New Faculty Getting-Started Check List


page 1 of 2
(Last updated: June 2017)
New Faculty Getting-Started Check List
NOTES: (1) A printable campus map is available in the right-hand menu here: http://inside.mines.edu/Parking.
(2) Numbers 1-7 are things most new employees will need to do and are numbered in roughly the order that they can be
done. You may need to do the other items depending on your campus roles.
#
WHAT
WHY
HOW
- Submit questions via the Mines Help Center at http://helpdesk.mines.edu/
- Additional details for getting started w/computer resources are at http://inside.mines.edu/CCIT-Getting-Started

1a.
CWID - Campus Wide ID
Needed for managing
Assigned by Human Resources (HR)/Academic Affairs and
number
employee information, record
distributed to new faculty in the Welcome Packet or by HR.

keeping, etc.

1b.
USERNAME &
Most major campus computer
Made available by Computing, Communications, and
MULTIPASS
systems will use your Mines
Information Technologies (CCIT). To claim your MultiPass

MultiPass login credentials.
account, visit https://identity.mines.edu.
MultiPass will give you access

to Windows and Linux
General information about activating your account can be
computer labs around campus,
found at http://ccit.mines.edu/CCIT-Account-Claim
to the Trailhead campus portal,

to email (Exchange for
For more information about getting started with computing at
faculty/staff; Google-based
Mines: http://ccit.mines.edu/CCIT-Getting-Started
MyMail for students), and more.

1c.
ONLINE SERVICES:
-Trailhead gives access to
Trailhead campus portal: http://trailhead.mines.edu
Trailhead Campus Portal
various resources for
Exchange email (faculty/staff): http://exchange.mines.edu

Email
employees and students.
MyMail (students): http://mymail.mines.edu
Windows computer labs
- All these services may be

Linux computer labs
accessed with your new
Note: After claiming your MultiPass, these services will be

MultiPass credentials.
available. Wait 5 minutes, however, before first accessing
Trailhead.

1d.
EMAIL
Required means of campus
Setting up your MultiPass credentials will allow you to log
communication. This needs to
into your Mines computer account.

be established after your online
accounts are set up.

2a.
NEW HIRE PAPERWORK
Forms submission is
(A) You MUST meet with Human Resources (HR) staff in
REQUIRED to get paid.
Guggenheim Hall (GH), Suite 110 on your first day of

employment;
(B) Submit forms (I-9, W4, BlasterCard form, etc.). You
MUST bring appropriate original form(s) of identification for
proof of employment eligibility, such as social security card
and driver’s license or passport (for more details, see
Section 2, Item 1 at http://www.uscis.gov/files/form/i-9.pdf).
NOTE: The New Employee Information Packet is also
available on-line at
http://inside.mines.edu/New_Employee_Information.

2b.
BlasterCard - Campus ID
Used for electronic key access,
Take BlasterCard form from HR to the Campus Living office
card
library material checkout,
Elm Hall (1795 Elm St.-west entrance).

campus debit card (dining,
Munch Money).

2c.
GET PAID
Direct deposit is required for all
Complete the Direct Deposit Form – found in your new-hire
State employees. Provide a
packet or at:

voided check or a direct deposit
http://inside.mines.edu/UserFiles/File/hr/HR%20Forms/Direc
authorization form from your
t%20Deposit%20Enrollment%20Form%20(1).pdf. Turn all
banking institution.
the documents in with your new hire packet.

2d.
VACATION/SICK LEAVE
Leave reporting. Only applies
Access via Trailhead/Self Service. Access to your
REPORTING
to benefits-eligible employees.
Vacation/Sick Leave account is available after the first of the

month following your first paycheck.

3.
PARKING PERMIT & LOT
Don’t get ticketed or towed. All
Go to http://inside.mines.edu/Parking to choose your price
ASSIGNMENT
vehicles parked on campus
and request a permit. Monthly payroll deduction is required.

(including campus street
Non-remunerated employees must pay in full at the Parking
parking) must be registered
Services office with receipt of permit. NOTE: You cannot
with Parking Services.
apply for parking online until the day after your Trailhead
account is activated.

