Employment Service Agreement
Required Forms
Human Resources Internal Home Page

ESA Table of Contents


ESA Word Form

ESA Home Page

Ancillary Activities List


"First-time" ESA  (Current LRCCD Employees that have never worked on an ESA before)

  1. SSA-1945 (submit only ONE copy to H.R.; Please give the employee a copy for his/her records)

  2. Compliance Checklist (submit only ONE copy to H.R.; Please give the employee a copy for his/her records)

  3. Statement of Mandated Reporter - click here for more information (unless form was previously submitted to H.R.)

  4. Employee FERPA Agreement Form (unless form was previously submitted to H.R.)

Note:  The ESA indicates that PARS paperwork should be completed and submitted for all first-time ESA's; however, this is only for first-time Professional Expert ESA's. If the ESA is for Instructional work, please have the employee complete a CalSTRS Permissive Membership form (MR350)

 Rehired ESA Employees without a break in service/current LRCCD employees

All appropriate paperwork should already be on file. If you are unsure, please check with Ashley Poole at (916) 568-3179 or poolea@losrios.edu.

NOTE: If the employee is NOT a CalSTRS member, and the ESA is NOT for instructional work, the employee must fill out the "Notice of Exclusion from CalPERS" form with each new ESA.  The exclusion form and additional information can be found below (Under "NEW ESA Employees)

 Rehired ESA Employees with a break in service of a year or more

If you are issuing an ESA to an employee who has not worked for the District for one or more years, then please call or email Ashley Poole at (916) 568-3179,  She will provide you with a list of any/all documents and/or processes that will be required prior to the employee starting his/her duties. Rehires should NOT  have their fingerprints taken without first receiving notification from H.R. that the employee is required to have his/her prints taken

NEW ESA employees (not currently employeed by Los Rios)

Please submit the forms along with the new ESA.  Please be sure that the employee completes his/her forms in their entirety.  Please also sign all appropriate sections that the hiring supervisor and/or HR representative should sign.

    NEW Instructional ESA's - Use this fillable PDF packet, which includes ALL of the required forms below.  This packet can be used for new ESA employees who will be contributing towards STRS.  To determine if the ESA is STRS eligible, please refer to the CalSTRS Determination page or the Instructional ESA's page.

    NEW Non-Instructional/Professional Expert ESA's - Use this fillable PDF packet, which includes ALL of the required forms below.  This packet is meant for new ESA employees who will be contributing towards PARS (e.g., Professional Experts and non-instructional ESAs).  To determine if the ESA is Non-Instructional or Professional Expert, please visit one of the hyperlinks.

  • Address/Name Change form - to be used when an ESA employee has a new address or name.  Please do not submit address changes through the ESA (i.e., if a new address is used on the ESA in the employees "home address" field, it will NOT change the address that the District has on file for them. For name changes, please be sure that the employee includes a copy of his/her Social Security card indicating the new name.

  • CalSTRS Permissive Membership Elect/Declination form (MR350) - Instructional ESA's ONLY (do not use if already a member of CalSTRS). An employee who performs creditable service and who is excluded from mandatory membership may elect membership in the CalSTRS Defined Benefit Program at any time while employed to perform creditable service. If membership is elected, then the election becomes irrevocable until employment has been terminated.  For additional information, please feel free to e-mail Ashley Poole.

  • CalSTRS Post-Retirement Earnings Information -all new or returning employees who have already retired from CalSTRS should complete this form BEFORE starting work.  The purpose of this form is to ensure that the District is in compliance with new CalSTRS regulations AND to ensure that employees who are CalSTRS retirees are aware of the annual post-retirement earnings limitations as set forth by CalSTRS.    

  • Compliance Checklist  - Please make a copy for the employee. 

  • Computer Use Regulations - Give this packet to the employee.

  • Conflict of Interest Rules Policy - Give this packet to the employee.

  • Demographic form  - All employees must complete this form.  The information is kept confidential and is not released to the campuses.  The demographic information is used for reporting purposes only.

  • EDD booklet - Optional (if the employee requests a hard copy). This is the link to the EDD department where you can print the booklet.  Or, the booklets should be available at your campus business office.

  • Emergency Information - Please ask each new ESA employee to complete this form so that the office of Human Resources can have up-to-date emergency contact information.  This form should also be used if and/or when an employee wishes to change his/her emergency contacts.

  • Employee Self Service Information - Give a copy of this form to the employee.  Please ask your employee to go on-line and complete the requested information. 

  • Employee FERPA Agreement Form - Please ask new ESA employees to read, sign, and date.

