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HR Forms

Administrative Services
Credentials, Contract & Compliance Services
Early Childhood Education
Employee Health Services
Employee Relations
Placement and Assignments
Recruitment and Selection
Risk Management
Salary Allocation
Substitute Unit
Title II

Policy Documents

Bulletins, Reference Guides, Memoranda
Administrative Regulations

Personnel Policy Guides

Classified Personnel Forms Click here


Administrative Services
last modified:
Number
Title
HR-1040 Certificated Request to Return From Leave (Administrative)
HR-1069 Request for Change in Employee's Pay Status (from annualized to paid-as-worked)
HR-4214 Request for Administrator Assignment Action
HR-6121 Interim Administrator Assignment
HR-9161A Request to Announce Non school Administrator Vacancy
HR-9161B Request for Administrator Assignment Action (non-school based)
HR-9161C Request to Announce School-Based Administrator Vacancy
HR-9161D Request for School Based Administrator Assignment
HR-9161E Administrator Position - Learn School Selection
HR-1436 Applicant Roster - Certificated Management Position Opening
HR-6115 Request for Transfer - School Based Administrator
HR-9051 Request for Extra Duty Pay for Administrators


Credentials and Contract Services
Number
Title
HR-1007 Board Permit (Authorization to teach a subject at a high school based on university coursework. No fee required)
HR-1219 Occupational Therapist/Physical Therapist Renewal Affidavit
HR-1220 Clear and Professional Credential Renewal Affidavit
HR-1282 Current Contracted Employees Informational Form
HR-1510 Middle School Authorization (Authorization to teach subject grades 6-8 based on university coursework. No fee required)
HR-1526 Application for Committee on Assignments Authorization (Refer to REF-1708.3)
HR-8641 Autism Option Request (includes HR-1231, Verification of Experience)
HR-8766 Emergency 30 Day Substitute Teaching Permit Affidavit
HR-9024 Conversion Non-Confidential Reference Form (Provisional to University Intern OR University Intern to Probationary Contract)
HR-9034 Conversion Non-Confidential Reference Form (Temporary to Probationary Contract)
HR-9059 Procedures for Teachers Converting to Intern / Probationary Contract Status
HR-9981 Retirement System Option Acknowledgement
ES 372 CALSTRS Retirement System Election


Early Childhood Education
Number
Title
  Additional Hours Application, Teachers
  Employment Application, Aide
  Employment Application, Teacher
  Permit/Credential Form
HR-8384 Request for Personnel Action
PC-5005 Request for Transfer, Aides (Change of Work Location)
HR-8152 Resignation Form and Instructions, Teachers
  Statement of Availability, Teachers (Eligibility List)
HR-6500 Substitute Inadequate Service Report , Teachers and Aides
HR-2501 Substitute Statement of Availability, Aides
HR-2501 Substitute Statement of Availability, Teachers
  Substitute Statement of Availability, Teachers ("C" Basis)
  Transfer Application, Teachers


Employee Health Services
Number
Title
Description
HR-8404 Authorization for Release and/or Exchange of Medical Information
HR-8424 Authorization to Release Tuberculosis Clearance Information
HR-8457 Certificate of Medical Examination & Tuberculosis Clearance Packet Verification of TB and health clearance. To be completed by a physician after selected for employment as a teacher or substitute.
HR-8459
HR-8472 Tuberculosis Test Results Verification of TB clearance for permanent employees.


Employee Relations
Number
Forms Title
HR-1024 Evaluation of Instructional Personnel - Initial Planning Sheet
HR-1025 Evaluation of Instructional Personnel - Observation / Conference Sheet
HR-1044 Evaluation of Certificated Management Personnel - Initial Planning Sheet.
HR-1049 Evaluation of Certificated Management Personnel - Observation / Conference Sheet
HR-1072 Evaluation of Service Personnel - Initial Planning Sheet
HR-1073 Evaluation of Service Personnel - Observation / Conference Sheet
HR-6087 Report of Conviction / Pending Criminal Court Cases
HR-8000 Change of Name Affidavit
HR-8040 Change of Name Request - Certification
HR-8101 Employment Verification Request
HR-8105 Applicant Fingerprint Information
  Change of Address Request (Payroll Department Form)
  Work Number Brochure