New Faculty Getting-Started Check List


page 2 of 2
(Last updated: June 2017)

4.
OFFICE ASSIGNMENT
A place to work.
See your department assistant.

5.
PHONE & PHONE #
Make & receive calls.
See your department assistant who can arrange with CCIT.

6.
KEYS/PHYSICAL ACCESS
Open the office or get in
Key or BlasterCard access to most buildings is issued by the
before/after regular business
Lock Shop in Facilities Management (1318 Maple Street).

hours.
Bring your BlasterCard and a typed and signed Access
Request Form (located at http://inside.mines.edu/Access)
from your department.
[Access to the Student Life areas and CTLM are granted at
the Campus Living office (1795 Elm St.) and the CTLM,
Room 244, respectively.
7.
MINES CAMPUS
Set your Mines Emergency
Setting your Mines Emergency Alert is done via Trailhead.
EMERGENCY ALERTS
Alert phone number and/or text
See http://inside.mines.edu/Mines_Emergency_Alert.

SETUP
address so that you can be

contacted in the case of a
campus emergency.
8.
CAMPUS EMAIL LISTS
Some campus email lists are
For information about campus email lists see
mandatory based on your
http://ccit.mines.edu/Mailman-Common-Lists.

campus role; other lists are
[Campus email lists are managed/supported by CCIT.]
optional based on your
interests.
9.
CANVAS LEARNING
Canvas is the campus
Accounts are created automatically the day after your email
MANAGEMENT SYSTEM
provided learning management
account is created.

system that can help faculty

organize and deliver course
To log in for the first time, click on the eLearning link on the
material, administer
inside.mines.edu page: elearning.mines.edu.
assignments, quizzes and
Select Canvas for Mines.
online discussions, grade
You should see all the courses that you are assigned to
student work, as well as
teach.
support other management

details of running a class such
Training information is available here -
as assigning groups and peer
https://trefnycenter.mines.edu/training.html
reviews of work.
10.
SSB/FINANCIAL
For those who manage
Submit Banner General Access Form to CCIT (CTLM) and
ACCOUNTS ACCESS
financial accounts, such as
Banner Finance Access Form to the Controller’s office (GH,

departmental or research lab
Room 224) (requires Account Codes & signatures).
accounts, or who receive
NOTE: Forms & training information are available at
professional development or
http://inside.mines.edu/FA-CO-banner-finance-info or by
discretionary funds; access is
calling the Controller’s office at x3166.
through Trailhead/Self Service.
11.
SSB/FACULTY SERVICES
Administrative office access to
Submit Banner General Access Form to CCIT; submit
ACCESS
student records; access is
Banner Student System Access form & FERPA form to the

through Trailhead/Self Service.
Registrar’s Office (Student Center, Room 018). Access
Faculty Services through the Self Service icon in Trailhead.
NOTE: Forms are available at
http://inside.mines.edu/Mines_Forms under “Banner Forms”
& training information is available at
http://inside.mines.edu/HR-training-bb.
12.
COMPUTER/
Most desktops & laptops on
Links to learn more about getting started with your computer
NETWORK/
campus are maintained by
setup & computer security are at

WIRELESS SETUP,
CCIT and data is stored on &
http://inside.mines.edu/CCIT-Getting-Started and
DEPARTMENTAL
backed up from managed

COMPUTER ACCOUNT,
servers. However, no backup
http://ccit.mines.edu/CCIT-NET-Getting-Connected.
OFFICE, AND/OR
system is foolproof. Please

RESEARCH LAB
make extra copies of all your
Please submit questions to http://helpdesk.mines.edu.
own data. Personally owned

PC maintenance & data stored
thereon is entirely the
responsibility of the owner/user





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



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



Colorado School of Mines Certification of Policy and Notice Review

Policy Names:

Work-Related Illness and Injury
Drug-free Workplace Policy Statement
Alcohol and Other Drugs Education and Prevention Policy
Amorous Relationships Policy (issued 07/15/2016)
Colorado Pregnancy Accommodation Posting (effective 08/10/2016)
Facilities Management Parking Services
Affirmative Action Statement
Electronic Mail Policy 10.13
Employment Communications Policy (issued 10/09/2007)
FERPA Confidential Student Data Agreement
Policy Prohibiting Gender-Based Discrimination, Sexual Harassment, and Sexual

Violence
Unlawful Discrimination Policy
Workplace Violence Policy (issued 10/10/2007)
Policy on the Protection of Minors (issued 04/24/2014)
C-SEAP Privacy Notice
Health Insurance Marketplace Notice
Holiday Schedule

Faculty Handbook (http://inside.mines.edu/POGO-Academic)

State Classified Staff Handbook
(https://www.colorado.gov/pacific/sites/default/files/State%20of%20Colorado%20EE%2
0Handbook_0.pdf)
State Personnel Board Rules (https://www.colorado.gov/pacific/spb/rules)

Board of Trustees Policies (http://inside.mines.edu/POGO-Board-of-Trustees_1)

Human Resources Policies: (http://inside.mines.edu/POGO-Human-Resources)

Classified Staff Grievance Policy:
(https://inside.mines.edu/UserFiles/File/PoGo/Policies/HRS/HRS_Classified_Grievance_
Process.pdf)

I hereby certify that I have been provided information on the location of 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.

Name _____________________________________
Date ___________________
Please Print

Signature
_______________________________________________________________________
Rev 08/10/2016






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


COLORADO SCHOOL OF MINES
RETIREMENT PLAN ELECTION FORM
ACADEMIC, ADMINISTRATIVE, and RESEARCH FACULTY

30 Day Election Period

Name:
Social Security #:

Date of Birth
Gender:
Daytime Phone:

Mailing Address:
PERA Retiree:  Yes  No

As a condition of employment, you must participate in either the Mines Defined Contribution Plan (MDCP) or in the Colorado Public
Employees Retirement Association Plan (PERA). To elect PERA as your retirement plan, you must be an active PERA member, an inactive
PERA member, or a PERA retiree with at least 12 months of PERA service credit. If you have worked at another Colorado Higher Education
Institution which offered an optional retirement plan and you made an irrevocable plan choice, that choice wil remain in effect at the School
of Mines. PERA retirees, however, may make a new plan selection upon rehire. Failure to return this form within 30 days of your date of
hire or eligibility will eliminate any option to select PERA (if eligible), and you wil be enrol ed in the MDCP.

RETIREMENT PLAN ELECTION
Mines Defined Contribution Plan (MDCP)
I elect to enrol in the MDCP. Go to www.valic.com and click on Enrol Now. Use the code 42465002

Elect the Disposition of your PERA Account
I do not have a PERA account or I am a PERA Retiree
I have a PERA account, and I elect the fol owing option:
 Terminate my PERA membership and authorize PERA to transfer al member contributions and interest
earned to the MDCP. By electing this option, I understand that I am waiving all future PERA benefits
associated with this account.
 Terminate future contributions to PERA but maintain my existing account with PERA. This option is available
only to individuals who have at least 12 months of PERA credited service. Member accounts with less than 12
months of PERA credited service wil automatically be transferred to the MDCP.

Public Employees’ Retirement Association (PERA)
I elect participation in PERA. I certify that have at least 12 months of PERA credited service credit as an active member,
an inactive member, or a retiree. I understand that PERA, not the School of Mines, determines my eligibility for PERA
membership. If PERA deems that I am not eligible, I wil be enrol ed in the MDCP.


I understand and acknowledge that:
 All of the information in this form is true and accurate
 My retirement plan election (MDCP or PERA) indicated above is irrevocable for the duration of this appointment at
the School of Mines, and unless I am a PERA retiree, wil apply to any future appointment at the School of Mines or at
any other Colorado Institution of Higher Education offering an Optional Retirement Plan.
 If my form is received after the payrol deadline (10th of the month), my deductions may be taken the fol owing month.
Please contact PERA Customer Service at 1-800-759-7372 with any PERA related eligibility or benefits questions.
Signature: Date:

PERA Verification  Yes  No per ___________ PERA Date: _______________ Eligibility Date: _________________


MINES DEFINED CONTRIBUTION PLAN
ENROLLMENT INFORMATION

Basics
• 8% mandatory pre-tax employee contribution
• 12% Mines contribution
• 3 Year vesting period
• This plan is a replacement for social security. No social security taxes will be deducted
from your pay
• You wil have a wide selection of investments funds to choose from. Funds are selected
independently of the plan administrator and are not proprietary to the plan
administrator
• There is a 0.26% administrative fee and fund expenses apply based upon the funds
chosen
• VALIC is our plan administrator

Enrol ment

STEP 1: Complete and turn in your Retirement Plan Election Form

STEP 2: Register on the VALIC website
• Go to www.valic.com
• Click on the “Enroll Now” button
• Enter code: 42465002
• Fol ow the website instruction

To schedule a meeting with a VALIC Financial Advisor please contact Fred Brandenburg at
fred.brandenburg@valic.com or at (720) 962-8016

If you have questions please contact the Mines Benefits Office at (303) 273-3052

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)

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.

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

CONFLICT OF INTEREST DISCLOSURE
The primary goal of an annual conflict of interest disclosure is to manage potential and actual conflicts
of interest. When completing this form, if you are unsure whether or not to include information, please
include it. The information provided is maintained in a confidential manner by Mines, subject to the
procedures outlined in the Conflict of Interest Policy.
Complete all the information
Name
Email
Position Title
Phone
Department or
Office Location
Center (primary)
College
Reporting Period
(Calendar Year)
Check all categories applicable to this submission
Initial Reporting
Annual
Change, Addition, or
Reporting
Correction to Reporting
Check all categories that apply to you
Full time
Academic Faculty
Post-Doc
External Investigator
Part time
Administrative Faculty
Visiting
Mines personnel responsible
Scholar
for Conduct, Design or
Reporting on research
Temporary
Research Faculty
Subcontractor
Other
Definitions:
Immediate Family – The immediate family member of a faculty member and includes the faculty
member’s spouse, domestic or civil union partner and dependent children.
Institutional Responsibilities - Institutional Responsibilities are the faculty member’s professional
responsibilities on behalf of CSM, and typical y refers to the performance of duties related to research,
scholarship, education and service. Examples may include, but not be limited to, activities such as
research, research consultation, teaching, work on scholarly publications, and service on institutional
committees.

Name:
COLORADO SCHOOL OF MINES
Check Yes
or No, or
DISCLOSURE QUESTIONNAIRE
complete
the blank.
YES 1. During the past 12 months, I (and/or my Immediate Family) received compensation
and/or other payments for services (remuneration), such as consulting fees or honoraria
that, when aggregated, exceed $5,000 in value from an external organization or activity
NO
that has/have a relationship to my Institutional Responsibilities.
(Do NOT include any salary or remuneration received from Mines if you are currently
employed or appointed by Mines.)
YES 2. During the past 12 months, I (and/or my Immediate Family) owned equity interests,
such as stocks, stock options, or other ownership interests either
a) in publicly traded corporations that when aggregated exceed either $5,000 in
NO
value or 5% ownership interests in any single entity that or
b) in privately-held entity has any dol ar value or any level of ownership and
has/have a relation to my Institutional Responsibilities.
(Do NOT include any equity interest in mutual or pooled funds that you or your
Immediate Family does not have direct control over.)
YES 3. I (and/or my Immediate Family) am an inventor of intel ectual property, outside of my
Mines employment, that has been or wil be licensed by an external organization to
which I:
NO
a) have received or wil receive financial consideration, such as license fees or
royalties or
b) created, discovered, or reduced to practice an invention(s) using Mines’
resources for which title has not been assigned to Mines.
(Do NOT include any payments you are receiving from Mines for Mines-owned
intel ectual property. “Mines resources” may include, but are not limited to: office/lab
space; computers; equipment; funding; grant funds; time; personnel; etc.)
YES 4. During the past 12 months, I was directly reimbursed for travel or was provided travel
by an external organization/party and this travel was related to my Institutional
Responsibilities.
NO
(Do NOT include travel reimbursed or sponsored by, or that flowed through the Mines’
payment system, a federal, state, or local government agency, an institution of higher
education, an academic teaching hospital, a medical center, or research institute that is
affiliated with an institution of higher education.)
YES 5. During the past 12 months, I (and/or my Immediate Family Member) served on a
board of directors, advisory board, or as an officer of an organization doing business
with Mines.
NO
v.1_2016
Page 2 of 5

