly notify the Superintendent or designee.
37
Complaints of sexual harassment shall be filed in accordance with AR 4031 - Complaints
Concerning Discrimination in Employment. An employee may bypass his/her supervisor in filing
a complaint where the supervisor is the subject of the complaint.
Any district employee who engages or participates in sexual harassment or who aids, abets,
incites, compels, or coerces another to commit sexual harassment against a district employee, job
applicant, or student is in violation of this policy and is subject to disciplinary action, up to and
including dismissal.
Legal Reference:
EDUCATION CODE
200-262.4 Prohibition of discrimination on the basis of sex
GOVERNMENT CODE
12900-12996 Fair Employment and Housing Act, especially:
12940 Prohibited discrimination
12950.1 Sexual harassment training
LABOR CODE
1101 Political activities of employees
1102.1 Discrimination: sexual orientation
7287.8 Retaliation
7288.0 Sexual harassment training and education
4900-4965 Nondiscrimination in elementary and secondary education programs receiving state
financial assistance
2000e-2000e-17 Title VII, Civil Rights Act of 1964, as amended
106.9 Dissemination of policy
COURT DECISIONS
Department of Health Services v. Superior Court of California, (2003) 31 Cal.4th 1026
Faragher v. City of Boca Raton, (1998) 118 S.Ct. 2275
Burlington Industries v. Ellreth, (1998) 118 S.Ct. 2257
Gebser v. Lago Vista Independent School District, (1998) 118 S.Ct. 1989
Oncale v. Sundowner Offshore Serv. Inc., (1998) 118 S.Ct. 998
Meritor Savings Bank, FSB v. Vinson et al., (1986) 447 U.S. 57
38
OFFICE OF CIVIL RIGHTS AND NATIONAL ASSOCIATION OF ATTORNEYS
GENERAL
Protecting Students from Harassment and Hate Crime, January, 1999
WEB SITES
California Department of Fair Employment and Housing: http://www.dfeh.ca.gov
Equal Employment Opportunity Commission: http://www.eeoc.gov
U.S. Department of Education, Office for Civil Rights:
http://www.ed.gov/about/offices/list/ocr/index.html
adopted: May 8, 2013 Santa Rosa, California
(11/01 3/04 7/05) 5/13
39
Sexual Harassment
AR 4119.11, 4219.11, 4319.11
Personnel
Definitions
Prohibited sexual harassment includes, but is not limited to, unwelcome sexual advances,
unwanted requests for sexual favors, or other unwanted verbal, visual, or physical conduct of a
sexual nature made against another person of the same or opposite sex in the work or educational
setting when: (Education Code 212.5; 5 CCR 4916)
1.
Submission to the conduct is made explicitly or implicitly a term or condition of the
individual's employment.
2.
Submission to or rejection of such conduct by the individual is used as the basis for an
employment decision affecting him/her.
3.
The conduct has the purpose or effect of having a negative impact upon the individual's
work or has the purpose or effect of creating an intimidating, hostile, or offensive work
environment. The conduct is sufficiently severe, persistent, pervasive, or objectively offensive so
as to create a hostile or abusive working environment or to limit the individual's ability to
participate in or benefit from an education program or activity.
4.
Submission to or rejection of the conduct by the other individual is used as the basis for
any decision affecting him/her regarding benefits, services, honors, programs, or activities
available at or through the district.
Other examples of actions that might constitute sexual harassment, whether committed by a
supervisor, a co-worker, or a non-employee, in the work or educational setting, include, but are
not limited to:
1.
Unwelcome verbal conduct such as sexual flirtations or propositions; graphic comments
about an individual's body; overly personal conversations or pressure for sexual activity; sexual
jokes or stories; unwelcome sexual slurs, epithets, threats, innuendoes, derogatory comments,
sexually degrading descriptions, or the spreading of sexual rumors
2.
Unwelcome visual conduct such as drawings, pictures, graffiti, or gestures; sexually
explicit emails; displaying sexually suggestive objects
3.
Unwelcome physical conduct such as massaging, grabbing, fondling, stroking, or
brushing the body; touching an individual's body or clothes in a sexual way; cornering, blocking,
leaning over, or impeding normal movements
Prohibited sexual harassment may also include any act of retaliation against an individual who
reports a violation of the district's sexual harassment policy or who participates in the
40
investigation of a sexual harassment complaint.
Training
Every two years, the Superintendent or designee shall ensure that supervisory employees receive
at least two hours of classroom or other effective interactive training and education regarding
sexual harassment. All newly hired or promoted supervisory employees shall receive training
within six months of their assumption of the supervisory position. (Government Code 12950.1)
The district's training and education program for supervisory employees shall include
information and practical guidance regarding the federal and state laws on the prohibition against
and the prevention and correction of sexual harassment, and the remedies available to the victims
of sexual harassment in employment. The training shall also include all of the content specified
in 2 CCR 7288.0 and practical examples aimed at instructing supervisors in the prevention of
harassment, discrimination, and retaliation. (Government Code 12950.1; 2 CCR 7288.0)
In addition, the Superintendent or designee shall ensure that all employees receive periodic
training regarding the district's sexual harassment policy, particularly the procedures for filing
complaints and employees' duty to use the district's complaint procedures.
Notifications
A copy of the Board policy and this administrative regulation shall: (Education Code 231.5)
1.
Be displayed in a prominent location in the main administrative building, district office,
or other area of the school where notices of district rules, regulations, procedures, and standards
of conduct are posted
2.
Be provided to each faculty member, all members of the administrative staff, and all
members of the support staff at the beginning of the first quarter or semester of the school year or
whenever a new employee is hired
3.
Appear in any school or district publication that sets forth the school's or district's
comprehensive rules, regulations, procedures, and standards of conduct
41
All employees shall receive either a copy of information sheets prepared by the California
Department of Fair Employment and Housing (DFEH) or a copy of district information sheets
that contain, at a minimum, components on: (Government Code 12950)
1.
The illegality of sexual harassment
2.
The definition of sexual harassment under applicable state and federal law
3.
A description of sexual harassment, with examples
4.
The district's complaint process available to the employee
5.
The legal remedies and complaint process available through DFEH and the Equal
Employment Opportunity Commission (EEOC)
6.
Directions on how to contact DFEH and the EEOC
7.
The protection against retaliation provided by 2 CCR 7287.8 for opposing harassment
prohibited by law or for filing a complaint with or otherwise participating in an investigation,
proceeding, or hearing conducted by DFEH and the EEOC
In addition, the district shall post, in a prominent and accessible location, DFEH's poster on
discrimination in employment and the illegality of sexual harassment. (Government Code
12950)
Regulation SANTA ROSA CITY SCHOOLS
approved: May 8, 2013 Santa Rosa, California
(3/04 7/05 3/08) 5/13
42
Board Policy
Employees With Infectious Disease
BP 4119.41
Personnel
BP 4119.41(a)
BP 4219.41
BP 4319.41
The Board of Education encourages each employee to inform the district as soon as possible if
he/she contracts an infectious disease which creates a physical or mental disability. The Board
will reasonably accommodate the needs of such individuals.
The Board may reassign or grant disability leave to an employee who is unable to perform
his/her job responsibilities because of illness or because the employee's illness significantly
endangers his/her health or safety or the health or safety of others.
(cf. 4161.1/4361.1 - Personal Illness/Injury Leave)
(cf. 4261.1 - Personal Illness/Injury Leave)
No employee will be discriminated against because of his/her disability. Legal protections
established for disabled persons extend to individuals significantly impaired by infectious
diseases.
(cf. 4112.4/4212.4/4312.4 - Health Examinations)
When informed that an employee has a disabling infectious disease, the Superintendent or
designee may request that the employee sign a release form to provide confidential medical
information and records.
In determining a reasonable accommodation of the employee's condition, the Superintendent or
designee may consult with public health officials or physicians with expertise in the diagnosis
and treatment of infectious disease. The Superintendent or designee may also communicate with
the employee's physician regarding the employee's ability to perform the essential requirements
of the job with reasonable accommodation and without posing significant health or safety risks to
the employee or others.
The Superintendent or designee shall prepare a confidential report which includes his/her
recommendation and the medical information upon which it is based. These recommendations
shall take into consideration:
1. The nature of the disease and the probability of its being transmitted, including the duration
and severity of the risk
2. The physical condition of the employee, including diagnosis, treatment, and prognosis of the
condition
43
Employees With Infectious Disease
(continued)
BP 4119.41(b)
BP 4219.41
BP 4319.41
3. The actual requirements of the employee's job and the expected type of interaction with
others in the school setting
This report shall be forwarded to the Board for confidential review and action.
The job assignment of an employee with a disabling infectious disease shall be reevaluated
whenever there is a change in medical knowledge or in the employee's medical regimen or health
which might affect his/her assignment.
Confidentiality
The Board and the Superintendent or designee shall ensure that employee rights to
confidentiality are strictly observed. The district shall disclose medical record information only
to the extent required or permitted by law. The medical records of any employee with a
disabling infectious disease shall be held in strict confidence.
Legal Reference:
CIVIL CODE
56-56.37 Confidentiality of medical information
GOVERNMENT CODE
120975-121020 Mandated blood testing and confidentiality to protect public health
7293.5 et seq.
701 et seq. Rehabilitation Act
12101-12213 Americans With Disabilities Act
COURT DECISIONS
School Board of Nassau County, Fla. v. Arline, 408 U.S. 273 (1987)
Policy
44
Board Policy
Exposure Control Plan For Bloodborne Pathogens
BP 4119.42
Personnel
BP 4119.42(a)
BP 4219.42
BP 4319.42
As part of its commitment to provide a safe and healthful work environment, the Board of
Education recognizes the importance of developing an exposure control plan. The
Superintendent or designee shall establish a written exposure control plan in accordance with
state and federal standards for dealing with potentially infectious materials in the workplace to
protect employees from possible infection due to contact with bloodborne pathogens, including
but not limited to hepatitis B virus, hepatitis C virus and human immunodeficiency virus (HIV).
(cf. 4119.43/4219.43/4319.43 - Universal Precautions)
(cf. 4157/4257/4357 - Employee Safety)
The Superintendent or designee shall determine which employees have occupational exposure to
bloodborne pathogens and other potentially infectious materials. In accordance with the district's
exposure control plan, employees having occupational exposure shall be offered the hepatitis B
vaccination.
The Superintendent or designee may exempt designated first aid providers from pre-exposure
hepatitis B vaccination under the conditions specified by state regulations. (8 CCR 5193(f))
Any employee not identified by the Superintendent or designee as having occupational exposure
may submit a request to the Superintendent or designee to be included in the training and
hepatitis B vaccination program. The Superintendent or designee may deny a request when there
is no reasonable anticipation of contact with any infectious material.
Legal Reference:
LABOR CODE
142.3 Authority of Cal/OSHA to adopt standards
144.7 Requirement to amend standards
3204 Access to employee exposure and medical records
5193 California bloodborne pathogens standards
1910.1030 OSHA bloodborne pathogens standards
CDE ADVISORIES
1016.89 Guidelines for Informing School Employees about Preventing the Spread of Infectious
Diseases, including Hepatitis B and AIDS/HIV Infections and Policies for Dealing with HIVInfected Persons in School Settings
45
(continued)
BP 4119.42(b)
BP 4219.42
BP 4319.42
WEB SITES
OSHA: http://www.osha.gov
Cal/OSHA: http://www.dir.ca.gov/occupational_safety.html
Centers for Disease Control and Prevention: http://www.cdc.gov
Policy
46
AR 4119.42
Personnel
AR 4119.42(a)
AR 4219.42
AR 4319.42
Definitions
Occupational exposure means reasonably anticipated skin, eye, mucous membrane, or parenteral
contact with blood or other potentially infectious materials that may result from the performance
of an employee's duties. (8 CCR 5193(b))
Exposure incident means a specific eye, mouth, other mucous membrane, nonintact skin, or
parenteral contact with blood or other potentially infectious materials that result from the
performance of an employee's duties. (8 CCR 5193 (b))
Parenteral contact means piercing mucous membranes or the skin barrier through such events as
needlesticks, human bites, cuts, and abrasions. (8 CCR 5193(b))
A sharp is any object that can be reasonably anticipated to penetrate the skin or any other part of
the body and to result in an exposure incident. (8 CCR 5193(b))
A sharps injury is any injury caused by a sharp, including but not limited to cuts, abrasions or
needlesticks. (8 CCR 5193(b))
Work practice controls are controls that reduce the likelihood of exposure by defining the
manner in which a task is performed. (8 CCR 5193(b))
Engineering controls are controls, such as sharps disposal containers, needleless systems, and
sharps with engineered sharps injury protection, that isolate or remove the bloodborne pathogens
hazard from the workplace. (8 CCR 5193(b))
Engineered sharps injury protection is a physical attribute built into a needle device or into a
non-needle sharp which effectively reduces the risk of an exposure incident. (8 CCR 5193(b))
Exposure Control Plan
The district's exposure control plan shall contain at least the following components: (8 CCR
5193(c))
1. A determination of which employees have occupational exposure to blood or other
potentially infectious materials
47
(continued)
AR 4119.42(b)
AR 4219.42
AR 4319.42
The district's exposure determination shall be made without regard to the use of personal
protective equipment and shall include a list of:
a. All job classifications in which all employees have occupational exposure
b. Job classifications in which some employees have occupational exposure
c. All tasks and procedures, or groups of closely related tasks and procedures, in which
occupational exposure occurs and which are performed by employees listed in item #b
above
2. The schedule and method of implementing:
a. Methods of compliance required by 8 CCR 5193(d), such as universal precautions, general
and specific engineering and work practice controls, and personal protective equipment
(cf. 4119.43/4219.43/4319.43 - Universal Precautions)
b. Hepatitis B vaccination
c. Bloodborne pathogen post-exposure evaluation and follow-up
d. Communication of hazards to employees, including labels, signs, information and training
e. Recordkeeping
3. The district's procedure for evaluating circumstances surrounding exposure incidents
4. An effective procedure for gathering information about each exposure incident involving a
sharp, as required for the log of sharps injuries
5. An effective procedure for periodically determining the frequency of use of the types and
brands of sharps involved in exposure incidents documented in the sharps injury log
6. An effective procedure for identifying currently available engineering controls and selecting
such controls as appropriate for the procedures performed by employees in their work
areas or departments
7. An effective procedure for documenting instances when a licensed healthcare professional
directly involved in a patient's care determines, in the reasonable exercise of clinical
judgment, that the use of an engineering control would jeopardize an individual's safety
or the success of a medical, dental or nursing procedure involving the individual
8. An effective procedure for obtaining the active involvement of employees in reviewing and
48
(continued)
AR 4119.42(c)
AR 4219.42
AR 4319.42
updating the exposure control plan with respect to the procedures performed by employees in
their respective work areas or departments
The exposure control plan shall be reviewed and updated at least annually and whenever
necessary to: (8 CCR 5193(c))
1. Reflect new or modified tasks and procedures affecting occupational exposure
2. To the extent that sharps are used in the district, reflect progress in implementing the use of
needleless systems and sharps with engineered sharps injury protection
3. Include new or revised employee positions with occupational exposure
4. Review and evaluate the exposure incidents which occurred since the previous update
5. Review and respond to information indicating that the exposure control plan is deficient in
any area
The district's exposure control plan shall be accessible to employees upon request. (8 CCR
3204(e))
Preventive Measures
The Superintendent or designee shall use engineering and work practice controls to eliminate or
minimize employee exposure, and shall regularly examine and update controls to ensure their
effectiveness. (8 CCR 5193(d))
Hepatitis B Vaccination
The hepatitis B vaccination and vaccination series shall be made available at no cost to all
employees who have occupational exposure. The hepatitis B vaccination shall be made available
after an employee with occupational exposure has received the required training and within 10
working days of initial assignment, unless the employee has previously received the complete
hepatitis B vaccination series, or antibody testing has revealed that the employee is immune, or
vaccination is contraindicated by medical reasons. (8 CCR 5193(f))
Employees who decline to accept the vaccination shall sign the hepatitis B declination statement.
(8 CCR 5193(f))
The Superintendent or designee may exempt designated first aid providers from the pre-exposure
hepatitis B vaccine in accordance with 8 CCR 5193 (f).
49
(continued)
AR 4119.42(d)
AR 4219.42
AR 4319.42
Information and Training
The Superintendent or designee shall ensure that all employees with occupational exposure
participate in a training program containing the elements required by state regulations, during
working hours and at no cost to the employee. This program shall be offered at the time of initial
assignment to tasks where occupational exposure may take place, at least annually thereafter, and
whenever a change of tasks or procedures affects the employee's exposure. (8 CCR 5193(g))
Designated first aid providers shall receive training that includes the specifics of reporting firstaid incidents which involve blood or body fluids which are potentially infectious. (8 CCR
5193(g))
Reporting Incidents
All exposure incidents shall be reported as soon as possible to the Superintendent or designee.
Unvaccinated designated first aid providers must report any first aid incident involving the
presence of blood or other potentially infectious material, regardless of whether an exposure
incident occurred, by the end of the work shift. The full hepatitis B vaccination series shall be
made available to such employees no later than 24 hours after the first aid incident. (8 CCR
5193(f))
Sharps Injury Log
The Superintendent or designee shall establish and maintain a log recording each exposure
incident involving a sharp. The exposure incident shall be recorded within 14 working days of
the date the incident is reported to the district. (8 CCR 5193(c))
The information recorded shall include the following, if known or reasonably available: (8 CCR
5193(c))
1. Date and time of the exposure incident
2. Type and brand of sharp involved in the exposure incident
3. A description of the exposure incident, including:
a. Job classification of the exposed employee
b. Department or work area where the exposure incident occurred
c. The procedure that the exposed employee was performing at the time of the incident
d. How the incident occurred
50
(continued)
AR 4119.42(e)
AR 4219.42
AR 4319.42
e. The body part involved in the incident
f. If the sharp had engineered sharps injury protection, whether the protective mechanism was
activated and whether the injury occurred before, during or after the protective
mechanism was activated
g. If the sharp had no engineered sharps injury protection, the injured employee's opinion as to
whether and how such a mechanism could have prevented the injury
h. The employee's opinion about whether any other engineering, administrative or work
practice could have prevented the injury
Post-Exposure Evaluation and Follow-up
Following a report of an exposure incident, the Superintendent or designee shall immediately
make available to the exposed employee, at no cost, a confidential medical evaluation, postexposure evaluation and follow-up. The Superintendent or designee shall, at a minimum: (8
CCR 5193(f))
1. Document the route(s) of exposure and the circumstances under which the exposure incident
occurred
2. Identify and document the source individual, unless that identification is infeasible or
prohibited by law
3. Provide for the collection and testing of the employee's blood for hepatitis B, hepatitis C and
HIV serological status
4. Provide for post-exposure prophylaxis, when medically indicated, as recommended by the
U.S. Public Health Service
5. Provide for counseling and evaluation of reported illnesses
The Superintendent or designee shall provide the health care professional with a copy of 8 CCR
5193; a description of the employee's duties as they relate to the exposure incident;
documentation of the route(s) of exposure and circumstances under which exposure occurred;
results of the source individual's blood testing, if available; and all medical records maintained
by the district relevant to the appropriate treatment of the employee, including vaccination status.
(8 CCR 5193(f))
The district shall maintain the confidentiality of the affected employee and the exposure source
during all phases of the post-exposure evaluation. (8 CCR 5193(f))
(cf. 9011 - Disclosure of Confidential/Privileged Information)
51
(continued)
AR 4119.42(f)
AR 4219.42
AR 4319.42
Records
Upon an employee's initial employment and at least annually thereafter, the Superintendent or
designee shall inform employees with occupational exposure of the existence, location and
availability of related records; the person responsible for maintaining and providing access to
records; and the employee's right of access to these records. (8 CCR 3204)
(cf. 1340 - Access to District Records)
(cf. 3580 - District Records)
Medical records for each employee with occupational exposure shall be kept confidential and not
disclosed or reported without the employee's written consent to any person within or outside the
workplace except as required by law. (8 CCR 5193(h))
Upon request by an employee, or a designated representative with the employee's written
consent, the Superintendent or designee shall provide access to a record in a reasonable time,
place and manner, no later than 15 days after the request is made. (8 CCR 3204(e))
Records shall be maintained as follows: (8 CCR 3204(d), 5193(h))
1. Medical records shall be maintained for the duration of employment plus 30 years.
2. Training records shall be maintained for three years from the date of training.
3. The sharps injury log shall be maintained five years from the date the exposure incident
occurred.
4. Exposure records shall be maintained for at least 30 years.
5. Each analysis using medical or exposure records shall be maintained for at least 30 years.
Regulation
52
Exhibit
E 4119.42
Personnel
Hepatitis B Vaccine Declination
I understand that due to my occupational exposure to blood or other potentially infectious
materials I may be at risk of acquiring hepatitis B virus (HBV) infection. I have been given the
opportunity to be vaccinated with hepatitis B vaccine, at no charge to myself. However, I
decline hepatitis B vaccination at this time. I understand that by declining this vaccine, I
continue to be at risk of acquiring hepatitis B, a serious disease. If in the future I continue to
have occupational exposure to blood or other potentially infectious materials and I want to be
vaccinated with hepatitis B vaccine, I can receive the vaccination series at no charge to myself.
____________________________________
Signature
____________________________________
Employee Name (Please print)
____________________________________
Date
Exhibit
version: February 13, 2008
53
Board Policy
Universal Precautions
BP 4119.43
BP 4219.43
BP 4319.43
BP 4119.43
Personnel
In order to protect employees from contact with potentially infectious blood or other body fluids,
the Board of Education requires that universal precautions be observed throughout the district.
Universal precautions are appropriate for preventing the spread of all infectious diseases and
shall be used regardless of whether bloodborne pathogens are known to be present.
(cf. 5141 - Health Care and Emergencies)
(cf. 5141.22 - Infectious Diseases)
(cf. 5141.24 - Specialized Health Care Services)
(cf. 5141.6 - Student Health and Social Services)
(cf. 6145.2 - Athletic Competition)
Employees shall immediately report any exposure incident or first aid incident in accordance
with the district's exposure control plan or other safety procedures.
(cf. 4119.42/4219.42/4319.42 - Exposure Control Plan for Bloodborne Pathogens)
Legal Reference:
117600-118360 Handling and disposal of regulated waste
120875 Providing information to school districts on AIDS, AIDS-related conditions and
Hepatitis B
120880 Information to employees of school district
5193 California bloodborne pathogens standard
1910.1030 OSHA bloodborne pathogens standards
CDE PROGRAM ADVISORIES
1016.89 Guidelines for Informing School Employees about Preventing the Spread of Infectious
Diseases, including Hepatitis B and AIDS/HIV Infections and Policies for Dealing with HIVInfected Persons in School Settings
WEB SITES
Centers for Disease Control and Prevention: http://www.cdc.gov
Policy
54
AR 4119.43(a)
AR 4219.43
AR 4319.43
AR 4119.43
Personnel
Definitions
Universal precautions are an approach to infection control. All human blood and certain human
body fluids, including but not limited to semen, vaginal secretions and any body fluid that is
visibly contaminated with blood, are treated as if known to be infectious for human
immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV) and other
bloodborne pathogens. (8 CCR 5193(b))
Personal protective equipment includes specialized clothing or equipment worn or used for
protection against a hazard. General work clothes such as uniforms, pants, shirts or blouses not
intended to function as protection against a hazard are not considered to be personal protective
equipment. (8 CCR 5193(b))
A sharp is any object that can be reasonably anticipated to penetrate the skin or any other part of
the body and to result in an exposure incident. (8 CCR 5193(b))
Engineered sharps injury protection is a physical attribute built into a needle device or into a
non-needle sharp which effectively reduces the risk of an exposure incident. (8 CCR 5193(b))
Employee Information
The Superintendent or designee shall distribute to employees information provided by the
California Department of Education regarding acquired immune deficiency syndrome (AIDS),
AIDS-related conditions, and hepatitis B. This information shall include, but not be limited to,
any appropriate methods employees may use to prevent exposure to AIDS and hepatitis B,
including information concerning the availability of a vaccine to prevent contraction of hepatitis
B, and that the cost of this vaccination may be covered by the health plan benefits of the
employees. Information shall be distributed at least annually, or more frequently if there is new
information supplied by the California Department of Education. (Health and Safety Code
120875, 120880)
(cf. 4119.42/4219.42/4319.42 - Exposure Control Plan for Bloodborne Pathogens)
Infection Control Practices
The Superintendent or designee shall ensure that the worksite is effectively maintained in a clean
55
(continued)
AR 4119.43(b)
AR 4219.43
AR 4319.43
and sanitary condition, and shall implement an appropriate written schedule for cleaning and
decontamination of the worksite. (8 CCR 5193(d))
Where occupational exposure remains after the institution of engineering and work practice
controls, the Superintendent or designee shall provide appropriate personal protective equipment
at no cost to the employee. Such equipment may include gloves, gowns, masks, eye protection,
and other devices that do not permit blood or other potentially infectious materials to pass
through or reach the employee's clothes, skin, eyes, mouth or other mucous membranes under
normal conditions of use. The Superintendent or designee shall maintain, repair, make accessible
and require employees to use and properly handle protective equipment. (8 CCR 5193(d))
The Superintendent or designee shall provide handwashing facilities which are readily accessible
to employees. When provision of handwashing facilities is not feasible, the Superintendent or
designee shall provide an appropriate antiseptic hand cleanser in conjunction with clean cloth or
paper towels, or antiseptic towelettes. (8 CCR 5193(d))
For the prevention of infectious disease, employees shall routinely: (8 CCR 5193(d))
1. Perform all procedures involving blood or other potentially infectious materials in such a
manner as to minimize splashing, spraying, spattering, and generating droplets of these
substances.
2. Use personal protective equipment as appropriate.
a. Appropriate clothing, including but not limited to, gowns, aprons, lab coats, clinic
jackets or similar outer garments, shall be worn in occupational exposure
situations.
If a garment becomes penetrated by blood or other potentially infectious materials, the
employee shall remove the garment immediately or as soon as feasible. All personal
protective equipment shall be removed prior to leaving the work area. When removed, it
shall be placed in an appropriately designated area or container for storage, washing,
decontamination or disposal.
b. Gloves shall be worn when it can be reasonably anticipated that the employee may have
hand contact with blood, other potentially infectious materials, mucous membranes and
nonintact skin, and when handling or touching contaminated items or surfaces.
Disposable gloves shall be replaced as soon as practical when contaminated, or as soon as
feasible if they are torn, punctured, or when their ability to function as a barrier is
compromised. They shall not be washed or decontaminated for reuse. Utility gloves may
be decontaminated for reuse if the integrity of the gloves is not compromised, but must be
discarded if they are cracked, peeling, torn, punctured, or exhibit other signs of
deterioration or when their ability to function as a barrier is compromised.
56
(continued)
AR 4119.43(c)
AR 4219.43
AR 4319.43
c. Masks in combination with eye protection devices or face shields shall be worn whenever
splashes, spray, spatter, or droplets of blood or other potentially infectious materials may
be
generated and eye, nose or mouth contamination can be reasonably anticipated.
