HR Student Forms Checklist
Undergraduate/Graduate CSM Student Employees

Students employed by CSM must turn in the following items along with a CSM Student Employment
Contract to Human Resources before starting employment.

Undergraduate/Graduate Students:

I-9 Form: Employment Eligibility Verification (NOTE: We must have original forms of
identification to go along with this document i.e. social security card, license, passport, etc.).

Social Security Card: YOU ARE NOT ALLOWED TO WORK OR RECEIVE A PAYCHECK
WITHOUT SUBMITTING YOUR SOCIAL SECURITY CARD. Please remember to bring your
card with you to Human Resources. This is a separate requirement from the I-9 identification.


Form I-551 Permanent Resident Card (if applicable)

EEO Gender & Ethnicity Voluntary Self-Disclosure Form

EEO Individuals with Disabilities & Veterans Voluntary Self-Disclosure Form

Emergency Contact Form

Certification of Policy Receipt

Amorous Relationships Policy

Colorado Pregnancy Accommodation Posting

SpeakUp@Mines Acknowledgment

FERPA Confidential Data Agreement

Drug-Free Workplace Policy

Work-Related Injuries or Illness Policy

Social Security Form SSA-1945

W-4 Form: Employee’s Withholding Allowance Certificate

Electronic Deposit Form & Voided Check (Colorado Fiscal Rules (Rule 9-2) requires that all
employees be on a Direct Deposit Payroll Program)

Faculty Oath (Required of all Graduate Research/Teaching Assistants)

International Students Only (in addition to the forms above)
Work Authorization Letter from the CSM International Office
I-94: Arrival/Departure Record
I-20 or DS-2019: Certificate of Eligibility for Nonimmigrant (F-1) Student Status - for Academic and
Language Students (I-20), Certificate of Eligibility for Exchange Visitor (J-1) Status (DS-2019)

Visa


Summer Student Contracts Only
TIAA Enrollment is required of all students working on the CSM campus during the summer who are not
enrolled in summer courses. CSM does not participate in Social Security (FICA) withholding; but by federal
law must have a replacement program in place. TIAA is the FICA replacement retirement fund deducted from
the pay in lieu of FICA taxes. Unlike with Social Security tax withholdings, students can apply for a refund of
these funds once they permanently end their employment at CSM. If a working student is not enrolled in
summer courses, TIAA enrollment will be set-up automatically by the Payroll Office.

Students may review or make changes to their account by visiting www.TIAA.org. TIAA Information
packets (formerly known as TIAA-CREF) are available for students in the Human Resources or




Background Checks
Effective 07/01/2011 – Employment is contingent upon the successful completion of a Background Check for
all new hire Graduate students, all new hire Undergraduate students employed by Athletics Camp, America
Reads Tutors (FA), Bursar’s/Cashier’s, HR, Legal, Museum, Payroll, Public Safety, Res. Life, Registrar,

operate a motor vehicle, or works with minors.





Revised 08/10/2016




AFFIRMATIVE ACTION STATEMENT

Colorado School of Mines has a moral and legal obligation to foster equality of
employment opportunity at the institution and to ensure that no one is
discriminatively excluded from its programs or activities because of her/his race,
color, religion, sex, national origin, veteran’s status, political affiliation, or
disability. All members of the College community are encouraged to comply with
the provisions of this Affirmative Action Plan as well as with all federal and state
laws prohibiting discrimination in employment and education.

With this thought in mind, all employment-related actions including recruitment,
hiring, training, promotion, salary and benefit plans, and terminations are to be
administered in a manner established to promote equal employment opportunity.
Employment-related decisions shall be made without regard to race, color,
religion, sex, national origin, veteran’s status, political affiliation, or disability and
shall be based solely on valid, nondiscriminatory criteria and requirements.

Colorado School of Mines will take whatever steps are necessary to prevent
unlawful discrimination in its educational, social, and recreational programs and
activities.

The Office of Human Resources is responsible for educating the College
community in implementing the Affirmative Action Program to monitor institutional
practices and procedures; to review and report on the College’s implementation
of the Affirmative Action Program defined by this Plan; to recommend measures
necessary to ensure compliance with this Plan and federal and state laws; and to
mediate, hear, and recommend resolution of complaints of unlawful employment.

You are urged to familiarize yourselves with this Plan and with federal and state
laws prohibiting discrimination. All faculty, staff, and students have a
responsibility to assure equal employment and educational opportunity for
current and future members of the Colorado School of Mines community.

Colorado School of Mines
Equal Employment Opportunity (EEO) Gender & Ethnicity
Self Disclosure Form

Colorado School of Mines is an equal employment opportunity employer. In order to comply
with EEOC, OFCCP and Affirmative Action regulations, the School is required to compile
summary data on the gender and ethnicity of its applicants and incumbent employees.
The information solicited is collected for the sole purpose of providing data to be used for
statistical analysis by the Office of Human Resources, maintained in separate files and is not
used in the determination of your eligibility for promotion, transfer or tenure. If an employee
declines to identify his or her race/ethnicity, Human Resources may use observer identification
or personnel records.

Today’s Date:
Department:

CWID:
Name:

(Or last 4-digits of SSN)
Gender: Female Male


Ethnic Origin:
Not Hispanic or Latino (Spanish Origin)
Hispanic or Latino (Spanish Origin) – A person of Cuban, Mexican, Puerto Rican,
South or Central American, or other Spanish culture or origin, regardless of race.

Racial Origin
Please select one or more racial categories:
White - A person having origins in any of the original peoples of Europe, the Middle
East, or North Africa.
Asian - A person having origins in any of the original peoples of the Far East,
Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China,
India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
Black or African American – A person having origins in any of the black racial
groups of Africa.
American Indian or Alaska Native - A person having origins in any of the original
peoples of North and South America (including Central America), and who maintain
tribal affiliation or community attachment.
Native Hawaiian or Other Pacific Islander - A person having origins in any of the
peoples of Hawaii, Guam, Samoa, or other Pacific Islands.


Colorado School of Mines
Individuals with Disabilities and Covered Veterans

Self-Disclosure Form
Colorado School of Mines is subject to section 503 of the Rehabilitation Act of 1973 and the Vietnam Era Veteran’s
Assistance Act of 1974, as amended, which requires government contractors to take affirmative action to employ and
advance in employment qualified individuals with disabilities, disabled veterans, special disabled veterans, Vietnam
veterans and al other eligible veterans.
If you have a disability or are a veteran as defined below and would like to be considered under the affirmative action
program, please tel us. You may inform us of your desire to benefit under the program at this time and/or at any time
in the future. Submission of this information is voluntary and refusal to provide it wil not subject you to any adverse
treatment. Information you submit about your disability will be kept confidential, except that (i) supervisors and
managers may be informed regarding restrictions on the work or duties of individuals with disabilities, and regarding
necessary accommodations; (ii) first aid and safety personnel may be informed, when and to the extent appropriate, if
the condition might require emergency treatment; and (ii ) government officials engaged in enforcing laws
administered by OFCCP or the Americans with Disabilities Act may be informed. The information provided would be
used only in ways that are consistent with Section 503 of the Rehabilitation Act and the Vietnam Era Veteran’s
Readjustment Act of 1974, as amended.
Today’s Date:

Department:

CWID:

Name:

(Or last 4-digits of SSN)
Faculty
Staff
Student Employee

Individuals with a Disability
An individual with a disability is defined as any person who: a) has a physical or mental impairment which
substantial y limits one or more of such person's major life activities; b) has a record of such an impairment; or c) is
regarded as having such an impairment. (41 CFR 60-741.42)
Do you consider yourself an individual with a disability?
Yes
No
If you need to request reasonable accommodation(s) or service(s) that would aid you in performing the essential functions of your
current position, please contact the Office of Human Resources.

Veteran Status (Please mark only one of the appropriate boxes):
DD 214, Certificate of Discharge or Separation from Active Duty, or other official documents issued by the
branch of service are required as verification of eligibility for Veterans preference. Please provide a copy of
the DD 214 or other official documents to the Office of Human Resources.
Vietnam Era Veteran - Are you a person who served on active duty for a period of more than 180 days any part of which
occurred between 8/5/64 and 5/7/75 or active duty occurred in the Republic of Vietnam between 2/28/61 and 5/7/75 and was
discharged or released there from with other than a dishonorable discharge or a service connected disability?
Other Protected Veteran - Are you a person who served on active duty in the U.S. military, ground, naval, or air service
during a war or in a campaign or expedition for which a campaign badge has been authorized, other than special disabled veterans
or veterans of the Vietnam era? A veteran qualifies under this criterion ONLY based upon military service IN the identified
campaign or expedition and NOT simply based on any military service during the time of the campaign or expedition.
Newly Separated Veteran - Are you a Veteran recently separated from service in the last 3 years?

Date of Separation: _____________________
Special Disabled Veteran - Are you a Veteran entitled to disability compensation under laws administered by the
Veterans Administration for disability rated at 30% or more, or rated at 10% or 20% in the case of a veteran who has been
determined to have a serious employment disability, or a person whose discharge or release from active duty was for a disability
incurred or aggravated in the line of duty?
Disabled Veteran - Are you (1) a Veteran of the U.S. military, ground, naval or air service who is entitled to compensation
(or who but for the receipt of military required pay would be entitled to compensation) under laws administered by the Secretary of
Veteran Affairs, or (2) a person who was discharged or released from active duty because of a service-connected disability?
Armed Forces Service Medal Veteran - Are you (1) a Veteran of the U.S. military, ground, naval, or air service who
is entitled to compensation (or who but for the receipt of military required pay would be entitled to compensation) under laws
administered by the Secretary of Veteran Affairs, or (2) a person who was discharged or released from active duty because of a
service-connected disability?

I do not wish to provide this information to Colorado School of Mines.

COLORADO SCHOOL OF MINES

Emergency Contact Information

Today’s Date: ________________


Employee name:


Employee home phone number:
Cell


First/Last name for contact in case of emergency:


Contact person’s street address:



City, State, Zip

Contact person’s phone number: home:
work:


Relationship to employee:



Names and telephone numbers of persons to contact if primary contact is unavailable:






























Revision date 06.06.2017

Colorado School of Mines Student Certification of Policy
and Notice Receipt


Policy Names:

Work-Related Illness and Injury
Drug Free Workplace Policy
Alcohol and Other Drugs Education and Prevention Policy
Amorous Relationships Policy (issued 07/15/2016)
Colorado Pregnancy Accommodation Posting (effective 08/10/2016)
FERPA Confidential Student Data Agreement
Policy Prohibiting Gender-Based Discrimination, Sexual Harassment, and Sexual

Violence
Health Insurance Marketplace Notice


I hereby certify that I have been provided information on the above policies or
that I have received the above policies on the date shown below. I acknowledge
that it is my responsibility to read and follow these policies. I understand the
rights and responsibilities in each policy and agree to abide by the procedures
set forth in the aforementioned policies, as they may be revised from time to
time.