Name:
COLORADO SCHOOL OF MINES
Check Yes
or No, or
DISCLOSURE QUESTIONNAIRE
complete
the blank.
YES 6. In the next 12 months, I anticipate change(s) to at least one item that I
reported above in items 1 through 5.
NO
If yes, please explain:
If you answered yes to any of the above questions, you must provide additional information in
the Conflict of Interest Disclosure Supplement.
By my signature below, I am acknowledging and agreeing to the fol owing:
• I have read and understand the Colorado School of Mines Faculty Handbook and Conflict of
Interest Policy, located in the Mines Policy Library and I am completing and filing this form in
accordance with Mines’ Policy;
• I understand that I have a continuing obligation to update and revise my disclosure form no
later than 30 calendar days after discovering or acquiring (e.g., through purchase, marriage,
inheritance or otherwise) any change in my and/or my Immediate Family’s outside activities or
related financial interests during the course of the next reporting period; AND
• I understand that annual conflict of interest disclosures are required as part of and a condition
to my employment with the Colorado School of Mines.
By my signature below, I certify to the best of my knowledge that the information I
have provided on this Conflict of Interest Disclosure and the Disclosure Supplement
hereto is true and complete, and that I am in compliance with the Colorado School of
Mines Conflict of Interest Policy.
Date:
Signature:
________________________________________________
__/__/__
v.1_ 2016
Page 3 of 5

COLORADO SCHOOL OF MINES
CONFLICT OF INTEREST DISCLOSURE SUPPLEMENT
Name: _______________________________
Date:
For any areas that you checked YES on the COI Disclosure, please provide additional
information in the appropriate chart.
Receiver of
Total $ received
Remuneration
Organization
Description of Services
in the last 12
(self, spouse,
months from each
child, partner)
$
$
$
If stock
Entity
Holder of
options, are
p licl
Number of
Percentage
Type
Name of Entity
Equity Interest
they
tra e on Shares,
of
(stock, stock
Stock/Options are
(self, spouse,
currently
a toc
options,
Market Value ownership
options, warrants,
Held in
child, partner)
exercisable?
e change warrants, etc. of Shares ($)
in entity
etc.)
(y/n)
n
%
%
%
Receiver of IP
Total $
related
Type
Subject Matter of IP
Owned by
Inventor(s)
received in
remuneration
Government
(patent,
ID number
(describe it)
(name)
(names)
the last 12
(self, spouse,
trademark,
months
partner, child)
copyright)
$
$
$
v.1_2016
Page 4 of 5

Name:
COLORADO SCHOOL OF MINES
Purpose
Traveler
Sponsor/Organizer of
(e.g., Scientific meeting, research
(Name, relationship Date of
Duration
Destination
Travel
collaboration, professional
to you)
Travel
service, professional
development, data collection)
Remuneration
Service
Time commitment
Duration of
(past 12
(Name, relationship to
Position
Organization
Position
(total days in the past 12
months total
you)
months)
money)
$
$
$
**If additional pages are necessary you may add them as needed.
v.1_2016
Page 5 of 5





Colorado School of Mines Faculty Oath



Pursuant to Section 22-61-104 of the Colorado Revised Statutes, I,
_____________________________, do hereby solemnly affirm that I will uphold
(print name)
the constitution of the United States and the constitution of the state of
Colorado, and I will faithfully perform the duties of the position upon which I am
about to enter.
__________________________ __________________________________
Date


Signature (Must be signed in front of Notary Public)
__________________________ __________________________________
CWID Department

To be completed by Notary Public:


Subscribed and affirmed before me in the County of _________________,
State of Colorado, this _____ day of _________________, ____.


[SEAL]





_____________________________________








Notary Public

My Commission expires: __________________


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

Services for New Employees

GENERAL INFORMATION

Mines Dining
Employees are welcome at all Mines Dining locations, including the all-you-care-to-eat option at
Mines Market (east side of Elm Hall), and a la carte dining locations, such as the Periodic Table /
Habaneros / Starbucks (Student Center), Einstein Bros. Bagels (CTLM), Subway/ Jamba Juice (Rec
Center), and Blaster's Brew (Starbucks & Simply to Go) (Brown Hall).

Classified Employee/Faculty Handbooks
Copies of the School Policies as well as the State of Colorado Employee Handbook for classified
staff and the Mines Faculty Handbook are at http://inside.Mines.edu/POGO-Human-Resources.

Classified Employee/Faculty Performance Management
Information on performance management is found at
http://inside.Mines.edu/Performance_Management.

Payroll
State rule mandates electronic direct deposit of payroll to your bank account. All full-time, regular
employees are paid on the last business day of the month. Classified hourly employees are paid on
th
the 15 and the last business day of the month.

Employee Parking
ALL employees are required to register vehicles with https://inside.Mines.edu/Parking. Unregistered
vehicles will be ticketed and/or towed.

