Teammate Handbook Cover

HUMAN RESOURCES SECTION

Department:

Job Title: _____________________________________

Date of birth:

Date of hire: __________________________________

Hours usually worked: per day

per month

Time employee began work:

Social Security Number:

Sex: Male

Female

Was employee paid full wages for the date of injury? If employee died, date of death: ______________ Was employee treated in an emergency room and released:

Yes

No Is salary being continued?

Yes

No

Yes No Employee usually works: ______ hours per day, ______ days per week, _______ total weekly hours Employment status: regular, full-time part-time temporary seasonal Gross wages/salary: $_____________ per _______________ Are there other payments not reported as wages/salary? (e.g. tips, meals, overtime, bonuses, etc.) Yes No

Completed by: __________________________________

Title: ___________________________________

Signature: ____________________________________

Date completed: __________________________

Revised 10/22