_____________________________________CWID__________________
Please Print Name


__________________________________Dept.___________________
Signature


Date_________________________________________
Rev 7/2016

Amorous Relationships Policy

Amended by the Colorado
Policy Contact:
School of Mines Board of
Title IX & Equity Compliance Office
Trustees July 15, 2016
krcurran@mines.edu


1.0
BACKGROUND AND PURPOSE

This policy is promulgated by the Board of Trustees of the Colorado School of Mines (“Mines” or
“the University”), pursuant to the authority conferred upon it by C.R.S. §23-41- 104(1). Through
this policy, Mines outlines its expectations regarding amorous relationships between Mines’
community members. This policy shall govern if any of its provisions conflict with other Mines
policies.

2.0
POLICY

For the protection of all Mines community members, amorous relationships with inherent
conflicts of interest and significant power differentials are prohibited unless and until the
conflict of interest is disclosed AND removed.

Even if both parties to the amorous relationship appear to have consented, if the parties are in
unequal positions relative to one another, this may result in significant power differentials. The
existence of a power differential may restrict the less powerful individual's choice to participate
freely and willingly in the relationship due to actual or perceived coercion and/or retaliation.
Mines considers there to be three categories of amorous relationships: a) those not subject to
the restrictions below; b) those that are permitted with appropriate disclosure and conflict of
interest monitoring; and c) those that are prohibited. The latter two are discussed below.

2.1
AMOROUS RELATIONSHIPS REQUIRING DISCLOSURE AND CONFLICT OF
INTEREST MONITORING

If an amorous relationship between Mines community members does not have a current conflict
of interest or power differential, but could reasonably result in either at some point in the future,
then disclosure to and monitoring by the appropriate supervisor are required. Examples of
amorous relationships that must be disclosed include, but are not limited to:

• Employees who have an amorous relationship with another person over whom they
have indirect supervisory responsibilities (e.g., influence over assignments, oversight of
hours worked or schedules, input regarding performance, etc.)

• An Instructor who engages in an amorous relationship with a student for whom the
Instructor has no current professional responsibility, but where there is a reasonable
expectation that the Instructor may have professional responsibility for the student at
some point in the future.

2.2
PROHIBITED AMOROUS RELATIONSHIPS

The following amorous relationships are prohibited under all circumstances:
Page 1 of 3

Amorous Relationships Policy

Amended by the Colorado
Policy Contact:
School of Mines Board of
Title IX & Equity Compliance Office
Trustees July 15, 2016
krcurran@mines.edu

• No person in a Position of Trust, as defined below, shall engage in an amorous
relationship with a student.

• No Instructor shall engage in an amorous relationship with a student who is enrolled in a
course being taught by the Instructor, whose academic performance is supervised by the
Instructor, or who volunteers for or performs work of any kind for the Instructor.

• No Supervisor shall engage in an amorous relationship with a person over whom they
have direct supervisory responsibilities.

• No Mines employee shall engage in an amorous relationship with another Mines student
or employee over whom they have evaluative responsibilities, such as in the context of a
thesis or a promotion/tenure committee.

Any such relationship will be presumed to be non-consensual by Mines. Any employee who is
aware of such a relationship is a mandatory reporter and must report the existence of a
prohibited relationship to the Title IX and Equity Compliance office.


3.0 VIOLATIONS AND SANCTIONS FOR VIOLATIONS

• Engaging in an amorous relationship that is prohibited by this policy constitutes a
violation that may result in sanctions up to and including removal of the employee’s
supervisory, instructional or evaluative responsibilities and/or termination.

• Failing to disclose an amorous relationship as required by this policy constitutes a
violation that may result in sanctions up to and including removal of the employee’s
supervisory, instructional or evaluative responsibilities, and/or termination.

• In cases where a student employee has engaged in an amorous relationship that may
have violated this policy, the matter will be referred to the Dean of Students for
adjudication.

4.0 RETALIATION PROHIBITION AND SANCTIONS FOR RETALIATION

Mines’ employees may not retaliate against an individual for making a report under this Policy or
participating in an investigation regarding allegations that fall within the Policy. Any employee
who engages in retaliation may be subject to disciplinary action up to and including termination
and/or expulsion. Reports of retaliation will be reviewed and investigated in the same manner in
which other allegations of misconduct are handled.


Page 2 of 3

Amorous Relationships Policy

Amended by the Colorado
Policy Contact:
School of Mines Board of
Title IX & Equity Compliance Office
Trustees July 15, 2016
krcurran@mines.edu


5.0 IMPLEMENTATION

Mines’ Board of Trustees directs the President or President’s delegates to develop, administer,
and maintain the appropriate administrative policies, procedures, and guidelines to implement
this policy.


6.0 DEFINITIONS

Amorous relationship: a romantic, dating, or sexual relationship. This definition excludes
marital or civil union relationships.

Employee: Any person employed or appointed by Mines, including but not limited to, academic
faculty, administrative faculty, state classified staff, graduate assistants, student hourly
employees, non-student hourly employees, non-paid staff, authorized volunteers, non-
remunerative appointees, and student work-study employees.

Instructor: Any person who performs any teaching, instruction, or coaching duties at Mines,
including academic faculty members, instructional staff, athletic coaches, non-remunerative
appointees and graduate students with teaching or tutorial responsibilities.

Person in a Position of Trust: Any person employed in a position that could or would
compromise the employee’s ability to perform his or her duties appropriately if they engaged in
an amorous relationship with a Student. Persons in Positions of Trust at Mines include, but are
not limited to, employees of the Admissions Office, Registrar’s Office, Student Life Division
including the Residence Life Office, Center for Academic Services and Advising (CASA), and
Public Safety Department.

Student: Any person who is applying to the University or who is currently enrolled at Mines,
regardless of age or status.

Supervisor: Any person employed at Mines who occupies a position of authority over another
employee with regard to hiring, administering discipline, conducting evaluations, granting salary
adjustments, or overseeing or assigning work.


7.0
REVIEW CYCLE AND HISTORY

The policy will be reviewed at least every two years by the Title IX and Equity Officer.
Promulgated by the CSM Board of Trustees on February 14, 1992.
Amended by the CSM Board of Trustees on June 18, 1992.
Amended and Administratively Adopted March 2012.
Amended by the CSM Board of Trustees on July 15, 2016.(formerly known as the “Personal
Relationships Policy”)
Page 3 of 3


Procedures for the
Responsible Administrative
Amorous Relationships
Unit:
Policy
Administration & Operations

Procedures Adopted:
Policy Contact:
July 15, 2016
Title IX & Equity Compliance Office

krcurran@mines.edu

1.0
BACKGROUND, PURPOSE AND JURISDICTION

On July 15, 2016, the Board of Trustees of the Colorado School of Mines (“Mines”) adopted the
Amorous Relationships Policy (“the Policy”). The Policy prohibits certain amorous relationships
involving one or more Mines Employees due to inherent conflicts of interest. The Policy also
mandates disclosure of amorous relationships between one or more Employees that could
reasonably result in a conflict of interest. This procedure implements the Policy and provides for
the following:

• a disclosure process through which Mines Employees can identify amorous
relationships;
• institutional responses to rectify current or future conflicts of interest arising from
amorous relationships; and
• a process for prompt, fair, and impartial investigation and resolution of complaints
arising under the Policy.

2.0
DISCLOSURE PROCESS

2.1
When an amorous relationship must be disclosed, it is the responsibility of the person in
the higher power position to initiate the disclosure.

2.2
The relationship must be reported immediately to the appropriate dean, department
head, or supervisor so that suitable arrangements can be made to avoid current and
future conflicts of interest.

2.3
The disclosure must be in writing and contain the following information:
• Name and status of the parties to the relationship;
• Identification of any potential or existing conflicts of interest;
• Date the relationship began; and
• Date the disclosure was required under this policy.

2.4
The supervisor who receives the disclosure will maintain the confidentiality of the
relationship to the extent practicable. Disclosure of the relationship to a third party by the
supervisor may be necessary in order for the supervisor to receive advice from the
Human Resources or other campus departments, to explain a change in assignments,
etc.

2.5
The supervisor will provide a copy of the disclosure document to the Title IX and Equity
Compliance office to avoid any confusion in the event that office receives a complaint
about the amorous relationship.


Page 1 of 2


Procedures for the
Responsible Administrative
Amorous Relationships
Unit:
Policy
Administration & Operations

Procedures Adopted:
Policy Contact:
July 15, 2016
Title IX & Equity Compliance Office

krcurran@mines.edu

3.0 CONFLICT OF INTEREST RESOLUTION AND/OR MITIGATION

3.1
Disclosure of an amorous relationship may result in the removal of the supervisory,
evaluative, or instructional responsibilities from the person in the higher position as
deemed necessary by the supervisor.

3.2
Even if the conflict of interest can be resolved, the person in the higher position shall be
held accountable for any unprofessional behavior resulting from the amorous
relationship.

4.0
COMPLAINT

4.1
Complaints regarding amorous relationships or suspected amorous relationships will be
referred to the Title IX and Equity Compliance office.

4.2
All complaints will be resolved through the Procedures for Resolving Complaints of
Gender-Based Discrimination, Sexual Harassment, and Sexual Violence Against
Employees or Third Parties, which are found in the Mines’ Policy Library.

4.3
In cases where a complaint is received about a student employee engaging in an
amorous relationship that may have violated the Student Code of Conduct, the matter
will be referred to the Dean of Students for adjudication.

5.0
SANCTIONS

5.1
Failure to disclose an amorous relationship referenced in the Policy may result in
disciplinary action up to and including removal of the Employee’s supervisory,
instructional or evaluative responsibilities and/or terminations of employment.

5.2
Misrepresentation of the circumstances of the amorous relationship by the disclosing
party may result in disciplinary action up to and including removal of the Employee’s
supervisory, instructional or evaluative responsibilities and/or terminations of
employment.

6.0
REVIEW CYCLE AND HISTORY

These procedures shall be reviewed concurrently with the Amorous Relationships Policy.
Procedures Administratively Adopted July 15, 2016.
Page 2 of 2


Title IX and Equity Compliance
1500 Illinois Street Golden, CO 80401
303.384.2558


NOTICE REGARDING RIGHTS OF PREGNANT APPLICANTS AND EMPLOYEES
Employees and applicants for employment in the State of Colorado may not be discriminated
against or subjected to unfair employment practices because of pregnancy, health conditions
related to pregnancy, or recovery from childbirth. Employees and applicants may request
reasonable accommodations to perform the essential functions of the job for health conditions
related to pregnancy or the physical recovery from childbirth
• If an applicant or an employee requests accommodation related to pregnancy, physical
recovery from childbirth, or a related condition, Mines shall engage in a timely, good-faith,
and interactive process with the employee or applicant to determine effective, reasonable
accommodations.
• Requested accommodations wil be granted unless the accommodation would impose an
undue hardship on Mines' business operations.
• An applicant for employment may request reasonable accommodations to perform the
essential functions of the job for health conditions related to pregnancy or the physical
recovery from childbirth unless the accommodation would impose an undue hardship on
the employer's business;
• Mines will not take adverse action against an employee who requests or uses a reasonable
accommodation related to pregnancy, physical recovery from childbirth, or a related
condition;
• Mines wil not deny employment opportunities to an applicant or employee based on the
need to make a reasonable accommodation related to the applicant's or employee's
pregnancy, physical recovery from childbirth, or a related condition;
• Mines will not require an applicant or employee affected by pregnancy, physical recovery
from childbirth, or a related condition to accept an accommodation that the applicant or
employee has not requested.
• Mines will not require an applicant or employee affected by pregnancy, physical recovery
from childbirth, or a related condition to accept an accommodation that is unnecessary for
the applicant or employee to perform the essential functions of the job.
• Mines will not require an employee to take leave if the employer can provide another
reasonable accommodation for the employee's pregnancy, physical recovery from
childbirth, or related condition.

