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HR Forms

Administrative Services
Adult Education - Salary Allocation
Career Ladder
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


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 1. Memo regarding Guidelines and Request for Extra Duty Pay
2. Guidelines for Extra Duty Pay for Certificated Administrators
3. Request for Extra Duty Pay for Certificated Administrators
4. Memo regarding Guidelines and Request for Extra Duty Pay for Supporting School Registration
5. List of Schools Allocated Administrator Z Time Allocation For School Registration Support

Adult Education - Salary Allocation
HR-APU-CA CA-Form - Application for Conference/Workshop/Seminar Attendance Application for submission of conference, workshops, and seminar attendance.
HR-APU-CP CP-Form - Application for Conference/Workshop Presentation Application for submission of presentations. All presentations are worth ten (10) hours regardless of length.
HR-APU-CW CW-Form - Application for College Course Work Approval Application for submission of Level I & II coursework or any related college coursework.
HR-APU-D D-Form - Application for Teacher Demonstration Application for teacher demonstration lessons.
HR-APU-O O-Form - Application for Observation Application for teacher classroom and Peer observations.
HR-APU-STEP Application for Step Advancement Application for the purpose of Step Advancement on the THR salary table.

Early Childhood Education
Number
Title
Description
HR-1112 Career Ladder Membership Packet To join the Career Ladder, please review the program overview in the Membership Packet and complete the included membership quiz. Email the quiz answers to ladder@lausd.net.
HR-4300 Tuition Reimbursement Request Career Ladder Tuition Reimbursement Request Form. Must be accompanied by official transcripts or signed unofficial transcripts and Academic Advisement Form if cumulative GPA is below 2.75.
HR-4301 CL Scholarship Application CL Scholarship Application contains a Commitment form to declare a credential goal and a Questionnaire. The complete application is to be submitted along with unofficial transcripts, CBEST test scores to apply.
HR-4303 CL Scholarship Request - July CL Scholarship Request Form for year-end disbursement in July. The entire form including the Information Update are submitted beginning in July along with unofficial transcripts with final grades for the academic year (July 1-June 30) and any required performance assessment(s). Requests must be received by September 30.
HR-4306 Career Ladder Advisement Form (Tuition Reimbursement) Advisement form to be completed by participants requesting Tuition Reimbursement with a cumulative GPA below a 2.75. (This is a different form than the Academic Advisement form included with the October CL Scholarship Request packet.)
HR-4307 CBEST Test Reimbursement Request Reimbursement request form for CBEST test fees. Must be accompanied by copy of CBEST test scores regardless of passing. $40 reimbursement, up to 2 times. PA 1 must be completed.
HR-4308 Test Prep Reimbursement Request Reimbursement Request form for CBEST, CSET/RICA Test preparation courses. PA 2 must be completed to qualify for any test preparation reimbursements.
HR-4310 PA Instructions Instructions for completing Performance Assessments for Career Ladder participants pursuing a teaching credential
HR-4311 PA 1 Performance Assessment 1 for all Career Ladder participants
HR-4312 PA 2 Performance Assessment 2 for all Career Ladder participants
HR-4313 PA 3 Performance Assessment 3 for Career Ladder participants pursuing a teaching credential
HR-4314 PA 4 Performance Assessment 4 for Career Ladder participants pursuing a teaching credential
HR-4320 PA Instructions - PPS Instructions for completing Performance Assessments for Career Ladder participants pursuing a teaching credential
HR-4323 PA 3 - PPS Performance Assessment 3 for Career Ladder participants pursuing a Pupil Personnel Services credential
HR-4324 PA 4 - PPS Performance Assessment 4 for Career Ladder participants pursuing a Pupil Personnel Services credential