  • Employment Eligibility Disclosure Form and P-881 (Report of convictions - complete and submit the P-881 form only if applicable; otherwise, you may leave this form blank)

  • Employment Eligibility Verification (Form I-9) - This form is required by law.  Please follow the instructions on the forms.  Include copies of the documents used to complete the I-9 form (i.e. social security card, drivers license, passport, etc.) Please submit pages 7 and 8 ONLY (in addition to the Social Security card and California Driver's License)

  • Fingerprints - ESA employees must have their fingerprints taken.  It is acceptable for the new ESA employee to start working as soon as Human Resources has received "proof" that the prints have been taken (proof is the completed "Request for Live Scan Service" form).  All ESAs will be approved for fingerprints unless you hear otherwise. Fingerprint packets are available through the division where the employee is working.  The packet also includes the required Payroll "Fingerprint Deduction" form, which must be returned to Human Resources (PLEASE return the original deduction form; our Payroll Department requires "wet" signatures on their forms).

  • Freedom From Disabling Disease Form (Required for employees who are retired from CalSTRS).

  • Hepatitis B (List of positions that require Hep-B training and the instructions for the training.  It is up to the hiring manager/supervisor to determine if the work being performed off of the ESA requires Hep-B training)

  • Health Insurance Marketplace Notice - This notice provides some basic information about the new Marketplace and employment-based health coverage offered by your employer.

  • Loyalty Oath - Required for all School District employees.

  • New Employee Training Checklist - Ask employee to complete the ENTIRE form.  Please give employee the information attached to the form.  Please be sure that the person who explains this form to the employee signs and dates the bottom of this form in the "Hiring Representative Signature" field.  Word "Fill-able Form" or "PDF Version" ; also, please provide the employee with a copy of the appropriate Job Safety Analysis form.

  • Notice of Exclusion from CalPERS Membership - This form should be submitted with each new non-instructional/professional expert assignment and/or with a break in service (no matter what length of time). The purpose of the form is to notify the employee that the duties being performed do not qualify for membership in CalPERS.   The supervisor or hiring manager should complete the "certifying officer" fields including the signature, title and date). 
    **Note: Employees should NOT complete this form if they are a CalSTRS member**

  • Notice of Workers Compensation - Give the employee his/her portion of the packet.  Please be sure that both the employee and the supervisor sign the Workers Compensation Form that is submitted with the new hire paperwork.

  • Facts About Workers' Compensation Brochure - Effective November, 2011, this brochure must be given to all new employees.  This brochure is in addition, not in place of, our existing Workers' Compensation form.  We will soon have a scanned version of this brochure which will be added to this web page.  Until then, please call or e-mail Ashley Poole at (916) 568-3179 and request a brochure for each new ESA employee you hire.  They are also available in your campus VPA Office.

  • PARS Packet - if applicable, see compliance checklist for additional information

  • Retirement Plans Participation Information Form - This form is optional.  If it is easier for you to ask the employee to use this form, instead of asking the employee to complete Question #3 on the ESA, you may leave the question on the ESA blank and attach this completed form instead.

  • Rights and Responsibilities - Give packet to employee

  • Social Security Card - For IRS purposes, a copy of the social security card must be included with the new hire paperwork.  Be sure to mail confidentially and in a sealed envelope. 

  • SSA-1945 - Statement Concerning Your Employment in a Job Not Covered by Social Security.  This form is applicable only to employees who contribute towards CalSTRS or PARS; however, we request that all employees complete this form upon hiring, even if it does not apply.  Please submit only ONE copy to Human Resources. 

  • Statement of Mandated Reporter - Community College employees are mandated reporters for child abuse and/or neglect. (child abuse and neglect reporting law, Penal Code:  11166.5)

  • TB clearance - Must be on file within 15 days of the first date of employment and every four years thereafter.

  • Timesheet - ESA employees are required to submit timesheets before payment can be processed.  Timesheets should be kept at the campus level.  The ESA timesheet is available in the "soft copy" format (as attached) or a hard-copy NCR form is available through the District Office duplicating department.

  • W-4 Form - Federal Withholding Allowance Certificate.  Can be submitted with, or without, the DE-4 form (State Withholding Allowance Certificate).  Please contact the payroll department if you have questions regarding the use of the DE-4 Form.  Note:  This is the 2015 Form W-4; please recycle the older blank W-4 forms and start using this new one, ASAP.  (PLEASE submit original tax withholding forms; our Payroll Department requires "wet" signatures on their forms).