Number
Bulletin Title
Summary
BUL-5334 Performance Evaluation and Professional Development for Certificated Management, Supervisory, and Confidential Personnel This Policy Bulletin outlines instructions and procedures for evaluating the job performance and the professional development of certificated management, supervisory, and confidential employees.
BUL-5334 Performance Evaluation for UTLA Bargaining Unit Personnel This Policy Bulletin delineates certificated bargaining unit personnel to be evaluated and administrative staff responsible for these evaluations.

Number
Reference Guide Title
Summary
REF-1172.2 Certificated Performance Evaluation System: Roster and Forms This Reference Guide defines the evaluation process for certificated personnel and to provide instructions and procedures for performance evaluation, utilizing rosters and appropriate forms for certificated employees.


Placement and Assignments
Number
Title
Description
HR-7024 Administrative Transfer Request To transfer a certificated employee from one location to another. Needs local district superintendent approval.
     
HR-13676 Categorical Limited Contract To contract an employee who provides certificated services to schools that are participants in one of the Categorically funded programs.
HR-1065 Certificated Request for Leave of Absence Request for a leave of absence for specified reasons and period of time.
HR-1038 Certificated Request to Return from Leave Form to return to work after an approved leave of absence.
HR-8152 Certificated Resignation Form and Instructions
HR-8414 Community Representative Application For employees who serve in an unclassified position as an advisor or consultant to the District.
Confidential Separation Questionnaire
HR-7762 Continuous Service Transfer Program 2012-13 Provides teachers with permanent or continuing status who meet certain conditions (refer to MEM-5672) eligibility to transfer to another location.
HR-8942 Non-Classroom Waiver Form To transfer from a location identifying the replacement and staff balance, if applicable.
HR-8938 Non-Routine Payment Request Form
HR-1421 Notice of Outstanding Service of Certificated Employee
HR-8937 Notification of Displacement Notice to inform a teacher in the event there is an over-teachered condition where there are more qualified teachers than positions at a school / program.
MEM-S-41
(Attachment A)
Off-Track Teacher Available to Substitute Form Form used to evaluate teachers at a specific location who want to substitute during off-track time.
HR-8239 Physician's Statement for Certificated Personnel Leave of Absence Formal approval from physician, if applicable.
HR-3167 Professional Expert Application Allows a school or office to employ a qualified person on a temporary basis for a unique and non-repetitive or specific project.
  Professional Expert Assignment Request Form Administrators who are interested in requesting approval for a professional expert assignment (refer to BUL-4305).
HR-1070 Reduced Workload Leave Agreement  
  Reduced Workload Packet  
HR-1765 Request for Auxiliary Teachers
  Request for Changes in Assignments and Salaries / Update to Hiring Freeze Request for Freeze Exemption: Staffing
HR-1067 Request for Change in Employee's Pay Status Form used to change pay status from "annualized" to "paid as worked". Word Version
HR-1006 Request for Emergency Credential / Permit
HR-9985 Request for Extended Illness Benefit - 10/90 Application
HR-9073 Request for Personnel Action (RPA) Enables a school or office to budget a position that is not norm generated.
HR-8415 Student Aide Application To employ a full-time student in an unclassified position part-time.
HR-7761 Teacher Initiated Transfer Application 2011-12 Provides credentialed probationary or permanent teachers who meet certain conditions (refer to MEM-5614) eligibility to transfer to another location.
HR-1150 Voluntary Displacement Form To be used only based on projected forecast at the end of a school year or at norm day when a school is over-teachered in a specific subject area.