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-1289 Speech and Language Renewal Affidavit
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-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
HR-2421 Additional Hours Application, Teachers
  Employment Application, Teacher
  Permit/Credential Form
HR-2414 Permit Renewal Confirmation
HR-8384 Request for Personnel Action
PC-5005 Request for Transfer, Aides (Change of Work Location)
HR-8152 Resignation Form and Instructions, Teachers (Updated form will be posted soon.)
HR-2465 Statement of Availability, Teachers (Eligibility List)
HR-6500 Substitute Inadequate Service Report , Teachers and Aides
HR-2501 Substitute Statement of Availability, Teachers
HR-2424 Substitute Statement of Availability, Teachers ("C" Basis)
HR-8461 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)

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-5335.3 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-8239 Certification of Health Care Provider Formal approval from physician, if applicable.
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 Provides teachers with permanent or continuing status who meet certain conditions (refer to MEM-6223.0) 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-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.
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".
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 2014-15 Provides credentialed probationary or permanent teachers who meet certain conditions (refer to MEM-6393.0) 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-1632 Alternate Work/Non-Teaching Reference Form Reference form to be submitted by all certificated applicants for non-teaching employment.
HR-1633 Teaching Experience or Student Teaching Reference Form Reference form to be submitted by all certificated applicants for teaching related employment/experiences, including student teaching.
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.
HR-2154 Non-Confidential Reference Form for Counselor, Pupil Services and Attendance (PSA) Forms for Counselor, Pupil Services and Attendance applicants
  Psychiatric Social Worker Application Packet Forms for Psychiatric Social Worker applicants
  Pupil Services and Attendance Counselor Application Packet

Pupil Services and Attendance Counselor Reference Form Only
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.
503-708 Los Angeles County Schools Employment Authorization for Retirant  
HR-2018 Student Teaching Reference Form Should be sent by the Master/Mentor teacher, please do not give to the applicant.

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 Emergency 30-Day Substitute Teaching Permit Affidavit
MEM S-41 Off-Track Teacher Available to Substitute Form
MEM-6133.0 District Policy and Procedure for Arranging Substitute Teacher Coverage New

Title II, Part A
Document Title
Vendor Application and Instructions
Conference Attendance Request
Contract Proposal Request 14-15
Travel Expense Claim Form
CA Department of Education NCLB Guidance Document

Policy Documents

Number
Bulletin Description
BUL-260.3 Culture, Language and Methodology Requirements for Administrators New
BUL-999.7 Acceptable Use Policy (AUP) For District Computer and Network Systems
BUL-2047.0 Hate-Motivated Incidents/Hate Crimes Policy
BUL-3772.2 Injury and Illness Prevention Program Requirements
BUL-4222.0 Military Leave of Absence for Certificated Employees
BUL-4223.1 Jury Service for Certificated Employees including Tchr Assistants (Unit F Represented Only) New
BUL-4759.1 Williams/Valenzuela Complaint Procedures
BUL-5688.0 Social Media Policy
BUL-5167.0 Code of Conduct with Students
BUL-5159.1 Uniform Complaint Procedures (UCP)
BUL-5181.1 Internet Safety
BUL-5212.1 Bullying and Hazing Policy


Number
Reference Guide Description
REF-1450.3 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


Number
Memorandum Description
MEM-5109.2 Support Provider Program Duties and Responsibilities Verification
MEM-5792.0 Tentative Assignment Dates for 2012-2013
MEM-6173.0 CalSTRS Pre-Retirement Workshop Schedule for Certificated EmployeesNew
MEM-6161.0 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
MEM-6261.0 Elementary Differential Rosters, Spring 2014 Master Plan For English Learners
MEM-6262.0 Secondary Differential Rosters, Spring 2014 Master Plan For English Learners


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
A7 Assignment - Mutiple
A12a Assignment - Temporary Advisor: Out-Of-Classroom
A12b Assignment - Temporary Advisor: Non-School
B2 Benefits - Holidays
B4 Benefits - Retirement
D1 Discipline Index
D2 Discipline Absence Without Leave
D3 Discipline Dismissal
D4 Discipline Suspensions
D5 Discipline Due Process Certificated Adjustment Procedure
D6 Discipline Conference Preceding Demotion or Dismissal
E2 Employment Age Limit
E3 Community Representatives
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
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)
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 Serving 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
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