Tax Sheltered Annuities
Under section 403(b) of the federal tax code, employees of educational institutions are allowed to
shelter a portion of their income for retirement. Contact the Human Resources office for additional
information.

SERVICES

Cash/Check Cashing Service
An ATM machine is located in the front entrance of the Student Center for your convenience.
The Cashier’s Office, located on the first floor of the Student Center, will cash personal checks
for MINES employees up to $50 per day.

Credit Union
Employees may join the Credit Union of Colorado. The Golden branch is located at 1800 Jackson
Street (across from Safeway) (303) 832-4816. The CUOFCO has several locations in the metro
area. Visit their website www.cuofco.org for more information.

Mines I.D. Cards (BlasterCard)
All employees must have I.D. cards made in the BlasterCard Office, located in the west side of Elm
Hall in the Campus Living Office, ext. 2273. The card enables employees to gain access to offices
and buildings, use the library, have access to physical education facilities, and receive a discount at
the campus bookstore, the Barnes & Noble in Denver West (see campus bookstore for more
information), and some Golden-area businesses. Spouses of employees may have an I.D. made for a
$5.00 fee.


Notary Public
Notary services are available in the Registrar, Financial Aid, and Human Resources offices. There is
no charge to Mines employees for this service. All parties must be present for witnessing purposes
and provide valid identification. All documents must be in English.

PROGRAMS

Tuition “Free” Courses at MINES
With approval of the supervisor, full-time employees may take up to 3 credit hours per semester or
up to 6 credit hours per year of tuition-free courses. Certain fees may apply. Applications for
courses must be authorized by the Office of the Vice President for Academic Affairs, Guggenheim
Hall. The form for Faculty and Staff to complete if they wish to take courses at Mines is located at
http://inside.Mines.edu/Mines_Forms.

Mines Discount Program
This is a program offered to all employees. Discounts are available on ski lift tickets, movie tickets,
and a variety of seasonal events. More information is available at the SAIL Office (Student
Activities, Involvement, and Leadership).

Work-Life Employee Discount Program
The State of Colorado has a discount program for state employees. Services include childcare,
computers, and cell phone discounts. Discounts are subject to change at any time and offers will
vary. Please visit the Work-Life webpage at http://www.colorado.gov/dpa/dhr/WL/worklife.htm for
a listing of the current discounts available to state employees.

Student Recreation Center
The Student Recreation Center (SRC) is a state-of-the-art facility offering a variety of activities,
equipment, classes, and programs serving the fitness needs of the Mines community. Membership to
the SRC is available to Mines employees and their family members. Visit the SRC website at
https://tour.mines.edu/student-recreation-center-src/ for more information on fees, programs, and
facilities.

Outdoor Recreation Center
Employees may take advantage of the programs offered through the Outdoor Recreation Program.
Visit their website at https://tour.mines.edu/outdoor-recreational-center-orc/ for more information on
upcoming events. Fees are generally associated with these activities.

Visit Mines’ website at http://www.Mines.edu for more information about campus services
and information.

Visit https://www.colorado.gov/dhr/jobs for information about state employment.

Holiday Schedule
2016 & 2017



2016 Holiday Schedule
January 1, 2016
Friday
New Year’s Day
May 30, 2016
Monday
Memorial Day
July 4, 2016
Monday
Independence Day
September 5, 2016
Monday
Labor Day
November 24, 2016
Thursday
Thanksgiving Day
November 25, 2016
Friday
Day after Thanksgiving
Winter Break (12/26/16 through 12/30/16)

December 26, 2016
Monday
Christmas Day (observed)
December 27, 2016
Tuesday
Winter Break
December 28, 2016
Wednesday
Winter Break
December 29, 2016
Thursday
Winter Break
December 30, 2016
Friday
Winter Break
2017 Holiday Schedule
January 2, 2017
Monday
New Year’s Day
January 16, 2017
Monday
Martin Luther King Day
May 29, 2017
Monday
Memorial Day
July 4, 2017
Tuesday
Independence Day
September 4, 2017
Monday
Labor Day
November 23, 2017
Thursday
Thanksgiving Day
November 24, 2017
Friday
Day after Thanksgiving

Winter Break (12/25/17 through 12/29/17)

December 25, 2017
Monday
Christmas Day
Dec