Mines may require an employee or applicant to provide a note stating the necessity of a reasonable
accommodation from a licensed health care provider before providing an accommodation.



Campus Colleagues,
Creating an ethical and safe workplace is of the utmost importance to Mines leadership. Mines expects
its faculty, staff, graduate teaching and research assistants, undergrad student employees, and
volunteers to perform the duties of their positions ethically and with integrity. Section 6 of the Faculty
Handbook, Section 4 of the State Employee Handbook, and the Student Code of Conduct provide more
detailed explanations of these expectations.
We all share the responsibility of creating a highly ethical, positive campus environment. This includes
the responsibility to SpeakUP when you see or experience misconduct of any kind. Mines provides
various mechanisms to assist and encourage individuals to come forward with reports or concerns about
suspected misconduct and compliance issues. While partnering with your supervisor or department
head to address concerns is best, we understand that there may be times when you feel uncomfortable
pursuing such interactions.
Mines has a third-party reporting system called SpeakUP@Mines. This system al ows you to use an
outside party to advise Mines of misconduct or areas of concern. Your concerns can be anonymous if
you so choose when making a report. The SpeakUP@Mines webpage contains reporting and contact
information.
The Whistleblower Policy provides protection to report without fear of reprisal or retaliation.
Whistleblower reports made to a supervisor or department head are to be forwarded immediately to
the Director of Internal Audit upon receipt by the supervisor or other personnel.
The reporting tool is not designed or intended for day-to-day disagreements or differences of perspective
(these issues should be addressed with your supervisor, department head, or leadership team member).
The reporting tool is NOT for emergencies—call 9-1-1 to obtain immediate assistance from Campus
Police.
~~~~~~~~~~~~~~~~~~~~~~~
I, the undersigned Colorado School of Mines employee, acknowledge receiving the above information. I
understand I am supposed to perform my job duties ethical y and with integrity. My signature below
indicates my acknowledgement of this responsibility.
_________________________________________

_______________________
Employee Name (please print legibly)



CWID

______________________________________________

____________________________
Employee Signature





Date

_______________________________________________
Employing Department


Rev 02.27.2017


Registrar’s Office
303-273-3200
FERPA
Family Educational Rights and Privacy Act of 1974
Confidential Student Data Agreement for All Mines Employees

FERPA, also known as the Buckley Amendment, helps protect the privacy of student records. The Act provides for:
• the right to inspect and review education records
• the right to seek to amend those records
• the right to consent the disclosure of information from the records
• the right to obtain a copy of the school’s Student Records policy

The act applies to all institutions that receive federal funding. Students who are currently enrolled in higher education
institutions or formerly enrolled, regardless of age or status with regard to parental dependency, are protected.
Deceased students are protected under FERPA as long as they were formerly enrolled. Students who have applied
but did not attend an institution are not protected.

The following is a list of those who are entitled to student information:
1. The student and any outside party who has the student’s written consent.
2. School officials who have “legitimate educational interest” as defined in FERPA.
3. Parents of a dependent student as defined by the Internal Revenue Code. Mines assumes all students are
independent, and thus requires the front page of the parents’ current Federal tax return to prove that the
student is dependent before giving out academic information. This can only be handled at the Registrar’s
Office and is only suggested as a last resort when a student is in a serious situation.
4. State or federal agencies for the purpose of obtaining Financial Aid.
5. Accreditation agencies during their on-campus review.
6. A judicial order or subpoena which allows the institution to release records without the student’s consent,
however, a “reasonable effort” must be made to notify the student before complying with the order.

Directory Information
The Colorado School of Mines will release the following Directory Information on any student (but not in aggregate
lists), unless the student signs a request to limit its release. This “stop of release” will remain in effect until the
Registrar’s Office is notified by the student. Notification to remove the stop of release must be made in person or
writing by the student, and notarized. The following data items are classified as Mines Directory Information.

Name
Current and permanent addresses and phone numbers
University Email Address
Student Photo
Date of birth
Major field of study
Dates of attendance
Full or part time status
Degrees awarded and dates
Last school attended
Participation in officially recognized activities and sports
Class (FR, SO, JR, SR, GR)
Academic honors

Parental Access to a Student’s Educational Record
When a student reaches the age of 18 or begins attending a post-secondary institution, regardless of age, FERPA
rights transfer from the parent to the student. Parents must obtain a signed consent from their child to receive non-
directory information. Schedules, attendance, class performance, and grades are among the non-directory protected
information and may not be released to parents without student release or proof of IRS requirements.

The Registrar’s Office keeps the consent form on file when it is completed in person in the Registrar’s Office. Should a
parent contact a Mines faculty/staff member regarding their child, records must first be checked for this release
authorization prior to the release of any non-directory information.

In the case that the parent wants access to non-directory information, the student is not available to sign the release,
and the student is a dependent of the parent according to the IRS code, the parent needs to provide a copy of the first
Revised 11/2016

Registrar’s Office
303-273-3200
page of the 1040 IRS tax forms filed for the most current year with the dependency information included. Income
amounts may be blacked out for privacy. This copy must be notarized and provided to the Registrar’s Office. This
form must be provided for each year during the student’s enrollment in order for the parent to continue receiving full
non-directory information concerning their student.

Posting of Grades and Release of Information by Faculty
• GRADES - The public posting of grades using the student’s name, social security number, student ID number,
or any portion thereof, without the student’s written permission is a violation of FERPA. This includes the
posting of grades electronically for students taking distance education or Blackboard courses that can be
viewed by anyone other than the student and professor of the class.
• Faculty members who post grades should use a system that ensures that FERPA requirements are met. This
can be accomplished either by obtaining the student’s written permission or by using code words or randomly
assigned numbers that only the professor and individual student should know.
• Papers with student names and grades on them may not be left in public areas for students to pick up,
whether in a classroom setting or in a hallway outside of faculty offices.
• If it is necessary for a faculty member to use a student record as an example in a public University meeting, all
identifying information (including name, address, student ID, etc.) must be removed from the documentation
before dissemination.
• Notification of grades via postcard violates a student’s privacy rights.
• Notification of grades via e-mail or fax is not recommended. There is minimal guarantee of confidentiality.
• Normal course grades (papers & tests) can be posted and viewed by students in the Blackboard system.
Midterm and final grades may be viewed on the student web system.
• RECOMMENDATIONS - If a student requests a recommendation for a prospective employer, scholarship or
other reason, you must get a signed release from that student listing exactly what you may share (gpa,
attendance, course performance, grades, etc.). The release must also include the name of the company or
individual to receive the information. This is permission to release the data only once to the stated third party.

Media Relations
If you are contacted by a member of the print or visual media, refer the requestor to Public Relations. Do not answer
any questions about any student, especially if the student has chosen to not release his/her directory
information. The appropriate statement for a student who has chosen to not release directory information is:

“I don’t have any information about that person.”

Even the word ‘student’ in this context could imply that the person is a Mines student, please use the word person.

WHEN IN DOUBT, DON’T GIVE IT OUT!

For specific questions regarding FERPA requirements contact the Registrar’s Office or University Legal Counsel.

AS A MINES EMPLOYEE, I UNDERSTAND THAT I MAY NOT PROVIDE STUDENT ACADEMIC (NON-
DIRECTORY) INFORMATION TO ANY THIRD PARTY WITHOUT THE PROPER AUTHORIZATION. I ALSO
UNDERSTAND THAT IF THE STUDENT HAS MADE HIS/HER RECORD CONFIDENTIAL, I MAY NOT
ACKNOWLEDGE THAT THE PERSON IS A STUDENT AT MINES AND I MAY NOT GIVE OUT DIRECTORY
INFORMATION. I MUST RESPOND BY SAYING “I HAVE NO INFORMATION ABOUT THAT PERSON.” IF
INFORMATION IS RELEASED WITHOUT AUTHORIZATION, ACTION MAY BE TAKEN THROUGH MY
SUPERVISOR AND HUMAN RESOURCES.

I HAVE READ AND UNDERSTAND THE INFORMATION CONTAINED HEREIN:




Printed Name:
Signature:






CWID:
Department:






Date:

Revised 11/2016

PROCEDURES
WORK-RELATED INJURIES OR ILLNESS


1. If you are injured on the job or experiencing work related illness, you must
notify your supervisor immediately. If it is determined that you have a life or limb
threatening injury or illness, you should call 911 and/or go to the nearest
emergency facility. The nearest emergency facilities to the Colorado School of
Mines are:

St Anthony’s Hospital

SCL Health Lutheran Hospital
11600 W. 2nd Place

8300 W. 38th Avenue
Lakewood, CO 80228

Wheat Ridge, CO 80033
(720) 321-0000


(303) 425-4500

If you do not have a life threatening injury you will have a choice of care at either:

1.1. SLC Health Systems (formerly Exempla) Occupational Medicine and
Rehabilitation Facilities, or
1.2 Concentra Medical Centers
1.3 Front Range Occupational Medicine
1.4 Rocky Mountain Medical Group Occupational Medicine

Both SLC Health Systems Occupational Health, Concentra Medical Centers, and
Rocky Mountain Medical Group have multiple locations and treat patients on a
walk-in basis. The closest locations to Colorado School of Mines are:

Concentra Medical Center
Front Range Occupational Medicine
11185 W. 6th Avenue

770 Simms St, Suite 100
Lakewood, CO 80215

Golden, CO 80401
(303) 239-6060


(303) 635-6337



SCL Health Systems

Rocky Mountain Medical Group
9830 W. I-70 Frontage Rd S.
605 Parfet St, Ste. 105
Wheat Ridge, CO 80033
Lakewood, CO 80228
(303) 467-4100


(303) 986-9610 (Urgent Care Only)

SCL Health Systems Occupational Health
12790-A W. Alameda Parkway
Lakewood, CO 80228 (303) 403-6350

Care from a non-designated provider will not be covered by workers’
compensation and is not covered under Mines or State of Colorado insurance
plans. You also will be ineligible for any work related leave benefits as outlined
under State of Colorado Personnel Rules or the Mines Faculty Handbook.

Updated November 2016


2. In non-emergency situations prior to going to a provider you, or your
supervisor, must notify the Human Resources Office at (303) 273-3052 as soon
as possible but no later than four days after the date of injury or illness. We will
request that you come the Human Recourses Office (GH 110 -1500 Illinois St.)
where you will be asked to complete a 1st Report of Injury and will be provided
with treatment authorizations for both SLC Health Systems Occupational Health,
Concentra Medical Centers, and Rocky Mountain Medical Group. If you are