Recruitment and Selection
Number
Title
Description
HR-1087 Confidential Reference Form Reference form to be submitted by all applicants not currently employed by LAUSD.
HR-3776 Elementary Coursework Sheet For non-certificated / licensed elementary school applicants. Used to list courses to qualify for Emergency, Pre-Intern and Intern teaching permits.
HR-2602 Non-Confidential Reference Form Reference form to be submitted by all applicants who are currently employed by LAUSD in any capacity.
HR-2851 Non-Confidential Reference Form for Psychiatric Social Worker (PSW) Reference form to be submitted by all PSW applicants who are currently employed by LAUSD in any capacity.
HR-9034 Conversion Non-Confidential Reference Form (KT to Probationary) Form used to evaluate K-12 teachers employed under a temporary (KT) contract.
  Psychiatric Social Worker Application Packet Forms for Psychiatric Social Worker applicants
  Pupil Services and Attendance Counselor Application Packet Forms for PSA Counselor applicants
HR-6087 Report of Conviction / Pending Criminal Court Cases To be completed by applicants who have pending criminal court cases or have been convicted, fined, placed on probation, or given a suspended sentence regardless or dismissal or expungement.
HR-1088 Report of Evaluation of Less Than Satisfactory Service To be completed by applicants who have received a less than satisfactory service evaluation
HR-2019 Secondary Coursework Sheet For non-certificated / licensed secondary school applicants. Used to list courses to qualify for Emergency, Pre-Intern and Intern teaching permits.
HR-1086 Teacher Employment or License Denial Cases To be completed by applicants who have been denied a previously requested teaching license or have been denied employment due to an adverse action.


Description
Certificated Request to Return from Leave
Benefits and Responsibilities of Employee Injured as a Result of an Act of Violence
Special Physical Injury (Act of Violence Report) to be filled out by Administrator
Employee Report of Incident or Work Related Injury / Illness On-The-Job
Alleged Act of Violence / Injury Check List
Act of Violence
Supplemental Report of Injury


Salary Allocation
Number
Title
Description
HR-3134 U-Form - Application for point credit approval or degree differential from an accredited institute of higher learning Application for salary point credit for coursework completed at accredited colleges and universities subsequent to rating in. May also be used to submit coursework for Multiculture credit and to register a masters and / or doctorate degree(s).
HR-3308 S-Form - Supplemental application for training and experience Supplemental application for training and experience credit completed prior to rating-in for a new employee who has already submitted the A&B rating-in forms.
HR-3128 M-Form - Application for multicultural credit Application for verification of completion of the requirements for multicultural study, including previously submitted coursework for which salary point credit has been granted.
HR-3127 NA-Form - Application for point credit approval for proposed study in non-accredited schools including foreign institutions Application for salary point credit for study completed in non-accredited schools including foreign institutions.
HR-3141 T-Form - Instructions for Education Travel Project Instructions and pre-approval from for Educational Travel Credit (pre-approval must be obtained to receive salary credit).


Substitute Unit
Number
Title
HR-1079 Certificated Day-to-Day Substitute Teacher Inadequate Service Report New
HR-1081 Certificated Day-to-Day Substitute Teacher Commendation Report New
HR-2139 Request for Extended Day-to-Day Substitute Online Form
HR-8938 Non-Routine Payment Request Form
HR-8766-2 Emergency 30-Day Substitute Teaching Permit Affidavit
MEM-5448 K-12 Teacher Summer Substitute Registration
MEM S-41 Off-Track Teacher Available to Substitute Form


Title II, Part A
Document Title
Vendor Application and Instuctions
Vendor Guide
Consultation Planning Form 2010
Consultation Planning Form 2011
Conference Attendance Request
Contract Proposal Request 11-12
Travel Expense Claim Form
CA Department of Education NCLB Guidance Document
Title Needs Assessment


Policy Documents



Number
Bulletin Description
BUL-260.3 Culture, Language and Methodology Requirements for Administrators New
BUL-4222 Military Leave of Absence for Certificated Employees
BUL-4223 Jury Service for Certificated Employees


Number
Reference Guide Description
REF-1450.2 CalSTRS Information
REF-2062.0 District Sponsored Training Rates
REF-5650.0 Identification and Evaluation of Preferred Substitute Teachers to Ensure Quality and Consistency of Classroom Instruction New