3. Wash hands and other skin surfaces thoroughly with soap and running water:
a. Immediately or as soon as feasible following contact of hands or any other skin or
mucous membranes with blood or other potentially infectious materials
b. Immediately after removing gloves or other personal protective equipment
When handwashing facilities are not available, the employee shall use antiseptic hand cleanser in
conjunction with clean cloth or paper towels, or antiseptic towelettes. In such instances, hands
shall be washed with soap and running water as soon as feasible.
4. Refrain from eating, drinking, smoking, applying cosmetics or lip balm, or handling contact
lenses in work areas with a reasonable likelihood of occupational exposure.
5. Clean and decontaminate all equipment and environmental and work surfaces after contact
with blood or other potentially infectious material, no later than the end of the shift or
more frequently as required by state regulations.
6. Rather than using the hands directly, use mechanical means such as a brush and dust pan,
tongs or forceps to clean up broken glassware which may be contaminated.
7. Use effective patient-handling techniques and other methods designed to minimize the risk of
a sharps injury in all procedures involving the use of sharps in patient care.
(cf. 5141.21 - Administering Medication and Monitoring Health Conditions)
(cf. 5141.24 - Specialized Health Care Services)
a. Needleless systems shall be used to administer medication or fluids, withdraw body
fluids after initial venous or arterial access is established, and conduct any other
procedure involving the potential for an exposure incident for which a needleless
system is available as an alternative to the use of needle devices. If needleless
systems are not used, needles or non-needle sharps with engineered sharps injury
protection shall be used.
b. Contaminated needles or other sharps shall not be broken, bent, recapped, removed
from devices, or stored or processed in a manner that requires employees to reach by
hand into the containers where these sharps have been placed.
c. Disposable sharps shall not be reused.
57
(continued)
AR 4119.43(d)
AR 4219.43
AR 4319.43
8. Handle, store, treat and dispose of regulated waste in accordance with Health and Safety Code
117600-118360 and other applicable state and federal regulations.
a. Immediately or as soon as possible after use, contaminated sharps shall be placed in
containers meeting the requirements of 8 CCR 5193(d)(3)(D). Containers shall be easily
accessible, maintained upright throughout use where feasible, and replaced as necessary
to
avoid overfilling.
b. Specimens of blood or other potentially infectious material shall be placed in a container
which prevents leakage during collection, handling, processing, storage, transport or
shipping.
(cf. 5141 - Health Care and Emergencies)
(cf. 5141.22 - Infectious Diseases)
(cf. 5141.6 - Student Health and Social Services)
Regulation
58
Appointment And Conditions Of Employment
AR 4212
Personnel
Upon recommendation of the Superintendent, the Board of Education shall approve the appointment of all
classified employees. The position shall be reported to the Board at a regular meeting.
Individuals appointed to the classified staff shall, at a minimum:
1. Submit to fingerprinting as required by law (Education Code 45125)
2. Not have been convicted of a violent or serious felony (Education Code 45122.1)
(cf. 4212.5 - Criminal Record Check)
3. Not have been convicted of any sex offense as defined in Education Code 44010 (Education Code
45123)
4. Not have been determined to be a sexual psychopath pursuant to Welfare and Institutions Code 63006332 (Education Code 45124)
5. If the individual will be working directly and in an unaccompanied setting with minor children on a
more than incidental and occasional basis or will have supervision or disciplinary power over minor
children, not be required to register as a sex offender pursuant to Penal Code 290 because of a conviction
for a crime where the victim was a minor under the age of 16 (Penal Code 290.95)
(cf. 3515.5 - Sex Offender Notification)
6. Not have been convicted of any controlled substance offense as defined in Education Code 44011
7. Submit to a physical examination or provide proof thereof as required by law and Board policy
(Education Code 45122, 49406)
(cf. 4112.4/4212.4/4312.4 - Health Examinations)
8. File the oath or affirmation of allegiance required by Government Code 3100-3109
(cf. 4112.3/4212.3/4312.3 - Oath or Affirmation)
9. Submit to drug and alcohol testing as required by Board policy
(cf. 4112.41/4212.41/4312.41 - Employee Drug Testing)
10. Fulfill any other requirements as specified by law, collective bargaining agreement, Board policy or
administrative regulation
59
(cf. 4112.8/4212.8/4312.8 - Employment of Relatives)
Notification of Classification and Compensation
When first employed and upon each subsequent change in classification, classified employees other than
short-term, limited-term or provisional employees shall be given two copies of their class specification,
salary data, assignment or work location, duty hours and prescribed work week. Salary data shall specify
pay period (monthly) and applicable rates of compensation (daily, hourly, and overtime). Employees
shall keep one copy of this information and shall sign and date the other copy and return it to their
supervisor. (Education Code 45169)
(cf. 4151/4251/4351 - Employee Compensation)
Legal Reference:
EDUCATION CODE
35161 Powers and duties
44010 Sex offense - definitions
44011 Controlled substance offense - definitions
44066 Limitation on certification requirements
45103 Classified service in districts not incorporating the merit system
45104 Positions not requiring certification qualifications
45105 Positions under various acts not requiring certification qualifications
45108 Restricted positions
45113 Rules and regulations for classified service in districts not incorporating the merit system
45122 Physical examinations
45122.1 Classified employees, conviction of a violent or serious felony
45123 Employment after conviction of sex offense or controlled substance offense
45125 Use of personal identification cards to ascertain conviction of crime
45169 Employee salary data
49406 Examination for tuberculosis
60850-60856 High school exit exam
GOVERNMENT CODE
3100-3109 Oaths or affirmations
12940-12950 Unlawful employment practices
PENAL CODE
290 Registration of sex offenders
290.95 Disclosure by person required to register as sex offenders
667.5 Prior prison terms, enhancement of prison terms
1192.7 Plea bargaining limitation
1203.4 Discharged petitioner, change of plea
6300-6332 Sexual psychopaths
Regulation
60
Board Policy
Demotion/Reassignment
BP 4313.2
Personnel
The Board of Education may authorize the demotion or reassignment of any administrative or
supervisory employee upon the recommendation of the Superintendent or designee and when
such action is determined to be in the best interest of the district.
(cf. 0520.2 - Title I Program Improvement Schools)
(cf. 0520.3 - Title I Program Improvement Districts)
(cf. 4300 - Administrative and Supervisory Personnel)
(cf. 4312.1 - Contracts)
(cf. 4314 - Transfers)
The Superintendent or designee shall ensure that the district complies with all applicable
statutory deadlines and due process procedures when an employee is to be demoted or
reassigned.
Legal Reference:
EDUCATION CODE
35031 Senior management employee in the classified service: nonreelection
44660-44665 Evaluation and assessment of performance of certificated employees
44850.1 No tenure in administrative or supervisory positions
44896 Transfer of administrator or supervisor to teaching position
44897 Classification of administrator or supervisor to a teaching position
44951 Continuation in position unless notified
45101 Definitions (including disciplinary action, cause)
45113 Rules for classified service in districts not incorporating the merit system
52055.5 Meeting or exceeding growth requirements
52055.57 Districts identified or at risk of identification for program improvement
6316 School and district improvement
COURT DECISIONS
Jefferson v. Compton Unified School District, (1993) 14 Cal. App. 4th 32
Schultz v. Regents of the University of California, (1984) 160 Cal. App. 3d 768
Ellerbroek v. Saddleback Valley Unified School District, (1981) 125 Cal. App 3d 348
Skelly v. California Personnel Board, (1975) 15 Cal.3d 194
Hentschke v. Sink, (1973) 34 Cal. App. 3d 19
adopted: April 11, 2012
61
Demotion/Reassignment
AR 4313.2
Personnel
Certificated Administrative Employees
Permanent certificated management staff are not entitled to seniority rights in their
administrative positions. However, such staff shall earn and/or retain any seniority earned in
service as a classroom teacher or site administrator pursuant to Education Code 44893, 44894, or
44956.5.
(cf. 4117.3 - Personnel Reduction)
(cf. 4117.6 - Decision Not to Rehire)
End of Year Release/Reassignment of Certificated Administrators
By March 15, an employee serving under a single year contract or appointment shall be notified
by either registered mail or in person that he/she may be released or reassigned from his/her
position for the following school year. If the notice is presented to the employee in person, the
district shall obtain his/her signature acknowledging receipt of the notice on the district's copy of
the written notice. (Education Code 44951)
If the March 15 notice indicates that release or reassignment is only a possibility, the Board of
Education shall take additional action to release/reassign the employee before the new school
year and shall send the employee a second notice by June 30 indicating that he/she has been
released or reassigned.
In the event the certificated administrator is serving under a contract or appointment of two or
more years, the required notice shall be given no later than 45 days in advance of the expiration
of the contract or appointment. (Education Code 35031)
Regulation
approved: April 11, 2012
62
Board Policy
Conduct
BP 5131
Students
The Board of Education believes that all students have the right to be educated in a positive
learning environment free from disruptions. Students shall be expected to exhibit appropriate
conduct that does not infringe upon the rights of others or interfere with the school program
while on school grounds, while going to or coming from school, while at school activities, and
while on district transportation.
(cf. 5131.1 - Bus Conduct)
Conduct is considered appropriate when students are diligent in study, careful with school
property, courteous, and respectful toward their teachers, other staff, students, and volunteers.
The Superintendent or designee shall ensure that each school site develops standards of conduct
and discipline consistent with district policies and administrative regulations. Students and
parents/guardians shall be notified of district and school rules related to conduct.
Prohibited student conduct that is related to school attendance or school activities includes, but is
not limited to:
1.
Conduct that endangers students, staff, or others
(cf. 5131.7 - Weapons and Dangerous Instruments) (cf. 5136 - Gangs)
(cf. 5142 - Safety)
2.
Conduct that disrupts the orderly classroom or school environment. A behavioral
intervention pyramid, student study team process, and process instruments are contained in
administrative regulation 5131.
(cf. 5131.4 - Student Disturbances)
3.
Harassment of students or staff, including bullying, "cyberbullying," intimidation, hazing
or initiation activity, ridicule, extortion, or any other verbal, written, or physical conduct that
causes or threatens to cause violence, bodily harm, emotional suffering or substantial disruption
in accordance with the section entitled "Bullying/Cyberbullying" below.
Cyberbullying includes but is not limited to, the transmission of communications, posting of
harassing messages, direct threats, social cruelty, or other harmful text, sounds, or images on the
Internet, social networking sites, or other digital technologies using a telephone, computer, or
any wireless communication device. Cyberbullying also includes breaking into another person's
electronic account and assuming that person's identity in order to damage that person's
reputation, or actions that create a hostile environment, and/or the transmission of obscene words
or images.
63
(cf. 5145.3 - Nondiscrimination/Harassment) (cf. 5145.7 - Sexual Harassment)
(cf. 5145.9 - Hate-Motivated Behavior)
4.
Damage to or theft of property belonging to students, staff, or the district
(cf. 3515.4 - Recovery for Property Loss or Damage) (cf. 5131.5 - Vandalism, Theft and Graffiti)
5.
Possession or use of laser pointers on school premises, unless used for a valid
instructional or other school-related purpose, including employment (Penal Code 417.27)
Prior to bringing a laser pointer on school premises, students shall first obtain permission
from the principal or designee. The principal or designee shall determine whether the requested
use of the laser pointer is for a valid instructional or other school-related purpose.
6.
Use of profane, vulgar, or abusive language
(cf. 5145.2 - Freedom of Speech/Expression)
7.
Plagiarism or dishonesty in school work or on tests
(cf. 5131.9 - Academic Honesty)
(cf. 6162.54 - Test Integrity/Test Preparation)
(cf. 6162.6 - Use of Copyrighted Materials)
8.
Inappropriate attire as defined by published school site dress codes
(cf. 5132 - Dress and Grooming)
9.
Tardiness or unexcused absence from school
(cf. 5113 - Absences and Excuses)
(cf. 5113.1 - Truancy)
10.
Failure to remain on school premises in accordance with school rules
(cf. 5112.5 - Open/Closed Campus)
11.
Possession, use, or being under the influence of tobacco, alcohol, or other prohibited
drugs
(cf. 5131.6 - Alcohol and Other Drugs)
(cf. 5131.62 - Tobacco)
(cf.5131.63 - Steroids)
Employees are expected to provide appropriate supervision to enforce standards of conduct and,
if they observe or receive a report of a violation of these standards, to immediately intervene or
call for assistance. If an employee believes a matter has not been resolved, he/she shall refer the
matter to his/her supervisor or administrator for further investigation.
64
Students who violate district or school rules and regulations may be subject to discipline
including, but not limited to, suspension, expulsion, transfer to alternative programs, and/or
denial of participation in the extracurricular activities in accordance with Board policy and
administrative regulation: The Superintendent or designee shall notify local law enforcement as
appropriate.
(cf. 1020 - Youth Services)
(cf. 1400 - Relations between Other Governmental Agencies and the Schools)
(cf. 5020 - Parent Rights and Responsibilities)
(cf. 5127 - Graduation Ceremonies and Activities)
(cf. 5144.1 - Suspension and Expulsion/Due Process)
(cf. 5144.2 - Suspension and Expulsion/Due Process (Students with Disabilities))
(cf. 6020 - Parent Involvement)
(cf. 6184 - Continuation Education)
(cf. 6185 - Community Day School)
Students also may be subject to discipline for any off-campus conduct during non-school hours
which poses a threat or danger to the safety of students, staff, or district property or substantially
disrupts the educational program of the district or of any other district in accordance with law,
Board policy, and administrative regulation.
Possession of Cellular Phones and Other Mobile Communications Devices
No student shall be prohibited from possessing or using an electronic signaling device that is
determined by a licensed physician or surgeon to be essential for the student's health and the use
of which is limited to health-related purposes. (Education Code 48901.5)
During any state or classroom assessment, students may not use electronic devices nor have
electronic devices on the desks or their person until all test materials have been collected by the
test administrator. Students will stow all electronic devices in their backpacks or lockers during
this time so that they are inaccessible until all test materials are collected and secure.
Grades K-6:
principal.
All electronic devices are prohibited without prior approval of the school
Grades 7-8: Students may possess but not use electronic devices during the school day in
accordance with published school rules.
Grades 9-12: Students may possess or use on school campus personal electronic signaling
devices including, but not limited to, pagers and cellular/digital telephones, as well as other
mobile communications devices including, but not limited to, digital media players, personal
digital assistants (PDAs), compact disc players, portable game consoles, cameras, digital
scanners, and laptop computers, provided that such devices are used in accordance with
published school rules, do not disrupt the educational program or school activity, and are not
used for illegal or unethical activities such as cheating on assignments or tests.
If a disruption occurs or a student uses any mobile communications device for improper
activities, a school employee shall direct the student to turn off the device and/or shall confiscate
it.
65
If a school employee finds it necessary to confiscate a device, he/she shall return it at the end of
the class period or school day.
In accordance with the Board's policy and administrative regulation on search and seizure, a
school official may search a student's mobile communications device, including, but not limited
to, reviewing messages or viewing pictures.
(cf. 5145.12 - Search and Seizure)
Students shall not use mobile communications devices, even in hands-free mode, while driving
on school grounds or to or from a school-related activity.
A student who violates this policy may be prohibited from possessing a mobile communications
device at school or school-related events and/or may be subject to further discipline in
accordance with Board policy and administrative regulation.
Bullying/Cyberbullying
The Board desires to prevent bullying by establishing a positive, collaborative school climate and
clear rules for student conduct.
(cf. 5137 - Positive School Climate)
(cf. 5138 - Conflict Resolution/Peer Mediation)
(cf. 6164.2 - Guidance/Counseling Services)
The district will provide students with annual instruction, in the classroom or other educational
settings, that promotes communication, social skills, and assertiveness skills and educates
students about appropriate online behavior, Internet safety, risks, and strategies to prevent and
respond to bullying and cyberbullying.
(cf. 1220 - Citizen Advisory Committees)
(cf. 6163.4 - Student Use of Technology)
School staff shall receive related professional development, including information about early
warning signs of harassing/intimidating behaviors and effective prevention and intervention
strategies in regards to bullying and cyberbullying. Parents/guardians may also be provided with
similar information.
Students may submit a verbal or written complaint of conduct they consider to be bullying to a
teacher or administrator and may also request that their name be kept in confidence. The
Superintendent or designee may establish other processes for students to submit anonymous
reports of bullying. Complaints of bullying or harassment shall be investigated and resolved in
accordance with site-level grievance procedures specified in AR 5145.7 - Sexual Harassment.
When a student is suspected of or reported to be using electronic or digital communications to
engage in cyberbullying against other students or staff or to threaten district property, the
investigation shall include documentation of the activity, identification of the source, and
specific facts or circumstances that explain the impact or potential impact on school activity,
school attendance, or the targeted student's educational performance.
66
Students shall be encouraged to save and print any messages sent to them that they feel constitute
cyberbullying and to notify a teacher, the principal, or other employee so that the matter may be
investigated.
Any student who engages in cyberbullying using district-owned equipment, or personal
equipment on school premises, or off-campus in a manner that impacts a school activity or
school attendance shall be subject to discipline in accordance with district policies and
regulations. If the student is using a social networking site or service that has terms of use that
prohibit posting of harmful material, the Superintendent or designee also may file a complaint
with the Internet site or service to have the material removed.
Legal Reference:
EDUCATION CODE
32280-32289 Comprehensive safety plan
35181 Governing board authority to set policy on responsibilities of students
35291-35291.5 Rules
44807 Duty concerning conduct of students
48900-48925 Suspension and expulsion
51512 Prohibition against electronic listening or recording device in classroom without
permission
CIVIL CODE
1714.1 Liability of parents and guardians for willful misconduct of minor
PENAL CODE
288.2 Harmful matter with intent to seduce
313 Harmful matter
417.25-417.27 Laser scope or laser pointer
647 Use of camera or other instrument to invade person's privacy; misdemeanor
653.2 Electronic communication devices, threats to safety
VEHICLE CODE
23123-23124 Prohibitions against use of electronic devices while driving
300-307 Duties of students
2000h-2000h6 Title IX, 1972 Education Act Amendments
COURT DECISIONS
J.C. v. Beverly Hills Unified School District, (2010) 711 F.Supp.2d 1094
LaVine v. Blaine School District, (2000, 9th Cir.) 257 F.3d 981
Emmett v. Kent School District No. 415, (2000) 92 F.Supp. 1088
Bethel School District No. 403 v. Fraser, (1986) 478 U.S. 675
New Jersey v. T.L.O., (1985) 469 U.S. 325
Tinker v. Des Moines Independent Community School District, (1969) 393 U.S. 503
CSBA PUBLICATIONS
Safe Schools: Strategies for Governing Boards to Ensure Student Success, 2011
Providing a Safe, Nondiscriminatory School Environment for All Students, Policy Brief, April
67
2010
Cyberbullying: Policy Considerations for Boards, Policy Brief, July 2007
CALIFORNIA DEPARTMENT OF EDUCATION PUBLICATIONS
Bullying at School, 2003
WEB SITES
California Department of Education, Safe Schools Office: http://www.cde.ca.gov/ls/ss
Center for Safe and Responsible Internet Use: http://cyberbully.org
National School Boards Association: http://www.nsba.org
National School Safety Center: http://www.schoolsafety.us
U.S. Department of Education: http://www.ed.gov
adopted: February 11, 2009 Santa Rosa, California
revised: June 13, 2012
68
Conduct - Elementary Plan
AR 5131
Students
In order to provide a safe, orderly, classroom or school environment, elementary schools shall
address conduct that endangers students, staff, or others; disrupts an orderly classroom or school
environment; especially when students exhibit chronically disruptive behavior. The Behavioral
Intervention Pyramid, Study Team Process, and associated instruments in this regulation are for
use to address such behaviors.
(cf. 0450 - Comprehensive Safety Plans)
(cf. 5131.7 -Weapons and Dangerous Instruments)
(cf. 5142 - Safety)
The attached plan and instruments were developed and recommended by a collaborative team
including teachers, a counselor, a psychologist, an elementary principal, the district Behaviorist,
the Director of K-6 Curriculum and Instruction, the Assistant Superintendent of K-6 Curriculum
and Instruction, and a representative from the Community Action partnership of Sonoma. They
were supported by the Teacher Advisory Committee.
The Behavioral Intervention Pyramid, Study Team Process, and associated instruments include
fill implementation of the best plan; documents interventions and evaluations; full
implementation of written behavior plans; and parent communications. Included are typical
interventions and sample behavior plans; resources for parents; behavior support plan
professional development with the psychologist or behaviorist; and collaborative behavioral plan
writing for support.
In order to create consistency with student discipline action, the following forms are used at all
elementary schools: K-6 Behavior Referral Form; Notice of Suspension form Class Form; and
BEST Think Tank Form.
Review of this plan should occur on an annual basis.
Regulation
revised: June 22, 2011
69
Exhibit
Conduct - Elementary Plan
E 5131
Students
PLEASE SEE DISTRICT MATERIAL IN THE DISTRICT OFFICE
FOR EXHIBIT 5131 ENTITLED:
"BEHAVIORAL INTERVENTION PYRAMID"
"STUDENT STUDY TEAM PROCESS"
"STEPS FOR REFERRAL TO THE STUDENT STUDY TEAM"
"STUDENT STUDY TEAM REFERRAL FORM"
"CHECKLIST OF ACCOMMODATIONS"
"BEHAVIORAL INTERVENTION PLAN FORM"
"BEHAVIOR AGREEMENT"
"BEHAVIOR SUPPORT PLAN"
"DAILY POSITIVE TARGET BEHAVIOR CHECKLIST"
"POSITIVE DAILY REPORT"
"NOTICE OF SUSPENSION FROM CLASS/PARENT CONFERENCE"
"BEHAVIOR REFERRAL FORM"
Exhibit : SANTA ROSA CITY SCHOOLS
version: June 22, 2011
70
Board Policy
Child Abuse Prevention And Reporting
BP 5141.4
Students
(cf. 1020 - Youth Services)
(cf. 5141.6 - School Health Services)
(cf. 6164.2 - Guidance/Counseling Services)
Child Abuse Prevention
The district's instructional program shall include age-appropriate and culturally sensitive child
abuse prevention curriculum. This curriculum shall explain students' right to live free of abuse,
include instruction in the skills and techniques needed to identify unsafe situations and react
appropriately and promptly, inform students of available support resources, and teach students
how to obtain help and disclose incidents of abuse.
(cf. 6142.8 - Comprehensive Health Education)
(cf. 6143 - Courses of Study)
The district's program also may include age-appropriate curriculum in sexual abuse and sexual
assault awareness and prevention. Upon written request of a student's parent/guardian, the
student shall be excused from taking such instruction. (Education Code 51900.6)
The Superintendent or designee shall, to the extent feasible, seek to incorporate community
resources into the district's child abuse prevention programs and may use these resources to
provide parents/guardians with instruction in parenting skills and child abuse prevention.
Child Abuse Reporting
The Superintendent or designee shall establish procedures for the identification and reporting of
known and suspected child abuse and neglect in accordance with law.
(cf. 4119.21/4219.21/4319.21 - Professional Standards)
Procedures for reporting child abuse shall be included in the district and/or school
comprehensive safety plan. (Education Code 32282)
District employees who are mandated reporters, as defined by law and administrative regulation,
are obligated to report all known or suspected incidents of child abuse and neglect.
The Superintendent or designee shall provide training regarding the duties of mandated reporters.
Legal Reference:
EDUCATION CODE
32280-32288 Comprehensive school safety plans
71
33195 Heritage schools, mandated reporters
33308.1 Guidelines on procedure for filing child abuse complaints
44252 Teacher credentialing
44691 Staff development in the detection of child abuse and neglect
44807 Duty concerning conduct of students
48906 Notification when student released to peace officer
48987 Dissemination of reporting guidelines to parents
49001 Prohibition of corporal punishment
51220.5 Parenting skills education
51900.6 Sexual abuse and sexual assault awareness and prevention
PENAL CODE
152.3 Duty to report murder, rape, or lewd or lascivious act
273a Willful cruelty or unjustifiable punishment of child; endangering life or health
288 Definition of lewd or lascivious act requiring reporting
11164-11174.3 Child Abuse and Neglect Reporting Act
15630-15637 Dependent adult abuse reporting
4650 Filing complaints with CDE, special education students
11434a McKinney-Vento Homeless Assistance Act; definitions
COURT DECISIONS
Camreta v. Greene (2011) 131 S.Ct. 2020
CALIFORNIA DEPARTMENT OF EDUCATION PUBLICATIONS
Health Education Content Standards for California Public Schools, Kindergarten Through Grade
Twelve
Health Framework for California Public Schools, Kindergarten Through Grade Twelve
WEB SITES
California Attorney General's Office, Suspected Child Abuse Report Form:
http://www.ag.ca.gov/childabuse/pdf/ss_8572.pdf
California Department of Education, Safe Schools: http://www.cde.ca.gov/ls/ss/ap
California Department of Social Services, Children and Family Services Division:
http://www.childsworld.ca.gov
U.S. Department of Health and Human Services, Child Information Gateway:
https://www.childwelfare.gov/can
(7/02 11/04 12/14)
Policy:
adopted:
72
January 13, 2016, Santa Rosa, California
Child Abuse Prevention And Reporting
AR 5141.4
Students
Definitions
Child abuse or neglect includes the following: (Penal Code 11165.5, 11165.6)
1.
A physical injury or death inflicted by other than accidental means on a child by another
person
2.
Sexual abuse of a child, including sexual assault or sexual exploitation, as defined in
Penal Code 11165.1
3.
Neglect of a child as defined in Penal Code 11165.2
4.
Willful harming or injuring of a child or the endangering of the person or health of a
child as defined in Penal Code 11165.3
5.
Unlawful corporal punishment or injury as defined in Penal Code 11165.4
(cf. 4119.21/4219.21/4319.21 - Professional Standards)
Child abuse or neglect does not include:
1.
A mutual affray between minors (Penal Code 11165.6)
2.
An injury caused by reasonable and necessary force used by a peace officer acting within
the course and scope of his/her employment (Penal Code 11165.6)
(cf. 3515.3 - District Police/Security Department)
3.
An injury resulting from the exercise by a teacher, vice principal, principal, or other
certificated employee of the same degree of physical control over a student that a
parent/guardian would be privileged to exercise, not exceeding the amount of physical
control reasonably necessary to maintain order, protect property, protect the health and
safety of students, or maintain proper and appropriate conditions conducive to learning
4.
An injury caused by a school employee's use of force that is reasonable and necessary to
quell a disturbance threatening physical injury to persons or damage to property, to
protect himself/herself, or to obtain weapons or other dangerous objects within the
control of a student (Education Code 49001)
73
(cf. 5131.7 - Weapons and Dangerous Instruments)
(cf. 6159.4 - Behavioral Interventions for Special Education Students)
5.
Physical pain or discomfort caused by athletic competition or other such recreational
activity voluntarily engaged in by a student (Education Code 49001)
(cf. 6142.7 - Physical Education and Activity)
6.
Homelessness or classification as an unaccompanied minor (Penal Code 11165.15)
Mandated reporters include, but are not limited to, teachers; instructional aides; teacher's aides or
assistants; classified employees; certificated pupil personnel employees; administrative officers
or supervisors of child attendance; athletic coaches, administrators, and directors; administrators
and employees of a licensed child day care facility; Head Start teachers; district police or
security officers; licensed nurses or health care providers; and administrators, presenters, and
counselors of a child abuse prevention program. The District may require volunteers to obtain
training in the identification and reporting of child abuse and neglect and to report known or
suspected incidents of child abuse or neglect. (Penal Code 11165.7)
Reasonable suspicion means that it is objectively reasonable for a person to entertain a suspicion,
based upon facts that could cause a reasonable person in a like position, drawing when
appropriate on his/her training and experience, to suspect child abuse or neglect. However,
reasonable suspicion does not require certainty that child abuse or neglect has occurred nor does
it require a specific medical indication of child abuse or neglect. (Penal Code 11166)
Reportable Offenses
A mandated reporter shall make a report using the procedures provided below whenever, in
his/her professional capacity or within the scope of his/her employment, he/she has knowledge of
or observes a child whom the mandated reporter knows or reasonably suspects has been the
victim of child abuse or neglect. (Penal Code 11166)
Any mandated reporter who has knowledge of or who reasonably suspects that a child is
suffering serious emotional damage or is at a substantial risk of suffering serious emotional
damage, based on evidence of severe anxiety, depression, withdrawal, or untoward aggressive
behavior toward self or others, may make a report to the appropriate agency. (Penal Code
11166.05, 11167)
Any district employee who reasonably believes that he/she has observed the commission of a
murder, rape, or lewd or lascivious act by use of force, violence, duress, menace, or fear of
immediate and unlawful bodily injury against a victim who is a child under age 14 shall notify a
peace officer. (Penal Code 152.3, 288)
74
Responsibility for Reporting
The reporting duties of mandated reporters are individual and cannot be delegated to another
person. (Penal Code 11166)
When two or more mandated reporters jointly have knowledge of a known or suspected instance
of child abuse or neglect, the report may be made by a member of the team selected by mutual
agreement and a single report may be made and signed by the selected member of the reporting
team. Any member who has knowledge that the member designated to report has failed to do so
shall thereafter make the report. (Penal Code 11166)
No supervisor or administrator shall impede or inhibit a mandated reporter from making a report.
(Penal Code 11166)
Any person not identified as a mandated reporter who has knowledge of or observes a child
whom he/she knows or reasonably suspects has been a victim of child abuse or neglect may
report the known or suspected instance of child abuse or neglect to the appropriate agency.
(Penal Code 11166)
(cf. 1240 - Volunteer Assistance)
Reporting Procedures
1.
Initial Telephone Report
Immediately or as soon as practicable after knowing or observing suspected child abuse
or neglect, a mandated reporter shall make an initial report by telephone to any police
department (excluding a school district police/security department), sheriff's department,
county probation department if designated by the county to receive such reports, or
county welfare department. (Penal Code 11165.9, 11166)
Child Protective Services – Sonoma County
1202 Apollo Way
Child Abuse Hotline – (707) 565-4300
Toll Free (800) 870-7064 (24 hour reporting lines)
When the initial telephone report is made, the mandated reporter shall note the name of
the official contacted, the date and time contacted, and any instructions or advice
received.
2.
Written Report
Within 36 hours of knowing or observing the information concerning the incident, the
mandated reporter shall then prepare and either send, fax, or electronically submit to the
appropriate agency a written follow-up report, which includes a completed Department of
Justice form (SS 8572). (Penal Code 11166, 11168)
75
The Department of Justice form may be obtained from the county probation or welfare
department or the police or sheriff's department.
Reports of suspected child abuse or neglect shall include, if known: (Penal Code 11167)
a.
The name, business address, and telephone number of the person making the report and
the capacity that makes the person a mandated reporter
b.
The child's name and address, present location, and, where applicable, school, grade, and
class
c.
The names, addresses, and telephone numbers of the child's parents/guardians
d.
The name, address, telephone number, and other relevant personal information about the
person who might have abused or neglected the child
e.
The information that gave rise to the reasonable suspicion of child abuse or neglect and
the source(s) of that information
The mandated reporter shall make a report even if some of this information is not known
or is uncertain to him/her. (Penal Code 11167)
The mandated reporter may give to an investigator from an agency investigating the case,
including a licensing agency, any information relevant to an incident of child abuse or neglect or
to a report made for serious emotional damage pursuant to Penal Code 11166.05. (Penal Code
11167)
3.
Internal Reporting
The mandated reporter shall not be required to disclose his/her identity to his/her supervisor, the
principal, or the Superintendent or designee. (Penal Code 11166)
However, employees reporting child abuse or neglect to an appropriate agency are encouraged,
but not required, to notify the principal as soon as possible after the initial telephone report to the
appropriate agency. When so notified, the principal shall inform the Superintendent or designee.
The principal so notified shall provide the mandated reporter with any assistance
necessary to ensure that reporting procedures are carried out in accordance with law, Board
policy, and administrative regulation. At the mandated reporter's request, the principal may assist
in completing and filing the necessary forms.
Reporting the information to an employer, supervisor, principal, school counselor, coworker, or other person shall not be a substitute for making a mandated report to the appropriate
agency. (Penal Code 11166)
76
Training
Within the first six weeks of each school year, the Superintendent or designee shall provide
training on mandated reporting requirements to district employees and persons working on their
behalf who are mandated reporters. Any school personnel hired during the school year shall
receive such training within the first six weeks of employment. (Education Code 44691; Penal
Code 11165.7)
The Superintendent or designee shall use the online training module provided by the California
Department of Social Services. (Education Code 44691)
The training shall include, but not necessarily be limited to, training in identification and
reporting of child abuse and neglect. In addition, the training shall include information that
failure to report an incident of known or reasonably suspected child abuse or neglect as required
by law is a misdemeanor punishable by imprisonment and/or a fine as specified. (Education
Code 44691; Penal Code 11165.7)
The Superintendent or designee shall obtain and retain proof of each mandated reporter's
completion of the training. (Education Code 44691)
Victim Interviews by Social Services
Whenever the Department of Social Services or another government agency is investigating
suspected child abuse or neglect that occurred within the child's home or out-of-home care
facility, the student may be interviewed by an agency representative during school hours, on
school premises. The Superintendent or designee shall give the student the choice of being
interviewed in private or in the presence of any adult school employee or volunteer aide selected
by the student. (Penal Code 11174.3)
A staff member or volunteer aide selected by a child may decline to be present at the interview.
If the selected person accepts, the principal or designee shall inform him/her of the following
requirements: (Penal Code 11174.3)
1.
The purpose of the selected person's presence at the interview is to lend support to the
child and enable him/her to be as comfortable as possible.
2.
The selected person shall not participate in the interview.
3.
The selected person shall not discuss the facts or circumstances of the case with the child.
4.
The selected person is subject to the confidentiality requirements of the Child Abuse and
Neglect Reporting Act, a violation of which is punishable as specified in Penal Code
11167.5.
If a staff member agrees to be present, the interview shall be held at a time during school hours
when it does not involve an expense to the school. (Penal Code 11174.3)
77
Release of Child to Peace Officer
When a child is released to a peace officer and taken into custody as a victim of suspected child
abuse or neglect, the Superintendent or designee and/or principal shall not notify the
parent/guardian, but rather shall provide the peace officer with the address and telephone number
of the child's parent/guardian. (Education Code 48906)
(cf. 5145.11 - Questioning and Apprehension by Law Enforcement)
Parent/Guardian Complaints
Upon request, the Superintendent or designee shall provide parents/guardians with procedures
for reporting suspected child abuse occurring at a school site to appropriate agencies. For
parents/guardians whose primary language is not English, such procedures shall be in their
primary language and, when communicating orally regarding those procedures, an interpreter
shall be provided.
To file a complaint against a district employee or other person suspected of child abuse or
neglect at a school site, parents/guardians may file a report by telephone, in person, or in writing
with any appropriate agency identified above under "Reporting Procedures." If a parent/guardian
makes a complaint about an employee to any other employee, the employee receiving the
information shall notify the parent/guardian of procedures for filing a complaint with the
appropriate agency. The employee also is obligated pursuant to Penal Code 11166 to file a
report himself/herself using the procedures described above for mandated reporters.
In addition, if the child is enrolled in special education, a separate complaint may be filed with
the California Department of Education pursuant to 5 CCR 4650.
Notifications
The Superintendent or designee shall provide to all new employees who are mandated reporters a
statement that informs them of their status as mandated reporters, their reporting obligations
under Penal Code 11166, and their confidentiality rights under Penal Code 11167. The district
also shall provide these new employees with a copy of Penal Code 11165.7, 11166, and 11167.
(Penal Code 11165.7, 11166.5)
Before beginning employment, any person who will be a mandated reporter by virtue of his/her
position shall sign a statement indicating that he/she has knowledge of the reporting obligations
under Penal Code 11166 and will comply with those provisions. The signed statement shall be
retained by the Superintendent or designee. (Penal Code 11166.5)
Employees who work with dependent adults shall be notified of legal responsibilities and
reporting procedures pursuant to Welfare and Institutions Code 15630-15637.
78
The Superintendent or designee also shall notify all employees that:
1.
A mandated reporter who reports a known or suspected instance of child abuse or neglect
shall not be held civilly or criminally liable for making a report and this immunity shall apply
even if the mandated reporter acquired the knowledge or reasonable suspicion of child abuse or
neglect outside of his/her professional capacity or outside the scope of his/her employment. Any
other person making a report shall not incur civil or criminal liability unless it can be proven that
he/she knowingly made a false report or made a report with reckless disregard of the truth or
falsity of the report. (Penal Code 11172)
2.
If a mandated reporter fails to timely report an incident of known or reasonably suspected
child abuse or neglect, he/she may be guilty of a crime punishable by a fine and/or
imprisonment. (Penal Code 11166)
3.
No employee shall be subject to any sanction by the district for making a report unless it
can be shown that he/she knowingly made a false report or made a report with reckless disregard
of the truth or falsity of the report. (Penal Code 11166)
(7/02 11/04 12/14)
Regulation:
adopted:
79
January 13, 2016, Santa Rosa, California
To Check
Entitlement
Absences p
To Review or Cancel
Your Upcoming
Phone System
Instructions for
Employees
Main Menu
Balances o
To Review or
Cancel a
Specific
Absence q
Review or Change
Personal Information r
Change Name recording n
1.800.942.3767
Hear Again n
Pressing the star key (‘*’) will always
take you back one menu level anywhere
in the phone system.
Change Pin number o
L
Change Phone number p
• If you work at multiple school locations
please refer to the Employee Web guide
for detailed instructions.
Hear Again o
• In the review menu, if a substitute has
accepted your absence Aesop will read off
his or her name.
Cancel Assignment o
• You can create an absence up to one
month in advance on the phone.
Cancel Absence p
• If Aesop prompts you, you will need to
make a voice recording. This should only
be your Name and Title:
c Name (First and Last Name)
d Title (Grade Level and/or Subject Matter)
Listen to next absence q
Special Things to Note
Aesop Phone Menu at a Glance
• To review or change the recording of your
name and title, Press n
• To change your Pin number, Press o
• To change your phone number, Press p
• To return to the previous menu, Press
To Create an
Information, Press r
Absence n
To Review or Change your Personal
c Select Start Date
d Enter Number of Days
e Enter Start and End Times
f Select Absence Reason
g Confirm Absence Details
h Enter Multiple Days
i Save Your Absence
When you call Aesop
1.800.942.3767
Learn how to
Create absences by phone
Review Upcoming
absences
Personalize the phone
system
www.aesoponline.com
When you call Aesop
1.
2.
3.
Dial 1.800.942.3767
Enter your ID number followed by the
pound key (‘#’)
Enter your PIN number followed by
the pound key (‘#’)
To Create an Absence, Press n
1. Select the Start Date
To enter an absence for:
• TODAY, Press n
• Tomorrow, Press o
• Another Day, Press p
• Monday, Press q
¾ If option p is selected then Aesop will prompt
you to enter the DAY OF MONTH followed by
the pound key (‘#’).
2. Enter the number of days
3. Enter the Start and End times
• For a Full Day, Press n
• For a Half-Day in the Morning, Press o
• For a Half-Day in the Afternoon, Press p
• For Specific Start/End Times, Press q
¾ If option q is selected then Aesop will prompt
you to enter time in “hh:mm” format and the
choice of AM or PM.
For example: 8:00 AM
a. Enter “800” followed by the pound key (‘#’)
b. Press n for AM or Press o for PM
www.aesoponline.com
When you call Aesop
When you call Aesop
4. Select Absence Reason
5. Confirm absence information
• If correct, Press n
• To re-enter, Press o
• To cancel, Press p
6. If
aa
multiple
day
absence
For
multiple
day
absence
c Enter the day of month followed by the
pound sign (‘#’)
d Aesop will ask the following:
• If the details are the same as previous
the previous
date,
Press
n
date, Press n
• To change some of the details, Press o
• To change all of the details, Press p
7. Save your absence
c If you can decide whether a sub is
needed:
• If your absence requires a substitute,
Press n
• If your absence does not require a
substitute, Press o
d If you can assign a substitute:
• If you want to select a specific sub to
assign to the absence, Press n
¾ It is your responsibility to contact the
sub to see if they are willing to accept
this absence PRIOR to assigning.