unable to file the 1st Report of Injury, your supervisor may do it on your behalf.
We ask that you complete your 1st Report of Injury no later than the 1st business
day following your treatment.

3. In the case of a life threatening emergency, please seek treatment
immediately! You should contact the Human Resources Office as soon as
possible after treatment, but no later than four days after the date of the
injury/illness to complete necessary paperwork. Failure to do so may result in
the denial of your claim. Follow-up care must be received from an SCL
Occupational Health clinic, Concentra Medical Center, or Rocky Mountain
Medical Group as noted above.

4. All information regarding processing work-related injuries and illnesses during
your employment with Mines is on file with our medical providers. All charges
are billed directly to Broadspire, the State of Colorado’s workers’ compensation
administrator.

5. (Applies to Classified Employees ONLY) If unable to return to work,
employees will be charged sick leave for the first 24 hours. If time off exceeds 24
hours, injury leave will be charged for the remaining time off. Classified Staff are
entitled to 90 occurrences of Injury Leave and “Make-Whole” as outlined in the
State Personnel Rules.

Academic, Administrative, Athletic, Library, and Research Faculty should consult
with Human Resources for leave reporting beyond the first 24 hours off due to
work-related injury or illness. Injury leave may last up to 60 days.

Student Employees: Student Employees should consult with the Human
Resources Office regarding benefits.

6. Employees who do not follow the above procedures may be held personally
responsible for any financial obligations incurred; your claim will be filed as a
questionable claim and may be denied.


Updated November 2016




EMPLOYEE ACKNOWLEDGEMENT FORM


Drug-Free Workplace Policy Statement
Alcohol and Other Drugs Education and Prevention Policy


I, the undersigned Colorado School of Mines employee, have read the CSM Drug-Free
Workplace Policy Statement (revision March 12, 2013) / Alcohol and Other Drugs
Education and Prevention Policy (revision March 12, 2013); and,

1. I understand the policies and my obligations thereunder; and

2. I agree to abide by the terms of the policy statement; and

3. I agree to notify my supervisor if I am convicted of violating a criminal drug statute
in the workplace no later than five (5) days after the date of such conviction.




__________________________________________
EMPLOYEE SIGNATURE

__________________________________________
DEPARTMENT

__________________________________________
DATE



Social Security Administration
Statement Concerning Your Employment in a Job
Not Covered by Social Security


Employee Name
Employee ID#

Employer Name Colorado School of Mines
Employer ID#
84-6000551




Your earnings from this job are not covered under Social Security. When you retire, or if you become disabled,
you may receive a pension based on earnings from this job. If you do, and you are also entitled to a benefit
from Social Security based on either your own work or the work of your husband or wife, or former husband or
wife, your pension may affect the amount of the Social Security benefit you receive. Your Medicare benefits,
however, will not be affected. Under the Social Security law, there are two ways your Social Security benefit
amount may be affected.

Windfall Elimination Provision
Under the Windfall Elimination Provision, your Social Security retirement or disability benefit is figured using a
modified formula when you are also entitled to a pension from a job where you did not pay Social Security tax.
As a result, you will receive a lower Social Security benefit than if you were not entitled to a pension from this
job. For example, if you are age 62 in 2013, the maximum monthly reduction in your Social Security benefit as
a result of this provision is $395.50. This amount is updated annually. This provision reduces, but does not
totally eliminate, your Social Security benefit. For additional information, please refer to Social Security
Publication, “Windfall Elimination Provision.”

Government Pension Offset Provision
Under the Government Pension Offset Provision, any Social Security spouse or widow(er) benefit to which you
become entitled will be offset if you also receive a Federal, State or local government pension based on work
where you did not pay Social Security tax. The offset reduces the amount of your Social Security spouse or
widow(er) benefit by two-thirds of the amount of your pension.

For example, if you get a monthly pension of $600 based on earnings that are not covered under Social
Security, two-thirds of that amount, $400, is used to offset your Social Security spouse or widow(er) benefit. If
you are eligible for a $500 widow(er) benefit, you will receive $100 per month from Social Security ($500 -
$400=$100). Even if your pension is high enough to totally offset your spouse or widow(er) Social Security
benefit, you are still eligible for Medicare at age 65. For additional information, please refer to Social Security
Publication, “Government Pension Offset.”

For More Information
Social Security publications and additional information, including information about exceptions to each
provision, are available at www.socialsecurity.gov. You may also call toll free 1-800-772-1213, or for the deaf
or hard of hearing call the TTY number 1-800-325-0778, or contact your local Social Security office.


I certify that I have received Form SSA-1945 that contains information about the possible effects of the
Windfall Elimination Provision and the Government Pension Offset Provision on my potential future
Social Security Benefits.



Signature of Employee
Date


Form SSA-1945 (01-2013)
Destroy Prior Editions


Information about Social Security Form SSA-1945 Statement Concerning Your
Employment in a Job Not Covered by Social Security

New legislation [Section 419(c) of Public Law 108-203, the Social Security Protection Act of 2004] requires
State and local government employers to provide a statement to employees hired January 1, 2005 or later in a
job not covered under Social Security. The statement explains how a pension from that job could affect future
Social Security benefits to which they may become entitled.

Form SSA-1945, Statement Concerning Your Employment in a Job Not Covered by Social Security, is
the document that employers should use to meet the requirements of the law. The SSA-1945 explains the
potential effects of two provisions in the Social Security law for workers who also receive a pension based on
their work in a job not covered by Social Security. The Windfall Elimination Provision can affect the amount of a
worker’s Social Security retirement or disability benefit. The Government Pension Offset Provision can affect a
Social Security benefit received as a spouse, surviving spouse, or an ex-spouse.

Employers must:
o Give the statement to the employee prior to the start of employment;
o Get the employee’s signature on the form; and
o Submit a copy of the signed form to the pension paying agency.

Social Security will not be setting any additional guidelines for the use of this form.

Copies of the SSA-1945 are available online at the Social Security website,
www.socialsecurity.gov/online/ssa-1945.pdf. Paper copies can be requested by email at
ofsm.oswm.rqct.orders@ssa.gov or by fax at 410-965-2037. The request must include the name, complete
address and telephone number of the employer. Forms will not be sent to a post office box. Also, if
appropriate, include the name of the person to whom the forms are to be delivered. The forms are available
in packages of 25. Please refer to Inventory Control Number (ICN) 276950 when ordering.


























Form SSA-1945 (01-2013)

DIRECT DEPOSIT FORM *RETURN TO PAYROLL*

Effective May 1, 2000, the State of Colorado Fiscal Rules (Rule 9-2) require that all employees be on the Direct Deposit
Payroll Program.

Please note: It is important that you fill out as much information as possible to prevent delays with your pay. Please
complete and return this form along with one (1) voided check or a copy of a Direct Deposit Authorization Form from your
bank to the PAYROLL DEPT.

****Please notify Payroll Services immediately, should you close or make any changes to your account(s). Direct
deposit(s) processed against a closed account can delay your pay up to 5 business days. ****

___ Enroll in Direct Deposit* ___ Replace Current Account* ___Additional Checking/Savings*
*Voided check or Bank Authorization form REQUIRED

___CANCEL existing Direct Deposit (Close Account)

Name:

CWID #:





Primary Account: [For remaining bal. if choose secondary account]

Savings:



Routing No

Checking:



Account No:

Bank Name:

Bank Phone No.
(if known)

Secondary Account: [Amount Specified]


Savings:



Routing No

Checking:



Account No:



Specific $ Amount:

Bank Name:

Bank Phone No.

(if known)

CSM Department: __________________________ CSM Extension or Contact No.:_________________

(Check one)
___Undergraduate ___Graduate ___ Classified ___Temp. Classified ___ Faculty___ Other

Signature: __________________________________
Date: ___________







Please TAPE your voided check here. DO NOT STAPLE

Form W-4 (2017)


The exceptions don’t apply to supplemental wages
Nonwage income. If you have a large amount of
greater than $1,000,000.
nonwage income, such as interest or dividends,
Basic instructions. If you aren’t exempt, complete
consider making estimated tax payments using Form
Purpose. Complete Form W-4 so that your
the Personal Allowances Worksheet below. The
1040-ES, Estimated Tax for Individuals. Otherwise,
employer can withhold the correct federal income
worksheets on page 2 further adjust your
you may owe additional tax. If you have pension or
tax from your pay. Consider completing a new Form
withholding allowances based on itemized
annuity income, see Pub. 505 to find out if you should
W-4 each year and when your personal or financial
deductions, certain credits, adjustments to income,
adjust your withholding on Form W-4 or W-4P.
situation changes.
or two-earners/multiple jobs situations.
Two earners or multiple jobs. If you have a
Exemption from withholding. If you are exempt,
Complete all worksheets that apply. However, you
working spouse or more than one job, figure the
complete only lines 1, 2, 3, 4, and 7 and sign the
may claim fewer (or zero) allowances. For regular
total number of allowances you are entitled to claim
form to validate it. Your exemption for 2017 expires
wages, withholding must be based on allowances
on all jobs using worksheets from only one Form
February 15, 2018. See Pub. 505, Tax Withholding
you claimed and may not be a flat amount or
W-4. Your withholding usually will be most accurate
and Estimated Tax.
percentage of wages.
when all allowances are claimed on the Form W-4
for the highest paying job and zero allowances are
Note: If another person can claim you as a dependent
Head of household. Generally, you can claim head
claimed on the others. See Pub. 505 for details.
on his or her tax return, you can’t claim exemption
of household filing status on your tax return only if
from withholding if your total income exceeds $1,050
you are unmarried and pay more than 50% of the
Nonresident alien. If you are a nonresident alien, see
and includes more than $350 of unearned income (for
costs of keeping up a home for yourself and your
Notice 1392, Supplemental Form W-4 Instructions for
example, interest and dividends).
dependent(s) or other qualifying individuals. See
Nonresident Aliens, before completing this form.
Exceptions. An employee may be able to claim
Pub. 501, Exemptions, Standard Deduction, and
Check your withholding. After your Form W-4 takes
exemption from withholding even if the employee is
Filing Information, for information.
effect, use Pub. 505 to see how the amount you are
a dependent, if the employee:
Tax credits. You can take projected tax credits into
having withheld compares to your projected total tax
account in figuring your allowable number of
for 2017. See Pub. 505, especially if your earnings
• Is age 65 or older,
withholding allowances. Credits for child or dependent
exceed $130,000 (Single) or $180,000 (Married).
• Is blind, or
care expenses and the child tax credit may be claimed
Future developments. Information about any future