Number
Memorandum Description
MEM-5109.2 Support Provider Program Duties and Responsibilities Verification
MEM-5441.0 Secondary Differential Rosters, Spring 2011 Master Plan For English Learners
MEM-5524.0 Tentative Assignment Dates for 2011-2012
MEM-5576.0 CalSTRS Pre-Retirement Workshop Schedule for Certificated Employees
MEM-5633.0 NCLB: Qualifications for Teachers; Parent Notification Requirements and Right to Know Procedures, Annual Principal Certification Form
MEM-5659.0 Authorization to Teach English Learner (EL) Students New
MEM-5669.0 2011-2012 Winter Recess and District Shutdown Days New


AR#
Administrative Regulation (AR) Description
Policy Guide #
4100 Due Process/Certificated Adjustment Procedure
4101 Conference Preceding Demotion or Dismissal of Certificated Employees
4200
4201
4210 Election of Eligible Substitutes to Qualifying or Probationary Status
4213
4214
4320 Release and Subsequent Reassignment of Personnel when Positions are Discontinued Because of Reduction-in-Force


Number
Personnel Policy Guide Description
A3 Assignment Basis
A5 Assignment - Day-To-Day Substitute Information (updated on 12/06/11)
A12a Assignment - Temporary Advisor: Out-Of-Classroom (added on 03/17/11)
A12b Assignment - Temporary Advisor: Non-School (added 03/17/11)
B2 Benefits - Holidays
B4 Benefits - Retirement
D3 Discipline Dismissal
D4 Discipline Suspensions
E2 Employment Age Limit
E6 Credentials Application/Renewal
E7 Employment - General Information
E8 Employment Health Standards
E10 Employment Eligibility
E12 Professional Expert Temporary Certificated Assignments
E14 Employment Resignation
E15 Retired Certificated Persons (updated 08/25/11)
E17 Employment Seniority Date
E18 Employment Status
E22 Termination-Death Reporting Procedures
E23 Definition of Years of Service
E25 Employment, Categorical Limited Contract Teachers (CLC) (added 02/02/10)
L2 Leave or Absence General Information
L3 Leave or Absence Bereavement
L7 Leave or Absence Government Order
L14 Reduced Workload Leave
L16 Substitute Leave
P2 Performance – Evaluations, Instructional, Service, And Management Personnel
P3 Performance Evaluations, Provisional Contract Employees, Extended Day-to-Day Substitutes, Contract Employees Assigned, March 1 or Thereafter, Limited Term Employees, Substitutes-Service, Substitutes-Management
P4 Performance Evaluations Day-to-Day Substitute Teacher
S3 Teachers with Regular Credentials (T)
Teachers with Regular Credentials (T) - by Annual Pay
S4 Teachers with Alternative Certification (L)
Teachers with Alternative Certification (L) - by Annual Pay
S5 Day-to-Day Substitutes Servicng in Place of Preparation Salary Table Employees
S6 Development Center/Early Education Center and Substitute Rates (C Table)
S7 Teacher Hourly Rate (THR) Schedule, Flat Hourly, Regular Schedule and Differential Rates
S8 Physicians and Dentist Salary (J) Table, Chest Specialist, and Psychiatrist
S9 Special Services Salary (D) Table
S10 Master Salary (G) Table for Certificated Administrators
S11 Unclassified classes, counseling assistant, certificated teacher assistants, and certain Unit G part-time
S13 Rating-In Education
S14 Rating-In Experience
S15 Step Advancement
S16 Schedule Advancement Multicutural Requirement
S17 Point Credit Accredited Schools (updated 10/31/11)
S20 Point Credit Non-Accredited Organizations
S22 Point Credit Professional Development Point Projects Classes
S23 Point Credit Educational Travel Projects
S24 Point Credit Educational Travel Projects
S25 Differentials General
S26 Differential Degree
S27 Differential Career Increment Preparation (L and T) tables
S27a Differential Career Increment Special Services Salary Table
S27b Differential, Career Increment, Master (G) Table
S27c Differential Career Increment Early Education Salary Table Development Center Salary Table