• If you want me (Aesop) to find a sub,
Press o
¾ if option n is selected you will need to enter
the sub’s full 10-digit phone number.
1.800.942.3767
L
When you have successfully created
an assignment Aesop will play back
the confirmation number.
To Check Entitlement Balances, Press o
Aesop will play back your entitlement
balances.
To Review or Cancel Your Upcoming
Absences, Press p
• To review your absences for the next 30
days, Press p
• To return to the Main Menu, Press
Aesop will read off all absence details:
• To hear this again, Press o
• To cancel this absence, Press p
• To listen to the next absence, Press q
• To return to the Main Menu, Press r
To Review or Cancel a Specific Absence,
Press q
Enter the confirmation number followed by
the pound key (‘#’).
Aesop will read off the absence details:
• To Hear again, Press n
• To cancel this absence, Press o
• To return to previous menu, Press r
Available 24/7
Penal Code § 11165.7. Mandated reporter defined
(a) As used in this article, “mandated reporter” is defined as any of the following:
(1) A teacher.
(2) An instructional aide.
(3) A teacher's aide or teacher's assistant employed by a public or private school.
(4) A classified employee of a public school.
(5) An administrative officer or supervisor of child welfare and attendance, or a certificated pupil
personnel employee of a public or private school.
(6) An administrator of a public or private day camp.
(7) An administrator or employee of a public or private youth center, youth recreation program,
or youth organization.
(8) An administrator or employee of a public or private organization whose duties require direct
contact and supervision of children.
(9) An employee of a county office of education or the State Department of Education whose
duties bring the employee into contact with children on a regular basis.
(10) A licensee, an administrator, or an employee of a licensed community care or child day care
facility.
(11) A Head Start program teacher.
(12) A licensing worker or licensing evaluator employed by a licensing agency, as defined
in Section 11165.11.
(13) A public assistance worker.
(14) An employee of a child care institution, including, but not limited to, foster parents, group
home personnel, and personnel of residential care facilities.
(15) A social worker, probation officer, or parole officer.
(16) An employee of a school district police or security department.
(17) A person who is an administrator or presenter of, or a counselor in, a child abuse prevention
program in a public or private school.
(18) A district attorney investigator, inspector, or local child support agency caseworker, unless
the investigator, inspector, or caseworker is working with an attorney appointed pursuant
to Section 317 of the Welfare and Institutions Code to represent a minor.
(19) A peace officer, as defined in Chapter 4.5 (commencing with Section 830) of Title 3 of Part
2, who is not otherwise described in this section.
(20) A firefighter, except for volunteer firefighters.
(21) A physician and surgeon, psychiatrist, psychologist, dentist, resident, intern, podiatrist,
chiropractor, licensed nurse, dental hygienist, optometrist, marriage and family therapist, clinical
social worker, professional clinical counselor, or any other person who is currently licensed
under Division 2 (commencing with Section 500) of the Business and Professions Code.
(22) An emergency medical technician I or II, paramedic, or other person certified pursuant to
Division 2.5 (commencing with Section 1797) of the Health and Safety Code.
(23) A psychological assistant registered pursuant to Section 2913 of the Business and
Professions Code.
(24) A marriage and family therapist trainee, as defined in subdivision (c) of Section 4980.03 of
the Business and Professions Code.
(25) An unlicensed marriage and family therapist intern registered under Section 4980.44 of the
Business and Professions Code.
(26) A state or county public health employee who treats a minor for venereal disease or any
other condition.
(27) A coroner.
(28) A medical examiner or other person who performs autopsies.
(29) A commercial film and photographic print or image processor as specified in subdivision (e)
of Section 11166. As used in this article, “commercial film and photographic print or image
processor” means a person who develops exposed photographic film into negatives, slides, or
prints, or who makes prints from negatives or slides, or who prepares, publishes, produces,
develops, duplicates, or prints any representation of information, data, or an image, including,
but not limited to, any film, filmstrip, photograph, negative, slide, photocopy, videotape, video
laser disk, computer hardware, computer software, computer floppy disk, data storage medium,
CD-ROM, computer-generated equipment, or computer-generated image, for compensation. The
term includes any employee of that person; it does not include a person who develops film or
makes prints or images for a public agency.
(30) A child visitation monitor. As used in this article, “child visitation monitor” means a person
who, for financial compensation, acts as a monitor of a visit between a child and another person
when the monitoring of that visit has been ordered by a court of law.
(31) An animal control officer or humane society officer. For the purposes of this article, the
following terms have the following meanings:
(A) “Animal control officer” means a person employed by a city, county, or city and county for
the purpose of enforcing animal control laws or regulations.
(B) “Humane society officer” means a person appointed or employed by a public or private
entity as a humane officer who is qualified pursuant to Section 14502 or 14503 of the
Corporations Code.
(32) A clergy member, as specified in subdivision (d) of Section 11166. As used in this article,
“clergy member” means a priest, minister, rabbi, religious practitioner, or similar functionary of
a church, temple, or recognized denomination or organization.
(33) Any custodian of records of a clergy member, as specified in this section and subdivision
(d) of Section 11166.
(34) An employee of any police department, county sheriff's department, county probation
department, or county welfare department.
(35) An employee or volunteer of a Court Appointed Special Advocate program, as defined
in Rule 5.655 of the California Rules of Court.
(36) A custodial officer, as defined in Section 831.5.
(37) A person providing services to a minor child under Section 12300 or 12300.1 of the Welfare
and Institutions Code.
(38) An alcohol and drug counselor. As used in this article, an “alcohol and drug counselor” is a
person providing counseling, therapy, or other clinical services for a state licensed or certified
drug, alcohol, or drug and alcohol treatment program. However, alcohol or drug abuse, or both
alcohol and drug abuse, is not, in and of itself, a sufficient basis for reporting child abuse or
neglect.
(39) A clinical counselor trainee, as defined in subdivision (g) of Section 4999.12 of the
Business and Professions Code.
(40) A clinical counselor intern registered under Section 4999.42 of the Business and Professions
Code.
(41) An employee or administrator of a public or private postsecondary institution, whose duties
bring the administrator or employee into contact with children on a regular basis, or who
supervises those whose duties bring the administrator or employee into contact with children on
a regular basis, as to child abuse or neglect occurring on that institution's premises or at an
official activity of, or program conducted by, the institution. Nothing in this paragraph shall be
construed as altering the lawyer-client privilege as set forth in Article 3 (commencing
with Section 950) of Chapter 4 of Division 8 of the Evidence Code.
(42) An athletic coach, athletic administrator, or athletic director employed by any public or
private school that provides any combination of instruction for kindergarten, or grades 1 to 12,
inclusive.
(43)(A) A commercial computer technician as specified in subdivision (e) of Section 11166. As
used in this article, “commercial computer technician” means a person who works for a company
that is in the business of repairing, installing, or otherwise servicing a computer or computer
component, including, but not limited to, a computer part, device, memory storage or recording
mechanism, auxiliary storage recording or memory capacity, or any other material relating to the
operation and maintenance of a computer or computer network system, for a fee. An employer
who provides an electronic communications service or a remote computing service to the public
shall be deemed to comply with this article if that employer complies with Section 2258A of
Title 18 of the United States Code.
(B) An employer of a commercial computer technician may implement internal procedures for
facilitating reporting consistent with this article. These procedures may direct employees who are
mandated reporters under this paragraph to report materials described in subdivision (e) of
Section 11166 to an employee who is designated by the employer to receive the reports. An
employee who is designated to receive reports under this subparagraph shall be a commercial
computer technician for purposes of this article. A commercial computer technician who makes a
report to the designated employee pursuant to this subparagraph shall be deemed to have
complied with the requirements of this article and shall be subject to the protections afforded to
mandated reporters, including, but not limited to, those protections afforded by Section 11172.
(44) Any athletic coach, including, but not limited to, an assistant coach or a graduate assistant
involved in coaching, at public or private postsecondary institutions.
(b) Except as provided in paragraph (35) of subdivision (a), volunteers of public or private
organizations whose duties require direct contact with and supervision of children are not
mandated reporters but are encouraged to obtain training in the identification and reporting of
child abuse and neglect and are further encouraged to report known or suspected instances of
child abuse or neglect to an agency specified in Section 11165.9.
(c) Employers are strongly encouraged to provide their employees who are mandated reporters
with training in the duties imposed by this article. This training shall include training in child
abuse and neglect identification and training in child abuse and neglect reporting. Whether or not
employers provide their employees with training in child abuse and neglect identification and
reporting, the employers shall provide their employees who are mandated reporters with the
statement required pursuant to subdivision (a) of Section 11166.5.
(d) School districts that do not train their employees specified in subdivision (a) in the duties of
mandated reporters under the child abuse reporting laws shall report to the State Department of
Education the reasons why this training is not provided.
(e) Unless otherwise specifically provided, the absence of training shall not excuse a mandated
reporter from the duties imposed by this article.
(f) Public and private organizations are encouraged to provide their volunteers whose duties
require direct contact with and supervision of children with training in the identification and
reporting of child abuse and neglect.
Penal Code § 11166. Report of child abuse or neglect; mandatory reporters; reasonable
suspicion defined; form of report; criminal liability for failure to report; investigation;
other reporters; joint reports; retaliation prohibited; report by county probation or
welfare department, or law enforcement agency, to investigatory agency and district
attorney
(a) Except as provided in subdivision (d), and in Section 11166.05, a mandated reporter shall
make a report to an agency specified in Section 11165.9 whenever the mandated reporter, in his
or her professional capacity or within the scope of his or her employment, has knowledge of or
observes a child whom the mandated reporter knows or reasonably suspects has been the victim
of child abuse or neglect. The mandated reporter shall make an initial report by telephone to the
agency immediately or as soon as is practicably possible, and shall prepare and send, fax, or
electronically transmit a written followup report within 36 hours of receiving the information
concerning the incident. The mandated reporter may include with the report any nonprivileged
documentary evidence the mandated reporter possesses relating to the incident.
(1) For purposes of this article, “reasonable suspicion” means that it is objectively reasonable for
a person to entertain a suspicion, based upon facts that could cause a reasonable person in a like
position, drawing, when appropriate, on his or her training and experience, to suspect child abuse
or neglect. “Reasonable suspicion” does not require certainty that child abuse or neglect has
occurred nor does it require a specific medical indication of child abuse or neglect; any
“reasonable suspicion” is sufficient. For purposes of this article, the pregnancy of a minor does
not, in and of itself, constitute a basis for a reasonable suspicion of sexual abuse.
(2) The agency shall be notified and a report shall be prepared and sent, faxed, or electronically
transmitted even if the child has expired, regardless of whether or not the possible abuse was a
factor contributing to the death, and even if suspected child abuse was discovered during an
autopsy.
(3) Any report made by a mandated reporter pursuant to this section shall be known as a
mandated report.
(b) If after reasonable efforts a mandated reporter is unable to submit an initial report by
telephone, he or she shall immediately or as soon as is practicably possible, by fax or electronic
transmission, make a one-time automated written report on the form prescribed by the
Department of Justice, and shall also be available to respond to a telephone followup call by the
agency with which he or she filed the report. A mandated reporter who files a one-time
automated written report because he or she was unable to submit an initial report by telephone is
not required to submit a written followup report.
(1) The one-time automated written report form prescribed by the Department of Justice shall be
clearly identifiable so that it is not mistaken for a standard written followup report. In addition,
the automated one-time report shall contain a section that allows the mandated reporter to state
the reason the initial telephone call was not able to be completed. The reason for the submission
of the one-time automated written report in lieu of the procedure prescribed in subdivision (a)
shall be captured in the Child Welfare Services/Case Management System (CWS/CMS). The
department shall work with stakeholders to modify reporting forms and the CWS/CMS as is
necessary to accommodate the changes enacted by these provisions.
(2) This subdivision shall not become operative until the CWS/CMS is updated to capture the
information prescribed in this subdivision.
(3) This subdivision shall become inoperative three years after this subdivision becomes
operative or on January 1, 2009, whichever occurs first.
(4) On the inoperative date of these provisions, a report shall be submitted to the counties and the
Legislature by the State Department of Social Services that reflects the data collected from
automated one-time reports indicating the reasons stated as to why the automated one-time report
was filed in lieu of the initial telephone report.
(5) Nothing in this section shall supersede the requirement that a mandated reporter first attempt
to make a report via telephone, or that agencies specified in Section 11165.9 accept reports from
mandated reporters and other persons as required.
(c) Any mandated reporter who fails to report an incident of known or reasonably suspected
child abuse or neglect as required by this section is guilty of a misdemeanor punishable by up to
six months confinement in a county jail or by a fine of one thousand dollars ($1,000) or by both
that imprisonment and fine. If a mandated reporter intentionally conceals his or her failure to
report an incident known by the mandated reporter to be abuse or severe neglect under this
section, the failure to report is a continuing offense until an agency specified in Section
11165.9 discovers the offense.
(d)(1) A clergy member who acquires knowledge or a reasonable suspicion of child abuse or
neglect during a penitential communication is not subject to subdivision (a). For the purposes of
this subdivision, “penitential communication” means a communication, intended to be in
confidence, including, but not limited to, a sacramental confession, made to a clergy member
who, in the course of the discipline or practice of his or her church, denomination, or
organization, is authorized or accustomed to hear those communications, and under the
discipline, tenets, customs, or practices of his or her church, denomination, or organization, has a
duty to keep those communications secret.
(2) Nothing in this subdivision shall be construed to modify or limit a clergy member's duty to
report known or suspected child abuse or neglect when the clergy member is acting in some
other capacity that would otherwise make the clergy member a mandated reporter.