using the Personal Allowances Worksheet below.
developments affecting Form W-4 (such as
• Will claim adjustments to income; tax credits; or
See Pub. 505 for information on converting your other
legislation enacted after we release it) will be posted
itemized deductions, on his or her tax return.
credits into withholding allowances.
at www.irs.gov/w4.

Personal Allowances Worksheet (Keep for your records.)

A Enter “1” for yourself if no one else can claim you as a dependent . . . . . . . . . . . . . . . . . .
A

B
Enter “1” if: { • You’re single and have only one job; or
• You’re married, have only one job, and your spouse doesn’t work; or
} . . . B
• Your wages from a second job or your spouse’s wages (or the total of both) are $1,500 or less.
C
Enter “1” for your spouse. But, you may choose to enter “-0-” if you are married and have either a working spouse or more
than one job. (Entering “-0-” may help you avoid having too little tax withheld.) . . . . . . . . . . . . . . C

D Enter number of dependents (other than your spouse or yourself) you will claim on your tax return . . . . . . . . D

E Enter “1” if you will file as head of household on your tax return (see conditions under Head of household above) . . E

F Enter “1” if you have at least $2,000 of child or dependent care expenses for which you plan to claim a credit . . . F

(Note: Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for details.)
G
Child Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information.
• If your total income will be less than $70,000 ($100,000 if married), enter “2” for each eligible child; then less “1” if you
have two to four eligible children or less “2” if you have five or more eligible children.
• If your total income will be between $70,000 and $84,000 ($100,000 and $119,000 if married), enter “1” for each eligible child.
G
H
Add lines A through G and enter total here. (Note: This may be different from the number of exemptions you claim on your tax return.) ▶ H

{t • If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions
For accuracy,
and Adjustments Worksheet on page 2.
complete all
• If you are single and have more than one job or are married and you and your spouse both work and the combined
worksheets
earnings from all jobs exceed $50,000 ($20,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2
that apply.
o avoid having too little tax withheld.
• If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W-4 below.

Separate here and give Form W-4 to your employer. Keep the top part for your records.


W-4
Employee’s Withholding Allowance Certificate
OMB No. 1545-0074
Form
Whether you are entitled to claim a certain number of allowances or exemption from withholding is
Department of the Treasury
2017
Internal Revenue Service
subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.
1
Your first name and middle initial
Last name
2 Your social security number
Home address (number and street or rural route)
3
Single
Married
Married, but withhold at higher Single rate.
Note: If married, but legally separated, or spouse is a nonresident alien, check the “Single” box.
City or town, state, and ZIP code
4 If your last name differs from that shown on your social security card,
check here. You must call 1-800-772-1213 for a replacement card.
5
Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2)
5
6
Additional amount, if any, you want withheld from each paycheck
. . . . . . . . . . . . . .
6 $
7
I claim exemption from withholding for 2017, and I certify that I meet both of the following conditions for exemption.
• Last year I had a right to a refund of all federal income tax withheld because I had no tax liability, and
• This year I expect a refund of all federal income tax withheld because I expect to have no tax liability.
If you meet both conditions, write “Exempt” here . . . . . . . . . . . . . . . ▶
7
Under penalties of perjury, I declare that I have examined this certificate and, to the best of my knowledge and belief, it is true, correct, and complete.
Employee’s signature
(This form is not valid unless you sign it.) ▶
Date
8
Employer’s name and address (Employer: Complete lines 8 and 10 only if sending to the IRS.)
9 Office code (optional) 10 Employer identification number (EIN)
Colorado School of Mines 1500 Illinois St. Golden CO 80401
84-6000551
For Privacy Act and Paperwork Reduction Act Notice, see page 2.
Cat. No. 10220Q
Form W-4 (2017)

Form W-4 (2017)
Page 2
Deductions and Adjustments Worksheet
Note: Use this worksheet only if you plan to itemize deductions or claim certain credits or adjustments to income.
1
Enter an estimate of your 2017 itemized deductions. These include qualifying home mortgage interest, charitable contributions, state
and local taxes, medical expenses in excess of 10% of your income, and miscellaneous deductions. For 2017, you may have to reduce
your itemized deductions if your income is over $313,800 and you’re married filing jointly or you’re a qualifying widow(er); $287,650
if you’re head of household; $261,500 if you’re single, not head of household and not a qualifying widow(er); or $156,900 if you’re
married filing separately. See Pub. 505 for details . . . . . . . . . . . . . . . . . . . . .
1
$

2
Enter: { $9,350 if head of household
} . . . . . . . . . . . 2 $

$12,700 if married filing jointly or qualifying widow(er)

$6,350 if single or married filing separately
3
Subtract line 2 from line 1. If zero or less, enter “-0-”
. . . . . . . . . . . . . . . .
3
$

4
Enter an estimate of your 2017 adjustments to income and any additional standard deduction (see Pub. 505)
4
$

5
Add lines 3 and 4 and enter the total. (Include any amount for credits from the Converting Credits to
Withholding Allowances for 2017 Form W-4 worksheet in Pub. 505.) . . . . . . . . . . . .
5
$

6
Enter an estimate of your 2017 nonwage income (such as dividends or interest) . . . . . . . .
6
$

7
Subtract line 6 from line 5. If zero or less, enter “-0-”
. . . . . . . . . . . . . . . .
7
$

8
Divide the amount on line 7 by $4,050 and enter the result here. Drop any fraction . . . . . . .
8


9
Enter the number from the Personal Allowances Worksheet, line H, page 1 . . . . . . . . .
9


10
Add lines 8 and 9 and enter the total here. If you plan to use the Two-Earners/Multiple Jobs Worksheet,
also enter this total on line 1 below. Otherwise, stop here and enter this total on Form W-4, line 5, page 1
10
Two-Earners/Multiple Jobs Worksheet (See Two earners or multiple jobs on page 1.)
Note: Use this worksheet only if the instructions under line H on page 1 direct you here.
1
Enter the number from line H, page 1 (or from line 10 above if you used the Deductions and Adjustments Worksheet)
1


2
Find the number in Table 1 below that applies to the LOWEST paying job and enter it here. However, if
you are married filing jointly and wages from the highest paying job are $65,000 or less, do not enter more
than “3”
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2


3
If line 1 is more than or equal to line 2, subtract line 2 from line 1. Enter the result here (if zero, enter
“-0-”) and on Form W-4, line 5, page 1. Do not use the rest of this worksheet . . . . . . . . .
3


Note: If line 1 is less than line 2, enter “-0-” on Form W-4, line 5, page 1. Complete lines 4 through 9 below to
figure the additional withholding amount necessary to avoid a year-end tax bill.
4
Enter the number from line 2 of this worksheet
. . . . . . . . . .
4


5
Enter the number from line 1 of this worksheet
. . . . . . . . . .
5


6
Subtract line 5 from line 4 . . . . . . . . . . . . . . . . . . . . . . . . .
6


7
Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here . . . .
7
$

8
Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed . .
8
$

9
Divide line 8 by the number of pay periods remaining in 2017. For example, divide by 25 if you are paid every two
weeks and you complete this form on a date in January when there are 25 pay periods remaining in 2017. Enter
the result here and on Form W-4, line 6, page 1. This is the additional amount to be withheld from each paycheck
9
$
Table 1
Table 2
Married Filing Jointly
All Others
Married Filing Jointly
All Others
If wages from LOWEST
Enter on
If wages from LOWEST
Enter on
If wages from HIGHEST
Enter on
If wages from HIGHEST
Enter on
paying job are—
line 2 above
paying job are—
line 2 above
paying job are—
line 7 above
paying job are—
line 7 above
$0 - $7,000
0
$0 - $8,000
0
$0 - $75,000
$610
$0 - $38,000
$610
7,001 - 14,000
1
8,001 - 16,000
1
75,001 - 135,000
1,010
38,001 - 85,000
1,010
14,001 - 22,000
2
16,001 - 26,000
2
135,001 - 205,000
1,130
85,001 - 185,000
1,130
22,001 - 27,000
3
26,001 - 34,000
3
205,001 - 360,000
1,340
185,001 - 400,000
1,340
27,001 - 35,000
4
34,001 - 44,000
4
360,001 - 405,000
1,420
400,001 and over
1,600
35,001 - 44,000
5
44,001 - 70,000
5
405,001 and over
1,600


44,001 - 55,000
6
70,001 - 85,000
6




55,001 - 65,000
7
85,001 - 110,000
7




65,001 - 75,000
8
110,001 - 125,000
8




75,001 - 80,000
9
125,001 - 140,000
9




80,001 - 95,000
10
140,001 and over
10




95,001 - 115,000
11






115,001 - 130,000
12






130,001 - 140,000
13






140,001 - 150,000
14






150,001 and over
15






Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this form
You are not required to provide the information requested on a form that is
to carry out the Internal Revenue laws of the United States. Internal Revenue Code sections
subject to the Paperwork Reduction Act unless the form displays a valid OMB
3402(f)(2) and 6109 and their regulations require you to provide this information; your employer
control number. Books or records relating to a form or its instructions must be
uses it to determine your federal income tax withholding. Failure to provide a properly
retained as long as their contents may become material in the administration of
completed form will result in your being treated as a single person who claims no withholding
any Internal Revenue law. Generally, tax returns and return information are
allowances; providing fraudulent information may subject you to penalties. Routine uses of
confidential, as required by Code section 6103.
this information include giving it to the Department of Justice for civil and criminal litigation; to
The average time and expenses required to complete and file this form will vary
cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in
depending on individual circumstances. For estimated averages, see the
administering their tax laws; and to the Department of Health and Human Services for use in
instructions for your income tax return.
the National Directory of New Hires. We may also disclose this information to other countries
under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to
If you have suggestions for making this form simpler, we would be happy to hear
federal law enforcement and intelligence agencies to combat terrorism.
from you. See the instructions for your income tax return.






Drug-free Workplace Policy
Responsible Administrative
Unit: Human Resources


Issued:
Policy Contact:

Associate Vice President, Human Resources,
Revised: March 12, 2013
mdougher@mines.edu


1.0 BACKGROUND AND PURPOSE
Mines is committed to protecting the health, safety, and wel-being of al employees,
students, and other individuals in our workplace and campus community. Alcohol abuse and
drug use can pose significant health, safety, and wel -being concerns within the Mines
working and learning environment.

1.1
There are many risks associated with the use of illicit drugs and the abuse of
alcohol, including physical and mental impairment, emotional and
psychological deterioration, and devastating effects on family, friends, and co-
workers. Obvious risks include being charged with driving under the influence,
sustaining or causing personal injury, and suffering immediate health risks
(hangovers, incapacitation, overdose, convulsions and death). A number of
less obvious risks include poor job performance, jeopardizing future career
prospects, unwanted and inappropriate sexual activity, slowed reaction times,
short-term memory impairment, irritability and depression, and mental
confusion. Information about the known effects of alcohol and specific drugs is
available from many on-line sources, the Mabel M. Coulter Student Health
Center, and the Colorado State Employees Assistance Program (C-SEAP).

1.2 As a recipient of federal contracts and grants, Mines is subject to federal
