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? ___ Yes ___ No Is salary being continued? ___ Yes __ No

If employee died, date of death: ______________

Was employee treated in an emergency room and released: ____ Yes _____ No

Employee usually works: ______ hours per day, ______ days per week, _______ total weekly hours

regular, full-time part-time temporary seasonal

Employment status:

Grass 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 01/22