(3)(A) On or before January 1, 2004, a clergy member or any custodian of records for the clergy
member may report to an agency specified in Section 11165.9 that the clergy member or any
custodian of records for the clergy member, prior to January 1, 1997, in his or her professional
capacity or within the scope of his or her employment, other than during a penitential
communication, acquired knowledge or had a reasonable suspicion that a child had been the
victim of sexual abuse that the clergy member or any custodian of records for the clergy member
did not previously report the abuse to an agency specified in Section 11165.9. The provisions
of Section 11172 shall apply to all reports made pursuant to this paragraph.
(B) This paragraph shall apply even if the victim of the known or suspected abuse has reached
the age of majority by the time the required report is made.
(C) The local law enforcement agency shall have jurisdiction to investigate any report of child
abuse made pursuant to this paragraph even if the report is made after the victim has reached the
age of majority.
(e)(1) Any commercial film, photographic print, or image processor who has knowledge of or
observes, within the scope of his or her professional capacity or employment, any film,
photograph, videotape, negative, slide, or any representation of information, data, or an image,
including, but not limited to, any film, filmstrip, photograph, negative, slide, photocopy,
videotape, video laser disc, computer hardware, computer software, computer floppy disk, data
storage medium, CD-ROM, computer- generated equipment, or computer-generated image
depicting a child under 16 years of age engaged in an act of sexual conduct, shall immediately,
or as soon as practically possible, telephonically report the instance of suspected abuse to the law
enforcement agency located in the county in which the images are seen. Within 36 hours of
receiving the information concerning the incident, the reporter shall prepare and send, fax, or
electronically transmit a written followup report of the incident with a copy of the image or
material attached.
(2) Any commercial computer technician who has knowledge of or observes, within the scope of
his or her professional capacity or employment, any representation of information, data, or an
image, including, but not limited, to any computer hardware, computer software, computer file,
computer floppy disk, data storage medium, CD-ROM, computer-generated equipment, or
computer-generated image that is retrievable in perceivable form and that is intentionally saved,
transmitted, or organized on an electronic medium, depicting a child under 16 years of age
engaged in an act of sexual conduct, shall immediately, or as soon as practicably possible,
telephonically report the instance of suspected abuse to the law enforcement agency located in
the county in which the images or material are seen. As soon as practicably possible after
receiving the information concerning the incident, the reporter shall prepare and send, fax, or
electronically transmit a written followup report of the incident with a brief description of the
images or materials.
(3) For purposes of this article, “commercial computer technician” includes an employee
designated by an employer to receive reports pursuant to an established reporting process
authorized by subparagraph (B) of paragraph (41) of subdivision (a) of Section 11165.7.
(4) As used in this subdivision, “electronic medium” includes, but is not limited to, a recording,
CD-ROM, magnetic disk memory, magnetic tape memory, CD, DVD, thumbdrive, or any other
computer hardware or media.
(5) As used in this subdivision, “sexual conduct” means any of the following:
(A) Sexual intercourse, including genital-genital, oral-genital, anal-genital, or oral-anal, whether
between persons of the same or opposite sex or between humans and animals.
(B) Penetration of the vagina or rectum by any object.
(C) Masturbation for the purpose of sexual stimulation of the viewer.
(D) Sadomasochistic abuse for the purpose of sexual stimulation of the viewer.
(E) Exhibition of the genitals, pubic, or rectal areas of any person for the purpose of sexual
stimulation of the viewer.
(f) Any mandated reporter who knows or reasonably suspects that the home or institution in
which a child resides is unsuitable for the child because of abuse or neglect of the child shall
bring the condition to the attention of the agency to which, and at the same time as, he or she
makes a report of the abuse or neglect pursuant to subdivision (a).
(g) Any other person who has knowledge of or observes a child whom he or she knows or
reasonably suspects has been a victim of child abuse or neglect may report the known or
suspected instance of child abuse or neglect to an agency specified in Section 11165.9. For
purposes of this section, “any other person” includes a mandated reporter who acts in his or her
private capacity and not in his or her professional capacity or within the scope of his or her
employment.
(h) When two or more persons, who are required to report, jointly have knowledge of a known or
suspected instance of child abuse or neglect, and when there is agreement among them, the
telephone report may be made by a member of the team selected by mutual agreement and a
single report may be made and signed by the selected member of the reporting team. Any
member who has knowledge that the member designated to report has failed to do so shall
thereafter make the report.
(i)(1) The reporting duties under this section are individual, and no supervisor or administrator
may impede or inhibit the reporting duties, and no person making a report shall be subject to any
sanction for making the report. However, internal procedures to facilitate reporting and apprise
supervisors and administrators of reports may be established provided that they are not
inconsistent with this article.
(2) The internal procedures shall not require any employee required to make reports pursuant to
this article to disclose his or her identity to the employer.
(3) Reporting the information regarding a case of possible child abuse or neglect to an employer,
supervisor, school principal, school counselor, coworker, or other person shall not be a substitute
for making a mandated report to an agency specified in Section 11165.9.
(j) A county probation or welfare department shall immediately, or as soon as practicably
possible, report by telephone, fax, or electronic transmission to the law enforcement agency
having jurisdiction over the case, to the agency given the responsibility for investigation of cases
under Section 300 of the Welfare and Institutions Code, and to the district attorney's office every
known or suspected instance of child abuse or neglect, as defined in Section 11165.6, except acts
or omissions coming within subdivision (b) of Section 11165.2, or reports made pursuant
to Section 11165.13 based on risk to a child which relates solely to the inability of the parent to
provide the child with regular care due to the parent's substance abuse, which shall be reported
only to the county welfare or probation department. A county probation or welfare department
also shall send, fax, or electronically transmit a written report thereof within 36 hours of
receiving the information concerning the incident to any agency to which it makes a telephone
report under this subdivision.
(k) A law enforcement agency shall immediately, or as soon as practicably possible, report by
telephone, fax, or electronic transmission to the agency given responsibility for investigation of
cases under Section 300 of the Welfare and Institutions Code and to the district attorney's office
every known or suspected instance of child abuse or neglect reported to it, except acts or
omissions coming within subdivision (b) of Section 11165.2, which shall be reported only to the
county welfare or probation department. A law enforcement agency shall report to the county
welfare or probation department every known or suspected instance of child abuse or neglect
reported to it which is alleged to have occurred as a result of the action of a person responsible
for the child's welfare, or as the result of the failure of a person responsible for the child's welfare
to adequately protect the minor from abuse when the person responsible for the child's welfare
knew or reasonably should have known that the minor was in danger of abuse. A law
enforcement agency also shall send, fax, or electronically transmit a written report thereof within
36 hours of receiving the information concerning the incident to any agency to which it makes a
telephone report under this subdivision.
Penal Code§ 11167. Report; contents; confidentiality of identity of persons reporting
(a) Reports of suspected child abuse or neglect pursuant to Section 11166 or Section
11166.05 shall include the name, business address, and telephone number of the mandated
reporter; the capacity that makes the person a mandated reporter; and the information that gave
rise to the reasonable suspicion of child abuse or neglect and the source or sources of that
information. If a report is made, the following information, if known, shall also be included in
the report: the child's name, the child's address, present location, and, if applicable, school, grade,
and class; the names, addresses, and telephone numbers of the child's parents or guardians; and
the name, address, telephone number, and other relevant personal information about the person
or persons who might have abused or neglected the child. The mandated reporter shall make a
report even if some of this information is not known or is uncertain to him or her.
(b) Information relevant to the incident of child abuse or neglect and information relevant to a
report made pursuant to Section 11166.05 may be given to an investigator from an agency that is
investigating the known or suspected case of child abuse or neglect.
(c) Information relevant to the incident of child abuse or neglect, including the investigation
report and other pertinent materials, and information relevant to a report made pursuant
to Section 11166.05 may be given to the licensing agency when it is investigating a known or
suspected case of child abuse or neglect.
(d)(1) The identity of all persons who report under this article shall be confidential and disclosed
only among agencies receiving or investigating mandated reports, to the prosecutor in a criminal
prosecution or in an action initiated under Section 602 of the Welfare and Institutions
Code arising from alleged child abuse, or to counsel appointed pursuant to subdivision (c) of
Section 317 of the Welfare and Institutions Code, or to the county counsel or prosecutor in a
proceeding under Part 4 (commencing withSection 7800) of Division 12 of the Family Code
or Section 300 of the Welfare and Institutions Code, or to a licensing agency when abuse or
neglect in out-of-home care is reasonably suspected, or when those persons waive
confidentiality, or by court order.
(2) No agency or person listed in this subdivision shall disclose the identity of any person who
reports under this article to that person's employer, except with the employee's consent or by
court order.
(e) Notwithstanding the confidentiality requirements of this section, a representative of a child
protective services agency performing an investigation that results from a report of suspected
child abuse or neglect made pursuant to Section 11166 or Section 11166.05, at the time of the
initial contact with the individual who is subject to the investigation, shall advise the individual
of the complaints or allegations against him or her, in a manner that is consistent with laws
protecting the identity of the reporter under this article.
(f) Persons who may report pursuant to subdivision (g) of Section 11166 are not required to
include their names.
CHILD ABUSE REPORTING STATEMENT
I, ______________________, acknowledge I have received a copy of Penal Code sections 11165.7, 11166, and
11167.
I have reviewed and familiarized myself with the provisions of these sections, and have had the opportunity to
have my questions about these provisions answered.
I further understand the following:
1.
I am considered a mandated reporter of suspected child abuse.
2.
Penal Code section 11166, attached, requires any mandated reporter who has knowledge of or observes
a child in his or her professional capacity or within the scope of his or her employment whom he or she
knows or reasonably suspects has been the victim of child abuse or neglect to report the known or
suspected instance of child abuse to a child protective agency immediately or as soon as practically
possible by telephone, and to prepare and send, fax or e-mail, a written report thereof within 36 hours of
receiving the information concerning the incident.
3.
“Mandated Reporters” are those individuals listed in Penal Code section 11165.7, attached, including
teachers, instructional aides, classified employees, coaches, administrative officers, supervisors of child
welfare and attendance, administrators of a public or private day camp, administrators and employees of
child day care facilities licensed to care for children, peace officers, healthcare practitioners, employees
or administrators of public or private post-secondary institutions whose duties bring them into contact
with children on a regular basis, the supervisors of those employees, and any athletic coach at a public or
private post-secondary institution.
4.
Penal Code section 11167, attached, generally provides that the identity of a reporter of suspected child
abuse, and the written child abuse report that is prepared by the reporter, is confidential and shall be
disclosed only among agencies involved in the investigation or by court order.
As an employee of ________________________________, I certify that I have read and understand
this statement and the above cited Penal Code sections, and will comply with my obligations under the
child abuse reporting law.
2013
___________________________________
Print Name of Employee
____________________________________
Signature of Employee
___________________________________
Date
____________________________________
Department
ing
Discrimination and Harassment in Employment
are Prohibited by Law
Laws enforced by the California Department of Fair Employment and Housing
(DFEH) protect you from illegal discrimination and harassment in
employment based on:
• Race
ployee or job applicant’s religious beliefs and practices.
• Require employers to reasonably accommodate employees
or job applicants with a disability in order to enable them to
perform the essential functions of a job.
• Color
• Religion
• Sex (includes pregnancy, childbirth, and related medical conditions)
• Gender, gender identity, and gender expression
• Sexual orientation
• Marital status
• National origin (includes language use restrictions)
• Ancestry
• Disability (mental and physical, including HIV and AIDS)
• Medical condition (cancer, or a record or history of cancer)
• Genetic information
• Age (40 and above)
• Denial of family and medical care leave
• Denial of pregnancy disability leave or reasonable
accommodation
The California Fair Employment and Housing Act (Part 2.8
commencing with Section 12900 of Division 3 of Title 2 of the Government Code) and the Regulations of the Fair Employment and Housing
Commission (California Code of Regulations, Title 2, Division 4,
Sections 7285.0 through 8504):
• Prohibit harassment of employees, applicants, and independent
contractors by any persons and require employers to take
all reasonable steps to prevent harassment. This includes a
prohibition against sexual harassment, gender harassment,
and harassment based on pregnancy, childbirth, or related
medical conditions.
• Prohibit employers from limiting or prohibiting the use of
any language in any workplace unless justified by business
necessity. The employer must notify employees of the language
restriction and consequences for violation.
• Require that all employers provide information to each of
their employees on the nature, illegality, and legal remedies
that apply to sexual harassment. Employers may either develop
their own publications, which must meet standards as set
forth in California Government Code Section 12950, or use a
brochure from the DFEH.
• Require employers with 50 or more employees and all
public entities to provide sexual harassment prevention
training for all supervisors.
• Require employers to reasonably accommodate an em-
• Permit job applicants and employees to file complaints
with the DFEH against an employer, employment agency, or
labor union that fails to grant equal employment as required
by law.
• Prohibit discrimination against any job applicant or employee
in hiring, promotions, assignments, termination, or any term,
condition, or privilege of employment.
• Require employers, employment agencies, and unions to
preserve applications, personnel records, and employment
referral records for a minimum of two years.
• Require employers to provide leaves of up to four months
to employees disabled because of pregnancy, childbirth, or a
related medical condition.
• Require an employer to provide reasonable accommodations requested by an employee, on the advice of her health
care provider, related to her pregnancy, childbirth, or related
medical conditions.
• Require employers of 50 or more persons to allow eligible
employees to take up to 12 weeks leave in a 12-month
period for the birth of a child; the placement of a child for
adoption or foster care; for an employee’s own serious health
condition; or to care for a parent, spouse, or child with a
serious health condition. (Employers are required to post a
notice informing employees of their family and medical leave
rights.)
