Employment Service Agreement
Required Forms
Human Resources Internal Home Page

ESA Table of Contents


ESA Word Form

ESA Home Page

Ancillary Activities List


Current LRCCD employees should complete and submit the following forms with each "first-time" ESA (Note:  "first-time ESA" means the very first time that an ESA issued to an employee - these forms are not required annually)

  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 (New!)  click here for more information

  4. Note:  The ESA indicates that PARS paperwork should also be completed and submitted with each first-time ESA; however, this is INCORRECTThe correct forms are listed above; and, should be submitted instead of the PARS paperwork, not "in addition to".

Rehires:  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 e-mail Stacy Robinson at (916) 568-3179 for further instructions (e.g., H.R. 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).  Lastly, 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

The following forms are required for all new ESA employees.  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.

    Here's a PDF document  (Revised:  1/28/2014; 2/5/2014; 9/23/2014) that includes ALL of the required forms below.  This packet can be used for new ESA employees who will be contributing towards PARS (e.g., Professional Experts and non-instructional ESAs).  Additional packets will be created for employees in other  retirement plans (i.e., CalSTRS, CalPERS, etc.)

  • Address/Name Change form  (added 1/19/2012)- 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 Elect/declination form number MR350 (revised 1/19/2012)  -  This form is NOT used for ALL ESAs.  It is used only for new employees who are performing instructional duties and who are NOT already members of the CalSTRS defined benefit plan.  For additional information, please feel free to e-mail Stacy Robinson.

  • CalSTRS Post-Retirement Earnings Information (added 2/7/2012) 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   (revised:  2/5/2014) Please make a copy for the employee. 

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

  • Conflict of Interest Rules Policy (new:  2/5/2014) Give this packet to the employee.

  • Demographic form  - (revised:  1/24/14; PDF version: 7/2014) 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 (added 1/19/11)- 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. 

  • 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) (revised:  March 2013) 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 SS card and CDL)

  • 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)

  • 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 (revised 1/19/2012) - This form should be submitted annually, along with "non-instructional" ESAs that are issued to employees who are non-members of CalSTRS.  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). 

  • Notice of Workers Compensation -(revised 9/23/2014) 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  (New)- 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 Stacy Robinson at (916) 568-3179 and request a brochure for each new ESA employee you hire.  Stacy can either send you a brochure, for the employee, or one can be mailed directly to the home address of the new ESA employee.

  • 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 (updated 3/27/2014) - Give packet to employee

  • Social Security Card (revised 1/19/2012)- 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 - (revised:  March 2013) 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 - (New 3/15/2013), 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 (revised 1/19/2012) - ESA employees are required to submit timesheets before payment can be processed.  Timesheets should be kept at the campus level.  The ESA timeshhet 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 - (revised: 2/17/2015)  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).