laws and regulations with respect to drug and alcohol use in the workplace.
The Drug-Free Workplace Act of 1988 requires that Mines establish drug
and alcohol policies and programs. In addition, former Colorado Governor Roy
Romer issued Executive Order D000291 regarding Substance Abuse by
State Employees1. In accordance with the above, Mines has enacted the
following policy applicable to al employees and certain other covered
individuals.2


2.0 POLICY
It is the policy of Colorado School of Mines to maintain a drug-free workplace and campus.
The unlawful possession, use, manufacture, or distribution of illicit drugs on the campus, in
the workplace, or as part of any School activity is prohibited. In addition, the illegal use of
alcohol or misuse of alcohol on the campus, in the workplace, or as part of any School
activity is also prohibited.3 The campus and workplace includes al Mines premises and any
premises where Mines activities are conducted.


1 This Drug-free Workplace Policy is also intended to comply with the Drug-Free Schools and Communities
Act of 1989. Additional information about maintaining a drug-free campus community may be found here:
AOD Education and Prevention Policy.
2 As described below including campus volunteers, contractors, and visitors.
3 Except as authorized under the Board of Trustees Institutional Alcohol Policy.




Page 1 of 3







Drug-free Workplace Policy
Responsible Administrative
Unit: Human Resources


Issued:
Policy Contact:

Associate Vice President, Human Resources,
Revised: March 12, 2013
mdougher@mines.edu


2.1 The unlawful possession, use, or distribution of illicit drugs and unlawful or
unauthorized use of alcohol by employees wil result in disciplinary action
(consistent with Mines policies, and local, state, and federal laws). While
Colorado’s Constitution allows for the legal use of marijuana under certain
circumstances, because of Mines’ status as a federal contractor and grant
recipient, and because marijuana use is still prohibited under federal law,
the use of marijuana at work, or outside of work if it impairs an employee’s
ability to perform his or her job, constitutes a violation of this policy.

2.2
Discipline, depending upon the circumstances involved, may range from
verbal warnings or counseling, written corrective action or disciplinary actions,
up to and including termination of employment. In addition to discipline, or in
lieu of it, employees may be referred to appropriate counseling or treatment
programs (at the employee’s expense). Employees found to be in violation of
this policy may be required to provide evidence of satisfactory participation in
a substance abuse assistance or rehabilitation program.

2.3
Violators of the policy may also be referred to the appropriate authorities for
prosecution depending on the circumstances of the violation.

2.4
It is not the intent of this policy to prohibit the possession or use of legally
prescribed controlled substances for medical reasons by the individual for
whom the medications are prescribed. Any employee taking prescribed or
over-the-counter medications is responsible for consulting the prescribing
physician or pharmacist to determine whether the medication may interfere
with the safe performance of his or her job. It is the responsibility of the
employee to use appropriate personnel procedures (e.g., proper use of sick
leave as needed and appropriate, etc.) and to inform his/her supervisor if such
medication may temporarily impair the employee's ability to safely and
satisfactorily perform assigned duties.

2.5
Irrespective of the use of legally prescribed drugs, controlled substances,
and the lawful use of alcohol, it is a violation of workplace standards to be at
work in an impaired status. If an employee is at work in an impaired
status, Mines has the right to take such disciplinary action as Mines deems
necessary to ensure work is safely and properly performed. Being unfit for
work because of use of drugs or alcohol is strictly prohibited, and is
grounds for termination of employment. While this policy refers specifical y to
alcohol and drugs, it is intended to apply to inhalants and al other forms of
substance abuse.

2.6
In accordance with the specific requirements of the Drug-Free Workplace Act
of 1988, employees who are convicted (including a plea of nolo
contendere) of a criminal drug statute violation occurring in the workplace must
notify the Colorado School of Mines in writing of their conviction within five (5)
days thereafter by informing their supervisors and the Associate Vice

Page 2 of 3







Drug-free Workplace Policy
Responsible Administrative
Unit: Human Resources


Issued:
Policy Contact:

Associate Vice President, Human Resources,
Revised: March 12, 2013
mdougher@mines.edu


President of Human Resources.

2.7
Employees who are required to obtain Commercial Drivers Licenses in
order to drive vehicles heavier than 26,000 pounds, vehicles placarded for the
transportation of hazardous materials, and/or vehicles designed to carry
sixteen (16) or more persons are subject to a protocol of testing for the use of
drugs and alcohol.

2.8
As a condition of employment, al Colorado School of Mines employees are
required to follow this policy.


3.0
REHABILITATION

3.1
Mines recognizes alcohol or drug dependencies are treatable conditions.
Employees who suspect they have an alcohol or drug dependency problem are
encouraged to seek assistance. Successful completion of an appropriate
rehabilitation program (including participation in aftercare) may be considered
as evidence of eligibility for continued or future employment.

3.2
Employees who are concerned about substance use, abuse, and
rehabilitation are strongly encouraged to contact their family physicians,
their health plan, or the Colorado State Employees Assistance Program.
(C-SEAP contacts are confidential and free of charge to the employee.)
Health insurance plans may provide coverage for substance abuse programs
that address substance abuse and rehabilitation. The Office of Human
Resources has information about the health plans. Additionally, the health
plan documents can be found at: http://inside.mines.edu/Employee_Benefits.


4.0
OTHER COVERED INDIVIDUALS

4.1
Individuals who are not Mines employees, but who perform work at Mines
for its benefit (e.g., independent contractors, temporary employees
provided by agencies, visitors engaged in joint projects at Mines, volunteers,
etc.) are required to comply with this policy. Mines expects personnel of
contractors, common carriers, and vendors working on Mines premises to
comply with this Drug Free Workplace Policy. Failure to cooperate with
Mines in this regard may result in removal from Mines premises and denial of
future entry.

5.0
HISTORY & REVIEW CYCLE
This policy is subject to Annual (As Needed) Review.
December 9, 2014 (Updated links, spel ing, history & review cycle added).


Page 3 of 3





Alcohol and Other Drugs
Responsible Administrative
Education and Prevention Unit: Student Life
Policy


Policy Contact:
Issued: March 12, 2013
Associate Dean of Students


dmorgan@mines.edu

Revised:


1.0
BACKGROUND AND PURPOSE

The Colorado School of Mines is committed to:
• Providing students educational programming about alcohol and other drugs (AOD), and
information and access to appropriate community resources and professional
counseling; and
• Protecting the safety, health, and well-being of all employees, students, and other
individuals in our workplace and campus community.

Alcohol abuse and illegal drug use can pose significant safety, health, and well-being problems
within the Mines working and learning environment. The federal Drug-Free Schools and
Communities Act Amendments of 1989 (P.L. 101-226) requires annual notice to the campus
community of specific requirements of the law applicable to both students and employees. This
policy addresses the following:

• Standards of conduct that clearly prohibit, at a minimum, the unlawful possession, use,
or distribution of illicit drugs and alcohol by students and employees on its property or as
part of its activities.
• The School’s commitment to imposing disciplinary sanctions on students and employees
consistent with local, state, and federal law, and a description of those sanctions, up to
and including expulsion or termination of employment and referral for criminal
prosecution.
• A description of the applicable legal sanctions under local, state, or federal law for the
unlawful possession or distribution of illicit drugs and alcohol (for students and
employees).
• A description of the health risks associated with the use of illicit drugs and the abuse of
alcohol.
• A description of alcohol and other drugs (AOD) counseling, treatment, or rehabilitation or
re-entry programs available to employees and students.
• The School’s commitment to conducting a biennial review of its program.

Employees, like students, are covered under the Drug Free Schools and Communities Act, and
are subject to this policy. In addition to reviewing this policy, employees should also review the
Mines’ Drug Free Workplace Policy.



2.0
POLICY STATEMENT

In compliance with the federal government’s Drug Free Schools & Communities Act, there are
community standards and potential consequences at the Colorado School of Mines pertaining to
the illegal use of alcohol or drugs. The unlawful possession, use, or distribution of illicit drugs,
and the unlawful or unauthorized use alcohol by employees and students at Mines will result in
disciplinary action consistent with School policies, and local, state, and federal laws.



Page 1 of 5





Alcohol and Other Drugs
Responsible Administrative
Education and Prevention Unit: Student Life
Policy


Policy Contact:
Issued: March 12, 2013
Associate Dean of Students


dmorgan@mines.edu

Revised:


While Colorado’s constitution allows for specific legal use, possession, and growing of marijuana
under certain circumstances, because of Mines’ status as a federal contractor and grant
recipient and because marijuana use is still prohibited under federal law, the use, possession
and growing of marijuana on campus is prohibited. Student use of alcohol and other drugs
(including marijuana) that results in an impaired ability to perform academically, or behavior that
violates the Code of Conduct constitutes a violation of this policy.


3.0
DISCIPLINARY SANCTIONS FOR STUDENTS

The School will impose sanctions on any student or employee found to be in violation of campus
standards as outlined in the Student Code of Conduct, or the Drug Free Workplace policy,
respectively. Sanctions include, but are not limited to: required completion of an appropriate
educational or rehabilitation program; suspension or expulsion from the School; and/or referral
to the appropriate law enforcement authorities for criminal prosecution.

In addition to facing criminal charges, students who fail to comply with the law will be subject to
appropriate campus disciplinary action, including probation, suspension, or dismissal. As a part
of the Mines’ disciplinary procedure, a student who has violated this policy and is allowed to
remain in school will be required to submit to drug testing as a condition of continued
enrollment.

The Colorado School of Mines offers through its Counseling Center proactive alcohol and drug
abuse programs designed to educate students about the dangers of substance abuse. Incoming
freshman are required to complete an online AOD education course prior to matriculation.
Students not completing the online course, who subsequently have AOD infractions, will be
required to complete an AOD course as one of the sanctions.


4.0
LEGAL SANCTIONS

4.1
State of Colorado Sanctions

Please see Colorado Drug Law Summary on the web or see Attachment A.

4.2
Federal Sanctions

Federal law has numerous penalties for the illegal possession of controlled substances,
possession of crack cocaine, and trafficking in methamphetamine, heroin, cocaine,
cocaine base, PCP, LSD, fentanyl, and fentanyl analogue.

Possession sentences range from up to one-year imprisonment and $1,000 fine to 20
years imprisonment and fines up to $250,000. Forfeiture of personal and real property
used to possess or to facilitate possession of a controlled substance can be a sanction
for convictions. Sanctions can also include denial of federal benefits, such as student