• Require employment agencies to serve all applicants
equally, refuse discriminatory job orders, and prohibit employers and employment agencies from making discriminatory pre-hiring inquiries or publishing help-wanted advertising that expresses a discriminatory hiring preference.
• Require unions not to discriminate in member admissions or
dispatching to jobs.
• Prohibit retaliation against a person who opposes, reports,
or assists another person in opposing unlawful discrimination.
The law provides for administrative fines and remedies for
individuals, including the following: hiring, front pay, back pay,
promotion, reinstatement, cease-and-desist order, expert witness
fees, reasonable attorney’s fees and costs, punitive damages, and
damages for emotional distress.
Job applicants and employees: If you believe you have experienced discrimination, you may file a complaint with the DFEH.
Independent contractors: If you believe you have been harassed, you may file a complaint with the DFEH.
Complaints must be filed within one year of the last act of discrimination/harassment, or, for victims who are under the age of 18, not
later than one year after that person’s eighteenth birthday.
For more information contact (800) 884-1684; TTY (800) 700-2320: Videophone for the Deaf (916) 226-5285; contact.center@dfeh.ca.gov; or www.dfeh.ca.gov.
Government Code Section 12940 and California Code of Regulations, Title 2, Section 7287 require all employers to post this document. It must be
conspicuously posted in hiring offices, on employee bulletin boards, in employment agency waiting rooms, union halls, and other places employees gather.
In accordance with the California Government Code and ADA requirements, this publication can be made available in Braille, large print, computer disk,
or voice recording as a disability-related accommodation for an individual with a disability. To discuss how to receive a copy of this publication in
an alternative format, please contact the DFEH at the numbers or e-mail adress above.
DFEH 162
(11/11)(05/06)
DFEH-162
3. Visual harassment
Noticeto all Staff
Sexualharassmentis prohibitedby this companyand
is againstthe law.
contractorshould
Everyemployeeand independent
be awareof:
. What sexualharassmentis;
.
What stepsto take if harassmentoccurs;and
.
for reportingsexual
Prohibition
againstretaliation
harassment.
P l e a s e r e a d t h i s i n f o r m a t i o ns h e e t . l { y o u h a v e
a n y q u e s t i o n so r c o n c e r n sa b o u t i t , c o n t a c ty o u r
personnel
department
representative
or your
supervisor,
investigative
officerfor furtherinformation.
What is SexualHarassment?
Althoughmany peoplethink of sexualharassmentas
involvinga male boss and a femaleemployee,this is
not alwaysthe case.Sexualharassmentofteninvolves
co-workers,other employeesof the companyor other
personsdoingbusinesswithor forthecompany.
lt'salso
againstthe law for females to sexuallyharass males
or for an employeeto sexuallyharassa personof the
samegenoer.
CaliforniaLaw
lawdefinessexualharassment
as harassment
California
basedon sexor of a sexualnature;genderharassment
(includingharassmentbased on gender identityor
genderexpression);
and harassment
dueto pregnancy,
or relatedmedicalconditions.
childbirth,breastfeeding
1. Verbal harassment
Exampfes: Sexualcomments,derogatory commentsor
Iing. beIinling. serually expltcil
slurs.ep ilhels.name-cal
or degrading words to descrrbean individual,sexually
explicitjokes,commentsaboutanemployee'sanatomy
and/or dress, sexually orrented noises or remarks
nt tpctinnc
2hnt
il .2. nprenn
c Jctr\t
nr2rliapq
L u tal
cr P
ts-rou/rJ
,cua'LLo,
'^^
r Jg
u
^'
u/
patronizingterms or remarks,verbalabuse, graphtc
verbalcommentarresabout the body.
2. Physical harassment
Exampfes: Physical touchrng,assault. tmpedrngor
blocking movement,pinching. patting. grabbrng,
hrt,ahiâ
-^-;-.t
ar nolinn
) nt . tl vh tat r t w
ut uat ttttu agatt tat ut yvr\r tv u
h vn vr 1) ,
vo tmtnt lPntvve) p <
t v o b
hazing or rnrtiationthat involvesa seuualcomponent
requiring an employee ta wear sexually suggestive
clothing,any physical interferencewith normal work
or movement.when drrectedat an individual
Examples: Displaying sexual prctures, derogatory
l/v)tq/
^-.t^^^^
D. vdt
IUvt
^.
1a v]
A.a,",iaaa
vt dvvtl tgo.
A'anla,,lâ
vtJPtayll
-^',,,-l
t!1 >c \udt
^^/:
t t tcutd
or eleclrontcinformatton.
suchas computertmages te\t
messages emails.web pages. or multimediacantent.
displayingsexualwrittngs
or objects,obscenelettersor
invitationsslaringat an employees anatomy leertng.
se<uallyorrentedgestures.moontng,unwantedlove
lettersor notes.
4. Sexualfavors
Exampfes:Unwantedsexualadvancesor acts whtch
condrtion
an emptoyment
benefttuponan e<changeo{
sexualfavors.Contrnuedrequestsfor dates any threat
of demotron,termtnatton,
etc.tfrequestedserualfavors
are nAtgtven. n ahtng Or threatentngrepriSalsafter a
negattveresponseIo serdaI advances.proposittantng
an tnatvtQUat.
I tl s i m p o s s i b lt eo d e fi n ee v e r ya c t i o no r a l l w o r d st h a t c o u l d
as sexualharassment.The
exampleslisted
be interpreted
above,alongwiththestatedefinitionof sexualharassment,
behavior
arenotmeanttobea completelistofobjectionable
nor do theyalwaysconstitutesexualharassment
This companytakes seriouslyits obligationto take all
reasonable
stepsto prevent
discrimination
andharassment
fromoccurringand recognizes
its own responsibility
and
potential
liability
forharassment
byitssupervisors
oragents.
lf harassment
doesoccur,thiscompanywilltakeeffective
action to stop any further harassmentand to correct
any effectsof the harassment.
This companywill take
appropriatedisciplinarymeasures- terminationis one
possibleaction- againstany employeewho engagesin
sexualharassment.
ProtectionAgainst Retaliation
Companypolicyand stateand federallawforbidretaliation
f iles
againstanyemployeewho
opposessexualharassment,
testifies,
in anymanner
a complaint,
assistsor participates
proceeding
in an investigation,
or hearingconducted
bythe
theDepartment
company,
of FairEmployment
andHousing
or the EqualEmploymentOpportunityCommission.
retaliation
Prohibited
includesbut is not limitedto:
. Demotion;
. Susoension:
.
Failureto hireor considerfor hire;
Failureto giveequalconsideration
in making
e m p l o y m e ndte c i s i o n s ;
FederalLaw
.
Underfederallaw,unwelcomesexualadvances,requests
for sexualfavors,and otherverbalor physicalconductof a
when:
sexualnatureconstitutesexualharassment
.
Failureto make impartialemployment
recommendations;
and
.
Adverselyaffectingworkingconditionsor otherwise
denyingany employmentbenefitto an individual.
1. Submission
to suchconductis madeeitherexplicitly
or
implicitly
ofanindividual's
employment;
atermorcondition
2 . S u b m i s s i o nt o o r r e j e c t i o no f s u c h c o n d u c tb y a n
individual
is usedas thebasisforemployment
decisions
a f f e c t i nsgu c hi n d i v i d u a l os r;
3 . S u c hc o n d u cht a s t h ep u r p o s eo r e f f e c t ouf n r e a s o n a b l y
i n t e r f e r i nw
g i t h a n i n d i v i d u a l 'ws o r k p e d o r m a n c eo r
h ,o s t i l eo r o f f e n s i v e
working
c r e a t i n ga n i n t i m i d a t i n g
environment.
V e r b a lp, h y s i c aal n d v i s u a lh a r a s s m e nat ,s d i s c u s s e d
in
t h e a b o v el i s to f e x a m p l e sa, r e a l s oa l l p r o h i b i t e ud n d e r
federallaw.
HarassersAre PersonallyLiable
lf you, as an employee,are found to have engagedin
sexualharassment,or if you as a managerknow about
t h e h a r a s s i n cgo n d u c o
t f a n e m p l o y e eo r n o n - e m p l o y e e
d o i n gb u s i n e s sw i t ht h e c o m p a n ya n d c o n d o n eo r r a t i f y
it, you may be personallyliablefor monetarydamages.
T h i s c o m p a n yw i l l n o t p a y d a m a g e sa s s e s s e da g a i n s t
you personaily.
Howto Stop SexualHarassment
.
When possible,talk to the harasserand ask him/
her to stop.
The harassermaynotrealizetheadvancesor behavior
Whenit is appropriate
are offensive.
and sensible,you
maywantto tellthe harasserthe behavioror advances
a r eu n w e l c o maen dm u s ts t o pA
. s i m p l ed i s c u s s i owni l l
s o m e t i m ees n d t h e s i t u a t i o n .
.
You are strongly encouragedto report any sexual
harassment.Contact your supervisor, personnel
departmentrepresentativeor appropriatemember
of management.
Sexualharassmentor retaliationshould be reportedin
writingor verbally.You may reportsuch activitieseven
though you were not the subject of the harassment.
Employeesshouldneverpressureother employeesnot
to comolainof harassment.
PREDESIGNATION OF PERSONAL PHYSICIAN
In the event you sustain an injury or illness related to your employment, you may be treated for such injury or illness
by your personal medical doctor (M.D.), doctor of osteopathic medicine (D.O.) or medical group if:
•
•
•
•
•
on the date of your work injury you have health care coverage for injuries or illnesses that are not work
related;
the doctor is your regular physician, who shall be either a physician who has limited his or her practice of
medicine to general practice or who is a board-certified or board-eligible internist, pediatrician,
obstetrician-gynecologist, or family practitioner, and has previously directed your medical treatment, and
retains your medical records;
your “personal physician” may be a medical group if it is a single corporation or partnership composed of
licensed doctors of medicine or osteopathy, which operates an integrated multispecialty medical group
providing comprehensive medical services predominantly for nonoccupational illnesses and injuries;
prior to the injury your doctor agrees to treat you for work injuries or illnesses;
prior to the injury you provided your employer the following in writing: (1) notice that you want your
personal doctor to treat you for a work-related injury or illness, and (2) your personal doctor's name and
business address.
You may use this form to notify your employer if you wish to have your personal medical doctor or a doctor of
osteopathic medicine treat you for a work-related injury or illness and the above requirements are met.
NOTICE OF PREDESIGNATION OF PERSONAL PHYSICIAN
Employee: Complete this section.
To: ____________________________ (name of employer) If I have a work-related injury or illness, I choose to be
treated by:
_________________________________________________________________
(name of doctor)(M.D., D.O., or medical group)
_________________________________________________________________ (street address, city, state, ZIP)
__________________________________________________ (telephone number)
Employee Name (please print):
_____________________________________________________________________________________________
Employee's Address:
_____________________________________________________________________________________________
Name of Insurance Company, Plan, or Fund providing health coverage for nonoccupational injuries or illnesses:
Employee's Signature ________________________________Date: __________
Physician: I agree to this Predesignation:
Signature: _________________ ___________________________Date: __________
(Physician or Designated Employee of the Physician or Medical Group)
The physician is not required to sign this form, however, if the physician or designated employee of the physician or
medical group does not sign, other documentation of the physician's agreement to be predesignated will be required
pursuant to Title 8, California Code of Regulations, section 9780.1(a)(3).
Title 8, California Code of Regulations, section 9783.
Predesignation of Personal Physician; Reporting Duties of the Primary Treating Physician
Regulations 8 C.C.R. section 9780, et seq. (Approved 02/12/2014)
NOTICE OF PERSONAL CHIROPRACTOR OR PERSONAL ACUPUNCTURIST
If your employer or your employer's insurer does not have a Medical Provider Network, you may be able to change
your treating physician to your personal chiropractor or acupuncturist following a work-related injury or illness. In
order to be eligible to make this change, you must give your employer the name and business address of a personal
chiropractor or acupuncturist in writing prior to the injury or illness. Your claims administrator generally has the
right to select your treating physician within the first 30 days after your employer knows of your injury or illness.
After your claims administrator has initiated your treatment with another doctor during this period, you may then,
upon request, have your treatment transferred to your personal chiropractor or acupuncturist.
NOTE: If your date of injury is January 1, 2004 or later, a chiropractor cannot be your treating physician after you
have received 24 chiropractic visits unless your employer has authorized additional visits in writing. The term
“chiropractic visit” means any chiropractic office visit, regardless of whether the services performed involve
chiropractic manipulation or are limited to evaluation and management. Once you have received 24 chiropractic
visits, if you still require medical treatment, you will have to select a new physician who is not a chiropractor. This
prohibition shall not apply to visits for postsurgical physical medicine visits prescribed by the surgeon, or physician
designated by the surgeon, under the postsurgical component of the Division of Workers’ Compensation’s Medical
Treatment Utilization Schedule.
You may use this form to notify your employer of your personal chiropractor or acupuncturist.
Your Chiropractor or Acupuncturist's Information:
_____________________________________________________________________________________________
(name of chiropractor or acupuncturist)
_____________________________________________________________________________________________
(street address, city, state, zip code)
_____________________________________________________________________________________________
(telephone number)
Employee Name (please print):
_____________________________________________________________________________________________
Employee's Address:
_____________________________________________________________________________________________
Employee's Signature ___________________________ Date: _________
Title 8, California Code of Regulations, section 9783.1.
(Optional DWC Form 9783.1 Effective date July 1, 2014)
Predesignation of Personal Physician; Reporting Duties of the Primary Treating Physician
Regulations 8 C.C.R. section 9780, et seq. (Approved 02/12/2014)