Appointment/Re-Appointment Form For Temporary Positions

1 Appointment/Re-Appointment Form For Temporary Positions **MULTI-PAGE DOCUMENT**. Background checks must be cleared by HR-Workforce Management Office prior to effective hire date. _____. Section I: Appointment Information COMPLETE ONLY ONE COLUMN IN SECTION I: COLUMN A COLUMN B COLUMN C. _____New Temporary Appointment OR _____Modify Current Active Explanation of Changes to Continued Temporary Appointment Appointment Original Appointment Terms with NEW Position Number IF NEW, which of these is true? Banner ID (U#):_____ Explain below: _____ Appointee has NO previous affiliation with UofM. IF CONTINUED, which of these is true? _____ Appointee has previous affiliation with UofM but NOT _____This is a continuation of a previously as an employee approved appointment; there are no changes to original appointment functions outside of work If yes, what is Banner ID (U#)? _____ dates _____ Appointee has previous affiliation with UofM as _____This is a continuation of a previously employee approved appointment; however, there ARE.

2 Changes to original appointment terms ( If yes, what is Banner ID (U#)? _____ duties, rate of pay, etc.) List changes in Column C. New Temporary hires must have an application on file in workforUM ( ) . Section II: Appointee Information Ensure that I-9 is processed by HR Records Management (AD 143) and W-4 & direct deposit paperwork is on file with Payroll (AD 272). Name: _____ Appointee E-mail Address: _____. First MI Last Current Address: _____. Street City State Zip Code Is appointee retired from the University of Memphis or another State of Tennessee agency? Yes _____ No _____. (If yes, please complete form for TCRS or ORP and ensure the employee is working within TCRS limits as indicated.). Section III: Job Information Hiring Department: _____ Campus Location: Main Campus Timesheet Override Org # (if any): _____. Description of job duties (attach additional sheet if necessary): Job Title: _____. Work Schedule: _____.

3 _____Hourly, _____Hourly, _____One-Time Pay Type of Benefits Ineligible Benefits Eligible Non-recurring Appointment: Multiple assignments Multiple assignments Cannot be paid as contractor Work Location: _____. permitted in TH only Hours permitted in TE only Background check not needed must be tracked Hours must be tracked No time sheet needed (E-Class TH) (E-Class TE) (E-Class TH) Supervisor: _____. Department Contact: _____ Contact Phone: _____. Comments: _____. Section IV: Payment Grid **ONE FORM PER ASSIGNMENT**. [You may wish to view payroll calendars before selecting the Effective Date and the End Date]. Proposed Approved Avg # Hours Posn # Effective Date Effective End Date per wk Pay Rate Index E-Class SOC. Date $ per Appointment/Re-Appointment Form For Temporary Positions **MULTI-PAGE DOCUMENT**. Background checks must be cleared by HR-Workforce Management Office prior to effective hire date. Section V: Terms of Employment As a Temporary employee, I understand: My appointment with the University of Memphis is contingent upon completion of the Employment Eligibility verification Form (Form I-9).

4 No later than the third day of employment as required by law to certify work eligibility. Failure to do so will result in immediate termination of my employment. Appointments are contingent upon receiving a satisfactory background report. I must participate in the direct deposit program and agree to provide necessary account information for deposit of my wages. (First payment may be a paper check.). I may be eligible for insurance coverage through the University, as defined by the Affordable Care Act (ACA). This does not include benefits such as leave, longevity pay, holiday pay, etc. I must abide by the terms of the Drug-Free Workplace Act of 1988 as defined in policy UM1563, and to notify the Department of Human Resources of any criminal drug conviction within five (5) calendar days of such conviction. This appointment is subject to the laws of the State of Tennessee, the requirements and policies of the Tennessee Board of Regents and the University of Memphis.