loans, grants, contracts, public housing tenancy, eligibility to receive or purchase
Page 2 of 5





Alcohol and Other Drugs
Responsible Administrative
Education and Prevention Unit: Student Life
Policy


Policy Contact:
Issued: March 12, 2013
Associate Dean of Students


dmorgan@mines.edu

Revised:


firearms, and professional and commercial licenses. Federal trafficking sanctions can
range from one-year imprisonment and $100 fine to life in prison and a fine of $8 million.


5.0
HEALTH RISKS OF DRUGS AND ALCOHOL

Drug use poses a serious threat to the health and welfare of anyone involved in the use of
illegal drugs, as well as a potential threat to the welfare of others within the campus community.
This threat includes negative impact on academic performance and work productivity,
estrangement of social relations, mental and physical health problems, reckless, negligent or
intentional physical or emotional harm to others, and, in some cases, the possibility of serious
bodily injury, illness, or death. Thus, the Colorado School of Mines’ position on drug use is that
all students must comply with state and federal laws concerning the manufacture, possession,
sale, and use of drugs.

5.1
Illicit Drugs

The use and overdose of illicit drugs, the non-medical use and overdose of prescription
drugs, and withdrawal, can lead to physical and psychological dependence, behavioral
changes, physical and psychological damage, and possible death.

Possible effects from the use of illegal narcotics include euphoria, drowsiness,
respiratory depression, constricted pupils, and nausea. Narcotic overdoses can produce
slow and shallow breathing, clammy skin, convulsions, coma, and death. Withdrawal
symptoms can include tremors, panic, cramps, nausea, chills, and sweating. Mothers
who use drugs during pregnancy may give birth to infants with physical abnormalities
and mental retardation.

The unlawful use of depressants can cause slurred speech, disorientation, and drunken
behavior. Overdoses can produce weak and rapid pulse, coma, and death. Withdrawal
syndrome can include tremors, delirium, convulsions, and death.

Illicit use of stimulants can cause increased alertness, excitation, euphoria, increased
pulse rate and blood pressure, insomnia, and loss of appetite. Agitation, increase in
body temperature, hallucinations, convulsions, and death can result from stimulant
overdose. Withdrawal syndrome can include apathy, long periods of sleep, irritability,
depression, and disorientation.

Possible effects of the use of hallucinogens include illusions and hallucinations and
altered perceptions of time and distance. Overdoses can produce longer, more intense
effects, psychosis, and death.

The use of marijuana can produce euphoria, relaxed inhibitions, increased appetite, and
disoriented behaviors. Overdoses can result in fatigue, paranoia, and psychosis.
Page 3 of 5





Alcohol and Other Drugs
Responsible Administrative
Education and Prevention Unit: Student Life
Policy


Policy Contact:
Issued: March 12, 2013
Associate Dean of Students


dmorgan@mines.edu

Revised:


Cannabis withdrawal can occasionally produce insomnia, hyperactivity, and decreased
appetite.

For further information, students can contact the Counseling Center or the Mabel Coulter
Student Health Center. Employees can contact the Colorado State Employees
Assistance Program (C-SEAP).

5.2
Alcohol

Alcohol consumption may cause a number of significant changes in behavior. Even low
doses significantly impair the judgment and coordination required to drive a car safely,
increasing the likelihood that the driver will be involved in an accident. Low to moderate
doses of alcohol also increase the incidence of a variety of aggressive acts, including
spouse and child abuse. Moderate to high doses of alcohol cause marked impairments
in higher mental functions, severely altering a person's ability to learn and remember
information. Very high doses cause respiratory depression and death. If combined with
other depressants of the central nervous system, much lower doses of alcohol will
produce the effects just described.

Repeated use of alcohol can lead to dependence. Sudden cessation of alcohol intake is
likely to produce withdrawal symptoms, including severe anxiety, tremors, hallucinations,
and convulsions. Alcohol withdrawal can be life-threatening. Long-term consumption of
large quantities of alcohol, particularly when combined with poor nutrition, can also lead
to permanent damage to vital organs such as the brain and liver.

Mothers who drink alcohol during pregnancy may give birth to infants with fetal alcohol
syndrome. These infants have irreversible physical abnormalities and mental retardation.
In addition, research indicates that children of alcoholic parents are at a greater risk than
other youngsters of becoming alcoholics.

Additional information can be found at: http://counseling.mines.edu/CNSL-services .


6.0
EDUCATION AND TREATMENT

6.1
On-campus Resources Available to Students

Anyone who has a concern about a student’s use of, the physiological and psychological
effects of, and the treatment resources for alcohol or other drugs should contact:
• Counseling Center at 273-3377, http://counseling.mines.edu ;
• Coulter Student Health Center, 303-273-3381, http://healthcenter.mines.edu ;
• Student Life Staff; or
• Vice President of Student Life/Dean of Students Office, 303-273-3231.
Page 4 of 5





Alcohol and Other Drugs
Responsible Administrative
Education and Prevention Unit: Student Life
Policy


Policy Contact:
Issued: March 12, 2013
Associate Dean of Students


dmorgan@mines.edu

Revised:


6.2
Engineers Choosing Healthy Options Program

The Engineers Choosing Healthy Options (ECHO) Program is the drug and alcohol
education arm of the Counseling Center, created through a Federal grant in 1989.
ECHO has a library of information on alcohol and other drugs that is readily available in
the Counseling Center, located on the second floor of the W. Lloyd Wright Student
Wellness Center. Presentations and programs on drug and alcohol education are also
available to any campus group that makes a request. Student referrals to the ECHO
program are encouraged from all segments of the campus community.

Students who require evaluation, education, or treatment beyond ECHO’s educational
scope are referred to appropriate agencies in the community. All care provided off-
campus is at the individual’s own expense.

6.3
Resources Available to Employees

Mines recognizes alcohol or drug dependency are treatable conditions. Employees who
suspect they have an alcohol or drug dependency problem are encouraged to seek
assistance. Details on assistance available to employees can be found in the Drug Free
Workplace Policy.


7.0
BIENNIAL REVIEW

The Division of Student Life will conduct a biennial review of alcohol and other drug program
effectiveness and consistency. The report will propose program and sanction changes as
necessary for administrative consideration.


8.0 HISTORY
April 2015 (links, punctuation, and titles updated)

REFERENCES20 U.S.C. § 1011i; 34 C.F.R. § 86.1 et seq.; 55 Fed. Reg. 33,580 (Aug. 16,
1990).

Education Department General Administrative Regulations (EDGAR) Part 86 Drug and Alcohol
Abuse Prevention, see http://www2.ed.gov/policy/fund/reg/edgarReg/edgar.html.

For further information on Colorado School of Mines AOD Programs, contact
the Division of Student Life at 303-273-3377.
Page 5 of 5





Policy Prohibiting Gender-Based Discrimination,
Sexual Harassment, and Sexual Violence


History:
Amended by the Colorado School of Mines Board of Trustees on
August 29, 2014. See ful history on page 4



1.0
BACKGROUND AND PURPOSE
The Board of Trustees of the Colorado School of Mines (“the School” or “Mines”)
promulgates this policy pursuant to the authority conferred by §23-41-104(1), C.R.S.,
Title IX of the Education Amendments of 1972, 20 U.S.C. §§ 1681 et seq., and its
implementing regulations, 34 C.F.R. Part 106; Titles IV and VII of the Civil Rights Act of
1964 (42 U.S.C. §§ 2000c and 42 U.S.C. §§ 2000e) and relevant sections of the
Violence Against Women Reauthorization Act of 2013 (42 U.S.C. §§ 14043e et seq.).
This policy supersedes the Board of Trustee’s Policy Prohibiting Sexual Harassment and
shal govern if any other Mines policy conflicts with this policy’s provisions. This policy
does not preclude application or enforcement of other Mines policies. Nothing in this
policy shal be construed to abridge academic freedom and inquiry, principles of free
speech or Mines’ educational purpose.

2.0
POLICY
Mines prohibits gender-based discrimination, sexual harassment or any form of sexual
violence among the Mines campus community. Mines does not discriminate against any
person because of gender, gender identity or gender expression. Mines wil not tolerate
any form of sexual harassment or sexual violence within the Mines campus community.
Mines wil also not tolerate any form of retaliation against a community member for
reporting complaints, cooperating with investigations and proceedings related to such
complaints, or opposing gender-based discrimination, sexual harassment or sexual
violence. Accordingly, the Board of Trustees adopts this policy prohibiting gender-based
discrimination, sexual harassment and sexual violence.
In order to prevent incidents of gender-based discrimination, sexual harassment and
sexual violence, Mines wil : (1) develop, administer, maintain and update procedures to
implement and resources to support this policy; (2) educate community members
regarding policies and procedures related to prevention, reporting and investigation of
gender-based discrimination, sexual harassment and sexual violence; (3) encourage
community members to report actual and potential incidents of gender-based
discrimination, sexual harassment and sexual violence; (4) take actions to prevent
incidents of gender-based discrimination, sexual harassment and sexual violence from
denying or limiting a community member’s ability to participate in or benefit from Mines’
educational and work programs; (5) make available timely services and resources for
those who have been affected by gender-based discrimination, sexual harassment and
sexual violence; (6) take actions to remedy any harm from incidents of gender-based
discrimination, sexual harassment and sexual violence; and (7) take actions to prevent
the recurrence of gender-based discrimination, sexual harassment and sexual violence.
Mines’ Unlawful Discrimination policy shal govern all other forms of harassment or
discrimination. No complainant shal be permitted to file a complaint under the Policy
Prohibiting Gender-Based Discrimination, Sexual Harassment and Sexual Violence and
Page 1 of 4





Policy Prohibiting Gender-Based Discrimination,
Sexual Harassment, and Sexual Violence


History:
Amended by the Colorado School of Mines Board of Trustees on
August 29, 2014. See ful history on page 4

any other Mines’ complaint or grievance policy or procedure when the complaint or
grievance arises out of an identical set of facts.

3.0
DEFINITIONS:
Gender-based discrimination involves treating a Mines community member
unfavorably because of that person's gender, gender identity or gender expression. Al
allegations involving gender-based discrimination wil be governed by this policy and its
implementing procedures.
Sexual harassment is a form of gender discrimination. Sexual harassment, without
regard to the gender of the individuals involved, consists of unwelcome sexual
advances, requests for sexual favors, and other verbal or physical conduct of a sexual
nature when: (1) either explicitly or implicitly, submission to such conduct is made a term
or condition of an individual's employment or educational endeavors; (2) submission to
or rejection of such conduct is used as the basis for employment or educational
decisions; or (3) such conduct has the purpose or effect of unreasonably interfering with
an individual's work or academic performance, or creating an intimidating, hostile, or
offensive working or educational environment. Al allegations involving sexual
harassment wil be governed by this policy and its implementing procedures.

Sexual violence includes rape, sexual assault, sexual battery, sexual abuse and sexual
coercion. In some cases, domestic violence, dating violence and stalking may also be
forms of sexual violence. Al allegations involving sexual violence wil be governed by
this policy and its implementing procedures.
For a more detailed discussion of the terms defined above, please see the Gender-
Based Harassment, Sexual Harassment and Sexual Violence Complaint, Investigation,
Resolution and Adjudication Procedure for Complaints Involving Student Behavior and
the Gender-Based Harassment, Sexual Harassment and Sexual Violence Complaint,
Investigation, Resolution and Adjudication Procedure for Complaints Involving Employee
or Third-Party Behavior.

4.0
PROHIBITION AGAINST RETALIATION
This policy prohibits retaliation against any individual for raising an allegation of gender-
based discrimination, sexual harassment or sexual violence, for cooperating in an
investigation or another proceeding related to such allegations, or for opposing gender-
based discrimination, sexual harassment or sexual violence. Complaints or instances of
retaliation shall be addressed as separate potential violations of this policy.

5.0
SANCTIONS FOR VIOLATIONS
A violation of this policy may result in the imposition of sanctions. Sanctions may include,
but are not limited to, the following: mandatory attendance at gender-based
discrimination, sexual harassment and/or sexual violence awareness and prevention
Page 2 of 4





Policy Prohibiting Gender-Based Discrimination,
Sexual Harassment, and Sexual Violence


History:
Amended by the Colorado School of Mines Board of Trustees on
August 29, 2014. See ful history on page 4

seminars; mandatory attendance at other training programs; oral reprimand and
warning; written reprimand and warning; student probation, suspension, or expulsion;
educational sanctions; restitution; suspension without pay; or termination of employment
or appointment.


6.0
ENCOURAGEMENT OF REPORTING
Mines considers the health and safety of its community members to be of paramount
importance. Therefore, Mines encourages community members to report all concerns
regarding gender-based discrimination, sexual harassment and/or sexual violence in
accordance with this policy and its procedures. There may be circumstances where
community members are hesitant to report prohibited conduct because they fear it may
result in other policy violations being discovered (such as drug use or underage alcohol
consumption). Community members should always consider the health and safety of
themselves and other Mines community members to be of primary concern and Mines
shal review, if necessary, any other policy violations separately from allegations raised
under this policy.

7.0
IMPLEMENTATION
Mines’ Board of Trustees directs the President or President’s delegates to develop,
administer and maintain the appropriate administrative policies, procedures and
guidelines to implement this policy.

8.0
RESOURCES
Contact for Complaints about Student Behavior:
 Rebecca Flintoft, Director of Auxiliary Services, Student Center, Room 218, 1200
16th Street Golden, Colorado 80401; Telephone - 303.273.3288; Email –
rflintof@mines.edu
 Brent Wal er, Director of Residence Life and Housing, 1733 Maple Street,
Golden, Colorado 80401; Telephone - 303.273.3046; Email –
bwal er@mines.edu
Policies and Procedures for Complaints regarding Student Behavior:
 Notice of Nondiscrimination
 Gender-Based Harassment, Sexual Harassment and Sexual Violence Complaint,
Investigation, Resolution and Adjudication Procedure for Complaints Involving
Student Behavior
 Procedures and Resources for Survivors of Sexual Assault or Other Sexual
Violence
Contact for Complaints about Employee or Third Party Behavior:
 Mike Dougherty, Associate Vice President for Human Resources, Guggenheim
Hall, 1500 Il inois Street, Room 110, Golden, CO 804021; Telephone -
303.273.3250; Email – mdougher@mines.edu
Page 3 of 4





Policy Prohibiting Gender-Based Discrimination,
Sexual Harassment, and Sexual Violence


History:
Amended by the Colorado School of Mines Board of Trustees on
August 29, 2014. See ful history on page 4


 Veronica Graves, Assistant Director of Human Resources, Guggenheim Hall,
1500 Il inois Street, Room 110, Golden, CO 804021; Telephone - 303.273.3250;
Email – vgraves@mines.edu
 Karin Ranta-Curran, Assistant Director for Human Resources, Guggenheim Hall,
1500 Il inois Street, Room XXX, Golden, CO 804021, Telephone - 303.384.2558;
Email - krcurran@mines.edu
Policies and Procedures for Complaints regarding Employee or Third-Party Behavior:
 Notice of Nondiscrimination
 Sexual and Gender-Based Harassment and Discrimination Complaint,
Investigation and Resolution Procedure for Complaints Involving Employee or
Third-Party Behavior
 Procedures and Resources for Survivors of Sexual Assault or Other Sexual
Violence
Title IX Coordinator:
 Karin Ranta-Curran, Assistant Director for Human Resources, Guggenheim Hall,
1500 Il inois Street, Room XXX, Golden, CO 804021, Telephone - 303.384.2558;
Email - krcurran@mines.edu
Other Relevant Policies:
 Unlawful Discrimination policy
 Workplace Violence policy
 Personal Relationships policy

9.0
HISTORY
Promulgated by the Colorado School of Mines Board of Trustees on March 13, 1992.
Amended by the Colorado School of Mines Board of Trustees on March 26, 1998.
Amended by the Colorado School of Mines Board of Trustees on June 10, 1999.
Amended by the Colorado School of Mines Board of Trustees on June 22, 2000.
Amended by the Colorado School of Mines Board of Trustees on June 7, 2003.
Amended by the Colorado School of Mines Board of Trustees on December 15, 2011.
Amended by the Colorado School of Mines Board of Trustees on August 29, 2014.
Page 4 of 4


New Health Insurance Marketplace Coverage
Options and Your Health Coverage
Form Approved
OMB No. 1210-0149
5 31 2020
PART A: General Information
:
What is the Health Insurance Marketplace?
Can I Save Money on my Health Insurance Premiums in the Marketplace?
Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace?
How Can I Get More Information?
Ann Hix (303) 273-3052

PART B: Information About Health Coverage Offered by Your Employer
3. Employer name
4. Employer Identification Number (EIN)
Colorado School of Mines
84-6000551
5. Employer address
6. Employer phone number
1500 Illinois Street
(303) 273-3052
7. City
8. State
9. ZIP code
Golden
CO
80401
10. Who can we contact about employee health coverage at this job?
Ann Hix
11. Phone number (if different from above)
12. Email address
ahix@mines.edu
Faculty with an anticipated 9 month appointment working at least 50% effort. Temporary salaried faculty working at
least 75% effort. Hourly employees averaging 30 hours over the applicable measurement period. All permanent
Classified employees. Graduate Student RA/TA and Residence Hall Assistants working 50% effort (stipend)
Legal spouse, an employees married or unmarried children until the end of the month of their 26th birthday. Any
dependent required by State law to be covered. Same gendered domestic partners of State Classified employees.

13. Is the employee currently eligible for coverage offered by this employer, or will the employee be eligible in
the next 3 months?
Yes (Continue)
13a. If the employee is not eligible today, including as a result of a waiting or probationary period, when is the
employee
eligible
for
coverage?

(mm/dd/yyyy)
(Continue)
No (STOP and return this form to employee)
14. Does the employer offer a health plan that meets the minimum value standard*?
s
Yes (Go to question 15)
No (STOP and return form to employee)
15. For the lowest-cost plan that meets the minimum value standard* offered only to the employee (don't include
family plans): If the employer has wellness programs, provide the premium that the employee would pay if he/ she
received the maximum discount for any tobacco cessation programs, and didn't receive any other discounts based on
wellness programs.
a. How much would the employee have to pay in premiums for this plan? $
b. How often? Weekly
Every 2 weeks
Twice a month
Monthly
Quarterly
Yearly
16. What change will the employer make for the new plan year?
Employer won't offer health coverage
Employer will start offering health coverage to employees or change the premium for the lowest-cost plan
available only to the employee that meets the minimum value standard.* (Premium should reflect the
discount for wellness programs. See question 15.)
a. How much would the employee have to pay in premiums for this plan? $
b. How often? Weekly
Every 2 weeks
Twice a month
Monthly
Quarterly
Yearly

Electronic Timesheet Instructions
(revised 3/31/2017)

IMPORTANT: You MUST submit a timesheet every pay period whether
or not you have worked any hours.

1. Log on to your trailhead account.
2. Proceed to the Self Service menu by clicking on the Self Service button in the upper left box of the screen.

3. Proceed to the Employee tab by clicking on the tab along the top or the link under the menu.

4. Click on the first link under the Employee menu called “Hourly Time Sheet Entry.”

5. Select the appropriate position AND time period from the drop-down menu under “Pay Period and
Status,” and then click on the Time Sheet button.




6. To enter the times you have worked, click on the ‘Enter Hours’ link under the appropriate day (each
day has its own link). Also, the “Next” button moves you to the end of the pay period.
7. Input your In and Out times, including the minutes (i.e., if you started working at 8 AM you must input
8:00 AM, NOT just “8”). Click “save” when you’re finished with that day.
*NOTE*ALL TIME MUST BE ENTERED AS THE FIRST SHIFT

8. Click on the time sheet button to return to the original time sheet page.



9. After all hours worked during the pay period have been entered, click “Submit for Approval”.
(Please note the “Submit by Date” deadline).
“Zero hour” Timesheet Instructions:
Log into trailhead
1. Log into trailhead
2. Select the “employee” tab
3. Select “timesheet”
4. Select the correct pay period
5. Select the position and open the timesheet
6. Click the “submit” button. You will get a warning that reads “No hours entered”. This
is okay because you did not work any hours.
7. Exit the timesheet by selecting the “back to trailhead” tab at the top of the page or by
exiting out of trailhead altogether.
8. The timesheet will go to an “error” status and that is correct.
PLEASE NOTE:
 Electronic Timesheets are due by the “Submit By Date” deadline, which is 2 business days after
the end of the work period. For example, a time sheet from December 1st to December 15th
must be submitted by December 17th at 11:59 pm, midnight.
 If you do not submit your electronic time sheet before the “Submit by Date” deadline, you
cannot submit electronically and will have to wait for the next supplement payroll.
 Holidays will have more strict submission cutoff dates. Please see the “Semi-Monthly Payroll
Schedule” for a breakdown of Semi-Monthly deadlines.
You can always submit timesheet early!




SEMI MONTHLY PAYROLL SCHEDULE 2017 - 2018
Year
SM
END OF PAY
STUDENT
APPROVAL
PAYDATE
#
PERIOD
SUBMISSION
DEADLINE
DEADLINE






2017
15
7/31/2017
8/2/2017
8/5/2017
8/15/2017
2017
16
8/15/2017
8/17/2017
8/20/2017
8/31/2017
2017
17
8/31/2017
9/2/2017
9/5/2017
9/15/2017
2017
18
9/15/2017
9/17/2017
9/20/2017
9/29/2017
2017
19
9/30/2017
10/2/2017
10/5/2017
10/13/2017
2017
20
10/15/2017
10/17/2017
10/20/2017
10/31/2017
2017
21
10/31/2017
11/2/2017
11/5/2017
11/15/2017
2017
22
11/15/2017
11/15/2017***
11/17/2017***
11/30/2017
2017
23
11/30/2017
12/2/2017
12/5/2017
12/15/2017
2017
24
12/15/2017
12/15/2017***
12/17/2017***
12/29/2017
2018
1
12/31/2017
1/2/2018
1/5/2018
1/15/2018
2018
2
1/15/2018
1/17/2018
1/20/2018
1/31/2018
2018
3
1/31/2018
2/2/2018
2/5/2018
2/15/2018
2018
4
2/15/2018
2/17/2018
2/20/2018
2/28/2018
2018
5
2/29/2018
3/2/2018
3/5/2018
3/15/2018
2018
6
3/15/2018
3/17/2018
3/20/2018
3/30/2018
2018
7
3/31/2018
4/2/2018
4/5/2018
4/15/2018
2018
8
4/15/2018
4/17/2018
4/20/2018
4/30/2018
2018
9
4/30/2018
5/2/2018
5/5/2018
5/15/2018
2018
10
5/15/2018
5/17/2018
5/20/2018
5/31/2018
2018
11
5/31/2018
6/2/2018
6/5/2018
6/15/2018
2018
12
6/15/2018
6/17/2018
6/20/2018
6/29/2018
2018
13
6/30/2018
7/2/2018
7/5/2018
7/15/2018
2018
14
7/15/2018
7/17/2018
7/20/2018
7/31/2018






***Indicates early submission and approval required so paychecks can be process prior to break.






As a general rule, students have two calendar days to submit their timesheet and supervisors have five
calendar days to approve. The payroll office will communicate with students and supervisors if
additional days will be authorized.


Document Outline