Rehire Packet Step 1 of 6 16% Employee Name* First Middle Last Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Safety Program StatementIt is the policy of ATS Construction to strive for the highest safety standards. Safety does not occur by chance. It is the result of careful attention to all company operative by those who are directly and indirectly involved. Employees at all levels must work diligently to execute the Company’s policy of maintaining safety and occupational health. The objective of this Safety Program is to prevent accidents from happening through training and safety meetings. Safety of the general public and of our employees is the top priority of all levels of our Company. By working together, we can prevent many employee accidents and much property damage and protect the general public as much a possible when they come into contact with our Company. It is, therefore, of the utmost importance that all aspects of the Company Safety Program be followed. Compliance with the employee handbook and the policies and procedures of ATS Construction is required of all employees. The information below, taken from the ATS Construction employee handbook, is a reminder of some of the employee responsibilities and requirements, but does not constitute all the information contained within the employee handbook. The following general guidelines are to be observed by employees. These are only general guidelines and do not constitute all the duties or responsibilities of employees of the Company. It shall be the responsibility of each employee to strive to follow all Company rules and regulations and to comply with all laws pertaining to employee safety and health. Unsafe acts or conditions observed by an employee shall be reported immediately to the supervisor. Employees shall strive to follow all policies and procedures contained within the employee handbook and all safety and health practices set forth within the industry and promulgated by State and Federal Agencies. Employees shall strive at all times to work safely and report any unsafe conditions on the job site to the supervisor or the safety director, Colin Faulkner. Employees shall report all injuries or accidents immediately to the supervisor and the safety director. Employees shall read and understand all policies and procedures in the employee handbook and that are in place by this Company. Employees shall understand the job task(s) which they will be completing while employed. If at any time the information or procedure for a job task is unknown, it is the employee’s responsibility to ask the supervisor or safety director Lifting Rules: Always lift correctly- get help if necessary. DO NOT try to move items that may be too large to move by yourself without help. It is your responsibility to get assistance Lift carefully. Remember to bend your knees when lifting an object and lift with the legs, NOT the back. It is very important for each employee’s safety and health to make sure not to lift any item that may be too heavy for one person to safely lift, push, pull, drag, or any other action that could cause injury by these or similar actions. Each employee must get assistance with any of the types of actions if necessary or use the proper equipment on the job site. * I agree to follow by the company safety practices, procedures, and policies described in the employee handbook, outlined by my supervisor and safety director, and the information contained in this handout. I further understand that there may be disciplinary actions as a result of breaking the rules or policies of the Company. Employee Injury and Health Report SheetTo help ATS Construction achieve the goal of minimizing the risk of injuries and accidents to employees and the public, it is critical to obtain health and safety information from employees returning to work. It is necessary to try to make sure employees are capable of safely performing the job tasks they were hired to complete without added risk to themselves or others due to any physical condition, injuries, medications, illness, etc., unknown to Company. Your call back to work will not be rescinded unless a medical review reveals that you cannot perform the essential functions of the job (with reasonable accommodations if requested), or you present a hazard to yourself or others. False or misleading statements are grounds for rescinding this offer and for termination of employment. Please note that workers’ compensation benefits in some states may also be affected by false or misleading information. This form must be accurate and complete. This information is considered persona; and medical in nature and will be treated as such my handling it confidentially in compliance with the Americans with Disabilities Act.Have you had any injuries (home, sports, hunting, auto, etc.,) or had any physical conditions or illnesses since the last date of work/layoff from ATS Construction?* Yes No Describe in detail any such injury, physical condition, or illness. (b) Identify any doctors or health care providers you have seen. (c) Identify anv health care facility or hospital you have been to. (d) State what treatment you received. (e) State whether you have been or are restricted from any physical activities. (f) Please provide a copy of any physical limitation, work restrictions, or release to return to work that you have been given. Please complete this section-use the back of this sheet if necessary.Are you taking any medications that could interfere with your safety or the safety of others while working on the job site; operating equipment, driving a vehicle, etc., or that would conflict with ATS Construction’s controlled Substance, alcohol, and prescription policy?* Yes No Describe and list all*Do you have a copy of and have you read the ATS Employee Handbook?* Yes No Do you understand the Company policies and safety procedures?* Yes No Do you have any illness or physical condition or have you suffered any injury for which you have not seen a doctor or sought treatment?* Yes No Please describe** I hereby affirm that the injury and health information provided is true and correct, and that there are no omissions, false information or misrepresentation of facts. I authorize any physician, medical facility, law enforcement agency, administrator, state agency, institution, information service bureau, insurance company or employer contacted by this company or an agent of this company to furnish or verify workers’ compensation information, medical records, or documentation of any kind as it pertains to any medical condition. Use of Prescribed or Over-the-counter MedicationsThe Company prohibits an employee from performing his “safety-sensitive job" duties while taking prescribed or over-the-counter medications that may adversely affect his ability to safely and effectively perform those job duties. Safety-sensitive jobs are any jobs which the Company deems to involve a risk to the safety of the employee, of other employees, workers or persons on the jobsite, or of the public, including, but not limited to, operating heavy equipment, working on or around heavy equipment, working as a flagged, driving construction vehicles or trucks. Regardless of whether an employee has a prescription, he will not be permitted to perform safety-sensitive jobs if he is taking a medication that may adversely affect his ability to safety and effectively perform those safety-sensitive job duties. All drugs that are a controlled substance as set forth under “II Scope of Policy“ unless otherwise stated herein, shall be deemed to adversely affect one’s ability to safely and effectively perform one’s safety-sensitive job duties. The employee shall immediately notify the Company’s Safety Director and immediate supervisor if he is taking such medication. ”*”SOME Drugs classified as Benzodiazepines, which have been prescribed by a licensed physician for the treatment of depression, anxiety or other mental illness may be evaluated under the subsequent paragraphs of this Section. This information must be provided to the Safety Director and reviewed by the company MRO for approval of use.*”* For all other medication the employee is responsible for consulting the prescribing physician to ascertain whether the medication he is taking may interfere with the safe performance of his safety- sensitive job duties. A written statement from the prescribing physician stating that the employee’s medication will not interfere with the safe performance of his safety-sensitive job duties is required for the Company to consider whether the employee may continue employment. The written statement from the prescribing physician will be reviewed by the Company and MRO (defined below) for a final determination of whether the medication may interfere with the safe and effective performance of the employee’s safety-sensitive job duties. If the Company makes a final determination that the medication the employee is taking may interfere with the safe performance of the employee’s safety-sensitive job duties, the employee may request that the Company attempt to reasonably accommodate the employee’s use of the medication and the side effects that the medication has on the employee. If no such request is made by the employee or the Company determines that a reasonable accommodation cannot be made, the employee shall be immediately placed on leave without pay. The Company is not required to create a position for an employee as doing so is not considered a reasonable accommodation. Employees taking a prescribed medication must carry it in the container labeled by a licensed pharmacist or be prepared to produce it if asked. THE EMPLOYEE’S FAILURE TO IMMEDIATELY NOTIFY THE COMPANY’S SAFETY DIRECTOR THAT HE IS TAKING PRESCRIBED OR OVER-THE-COUNTER MEDICATIONS THAT MAY ADVERSELY AFFECT HIS SAFE AND EFFECTIVE PERPFORMANCE OF HIS SAFETY-SENSITIVE JOB DUTIES WILL RESULT IN DISCIPLINE OF THE EMPLOYEE WHICH MAY INCLUDE, BUT NOT LIMITED TO, IMMEDIATE TERMINATION. BELOW IS A LIST OF THE CATAGORIES OF DISQUALIFYING DRUGS AND MEDICATIONS “Drug” means a controlled substance as defined in US 218A.010(6) and as established in 502 KAR Chapter 55 including, but not limited to: Amphetamines; Cannabanoids /THC; Cocaine; Opiates; Phencyclidine (PCP); Benzodiazepines; Piopoxyphene; Methaqualone; Methadone; Suboxone; Rarbitutates; Synthetic narcotics; Illicit substances; and Volatile substances as defined by US 217.900(1). * I hereby acknowledge I have read and understand the information provided in the Use of Prescribed or Over-the-counter Medications section. Master Data SheetCall Back/Rehire EmployeesChange of Address* Yes No New address*Change of Phone Number* Yes No New Phone Number*Change of Banking Information* Yes No Bank Account Type* Checking Savings New Bank Routing Number*New Bank Account Number*Change of Email for Pay Stub Delivery* Yes No New Email Address* Change to Amount or Percentage of 401k* Yes No Change to Percentage for 401k*Enter two digits (for example, 05 for 5%)Change to Amount for 401K*Photo for Drivers License*Please upload a photo of your current, active drivers license for our recordsMax. file size: 300 MB. Employment Eligibility VerficationDepartpment of Homeland Security U.S. Citizenship and Immigration ServicesANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the documentation presented has a future expiration date may also constitute illegal discrimination.Other Last Names Used (if any)Date of Birth* MM slash DD slash YYYY This field is hidden when viewing the formU.S. Social Security NumberEmail Address* Telephone Number* I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form. I attest, under penalty of perjury, that I am (check one of the following boxes) A citizen of the United States. A noncitizen national of the United States: An individual born in American Samoa, certain former citizens of the former Trust Territory of the Pacific Islands, and certain children of noncitizen nationals born abroad. A lawful permanent resident: An individual who is not a U.S. citizen and who resides in the United States under legally recognized and lawfully recorded permanent residence as an immigrant. This term includes conditional residents. Asylees and refugees should not select this status, but should instead select "An Alien authorized to work" below. An alien authorized to work: An individual who is not a citizen or national of the United States, or a lawful permanent resident, but is authorized to work in the United States. Enter your 7- to 9-digit Alien Registration Number (A-Number), including the “A,” or USCIS Number in the space provided. Use the dropdown provided to indicate whether you have entered an Alien Number or a USCIS Number. At this time, the USCIS Number is the same as the A-Number without the “A” prefix.Please choose*Alien NumberUSCIS NumberAre you a refugee, asylee or a citizen of the Federated States of Micronesia, the Republic of the Marshall Islands, or Palau, and other alien whose employment authorization does not have an expiration date? Yes No Enter 'N/A' below to indicated that your employment authorization does not have an expiration date*Enter the date that your employment authorization expires, if any, in the space provided. In most cases, your employment authorization expiration date is found on the document(s) evidencing your employment authorization. In some cases, such as if you have Temporary Protected Status, your employment authorization may have been automatically extended; in these cases, you should enter the expiration date of the automatic extension in this space. MM slash DD slash YYYY Aliens authorized to work must enter one of the following* Alien Registration Number (A-Number)/USCIS Number Form I-94 Admission Number Foreign Passport Number and the Country of Issuance Enter your 7- to 9-digit Alien Registration Number (A-Number), including the “A,” or USCIS Number in the space provided. Use the dropdown provided to indicate whether you have entered an Alien Number or a USCIS Number. At this time, the USCIS Number is the same as the A-Number without the “A” prefix.Please choose*Alien NumberUSCIS NumberEnter your Form I-94 Admission Number*Enter your Foreign Passport NumberEnter your Passport Country of IssuanceI attest, under penalty of perjury, that I have assisted in the completion of this form and that to the best of my knowledge the information is true and correct.*Section Break Δ
3009 Atkinson Ave.,
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