5 This appointment does not constitute any assurance, obligation or guarantee of subsequent appointments or employment. This appointment may be terminated without cause, at any time, without prior notice. This appointment is not binding until it is approved by the Department of Human Resources and executed by me (appointee). Section VI: Appointee Signature _____ The New Health Insurance Marketplace Coverage notice has been made available to me. (Please initial box.). Temporary Appointee: _____. Date Section VII: Approvals I understand that under the Affordable Care Act (ACA), this employee's Temporary assignment is insurance-eligible (e-class TE) or can become insurance-eligible (e-class TH). Employer portions of health insurance costs are the responsibility of the hiring department(s). Insurance charges for grants will be charged to the home department. Fin Mgr/Designee: _____ _____ _____. (Print Name) Signature Date Next Level Approval: _____ _____ _____.

6 (if required) (Print Name) Signature Date Section VIII: Human Resources Administrative Use Only Approved by Workforce Management _____ Date _____ Background Check _____. Remarks_____. _____. Please submit original to: Department of Human Resources Workforce Management 165 Administration Building An Equal Opportunity/Affirmative Action University You are receiving this notice as an employee of the University of Memphis. In March of 2010, President Obama signed the Affordable Care Act (ACA). The law will put in place many health insurance changes that roll out over four years and beyond, such as eliminating pre-existing conditions for children, keeping young adults eligible for their parents'. health plans through the age of 26, and covering preventive care at no cost to the participants. For more information about the ACA, please visit This federally mandated notice is to provide you with information you need to know regarding some of the key changes for 2014.

7 Below are highlights of interest: This notice provides you with information about your health insurance eligibility at the University of Memphis. You will need to know this in order to make decisions about the Health Insurance Marketplace. Think of the Marketplace as a place to shop for health insurance coverage for you and your family. You can get more information about the marketplace at You may be eligible for lower monthly premiums in the Marketplace, but only if you are not eligible for coverage at the University of Memphis. The information in Part B of this notice will help you complete the insurance application in the Marketplace. If you have any questions regarding your eligibility for insurance as an employee of the University of Memphis, please contact the University Benefits Administration Office at or 901-678-3573. For more information about the new health insurance options under the Marketplace, please visit New Health Insurance Marketplace Coverage Form Approved Options and Your Health Coverage OMB No.

8 1210-0149. (expires 1-31-2020). PART A: General Information When key parts of the health care law take effect in 2014, there will be a new way to buy health insurance: the Health Insurance Marketplace. To assist you as you evaluate options for you and your family, this notice provides some basic information about the new Marketplace and employment based health coverage offered by your employer. What is the Health Insurance Marketplace? The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. The Marketplace offers "one-stop shopping" to find and compare private health insurance options. You may also be eligible for a new kind of tax credit that lowers your monthly premium right away. Open enrollment for health insurance coverage through the Marketplace begins in October 2013 for coverage starting as early as January 1, 2014. Can I Save Money on my Health Insurance Premiums in the Marketplace?

9 You may qualify to save money and lower your monthly premium, but only if your employer does not offer coverage, or offers coverage that doesn't meet certain standards. The savings on your premium that you're eligible for depends on your household income. Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace? Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be eligible for a tax credit through the Marketplace and may wish to enroll in your employer's health plan. However, you may be eligible for a tax credit that lowers your monthly premium, or a reduction in certain cost-sharing if your employer does not offer coverage to you at all or does not offer coverage that meets certain standards. If the cost of a plan from your employer that would cover you (and not any other members of your family) is more than of your household income for the year, or if the coverage your employer provides does not meet the "minimum value" standard set by the Affordable Care Act, you may be eligible for a tax Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered by your employer, then you may lose the employer contribution (if any) to the employer-offered coverage.

10 Also, this employer contribution -as well as your employee contribution to employer-offered coverage- is often excluded from income for Federal and State income tax purposes. Your payments for coverage through the Marketplace are made on an after- tax basis. How Can I Get More Information? For more information about your coverage offered by your employer, please check your summary plan description or contact the University Benefits Administration Office at or 901-678-3573. The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the Marketplace and its cost. Please visit for more information, including an online application for health insurance coverage and contact information for a Health Insurance Marketplace in your area. 1 An employer-sponsored health plan meets the "minimum value standard" if the plan's share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs.