[Ord. No. 18-07, 3-12-2018]
[Ord. No. 18-07, 3-12-2018]
Forms in substantially the following formats are held on file
and available upon request at City Hall.
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CITY OF ORONOGO
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PERSONNEL POLICY MANUAL
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ACKNOWLEDGEMENT
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I acknowledge that I have received a copy of the City of Oronogo
Personnel Policy Manual dated __________, 20___. I understand that
it contains important information about the City's general personnel
policies and about my privileges and obligations as an employee.
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Since employment with the City is considered to be "at-will"
employment, I understand that my employment is not for a specified
term and is at the mutual consent of the City and myself. Accordingly,
either the City or I may terminate the employment relationship with
or without cause at any time. I further acknowledge that revisions
to the Manual may occur, with the exception of the City's policy of
employment-at-will. Furthermore, I acknowledge that this Manual is
not a contract of employment. I have received this Manual, and I understand
that it is my responsibility to read and comply with the policies
contained in this Manual and any revisions to it.
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__________
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Employee Name (Printed)
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__________
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__________
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Employee Signature
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Date
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[A copy of the Employee Acknowledgement is to be signed and
placed in the employee's personnel file.]
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CITY OF ORONOGO
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ACKNOWLEDGEMENT OF RECEIPT OF DRUG POLICY
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I affirm that I have read and understand the City of Oronogo's
Substance Abuse Policy and I understand that I may be subject to discipline,
including termination for violating this policy or any other disciplinary
policies or work rules of the City. I agree to fully comply with and
abide by all rules and regulations set forth in the Substance Abuse
Policy as a condition of continued employment by the City.
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I further understand that the City has the right to request,
in accordance with its Substance Abuse Policy, that I submit to a
drug and alcohol screen as a condition of continued employment with
the City. I understand that refusal to consent to such a drug and
alcohol screen will be considered by the City as insubordination and
will result in an employee's termination. I also understand that any
attempt to tamper with, adulterate, or substitute the test sample
in a drug and alcohol screen will result in an employee's termination.
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__________
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__________
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Employee
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Date
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__________
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_________
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Witness
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Date
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CITY OF ORONOGO
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CONSENT FORM FOR ALCOHOL AND DRUG TESTING
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I, __________, consent to the collection of blood, urine, saliva,
hair or breath samples from me and to conduct other medical tests
to determine the presence or use of alcohol, drugs or controlled substances.
I understand that refusal to consent to such a drug and alcohol screen
will be considered by the City as insubordination and may result in
an employee's termination. I further understand that any attempt to
adulterate the test sample will be considered by the City as insubordination
and may result in an employee's termination. I realize that a positive
result for the presence of either drugs or alcohol, or both, in any
specimen of mine may lead to discipline, up to and including termination.
I further certify that I have read and understand City of Oronogo's
Substance Abuse Policy and my right to appeal.
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I hereby authorize the laboratory or facility conducting this
test to release the results of the test to the City and release the
City, any doctor, medical personnel, laboratory and testing facility
from any and all liability arising from the release or use of this
information.
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AGREED TO:
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__________
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__________
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Employee's Signature
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Date
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__________
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__________
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Witness
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Date
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CITY OF ORONOGO
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EMPLOYEE FAMILY MEDICAL LEAVE ACT FACT SHEET
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ACKNOWLEDGEMENT OF RECEIPT
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I acknowledge that the City of Oronogo, MO has provided and
I have received a copy of the Family Medical Leave Act of 1993 Fact
Sheet as prepared by the United States Department of Labor - Wage
and Hour Division. I understand that it contains important information
about the Family Medical Leave Act of 1993 and about my privileges
and rights as an employee working for an employer subject to the FMLA.
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__________
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Employee Name (Printed)
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__________
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__________
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Employee Signature
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Date
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[A copy of the Employee Acknowledgement is to be signed and
placed in the employee's personnel file.]
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CITY OF ORONOGO
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SEXUAL HARRASSMENT
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ACKNOWLEDGEMENT OF RECEIPT
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I acknowledge that I received training regarding the prevention
of sexual harassment on __________ (date). I agree to abide by the
principles that were explained in this training. I understand that
if I have any questions that were not addressed in training or if
I encounter any problems, I can contact my supervisor or the City
Clerk.
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__________
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Employee Name (Please Print)
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__________
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Employee Signature
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[A copy of the Employee Acknowledgement is to be signed and
placed in the employee's personnel file.]
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CITY OF ORONOGO
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GRIEVANCE FORM
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Before submitting this Grievance Form, be sure the following
is completed.
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Claimant: __________
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Date: __________
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Supervisor: __________
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Department: __________
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Did you first discuss your grievance with your immediate Supervisor?
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_____Yes _____No
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If so, was your Supervisor able to resolve your grievance?
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_____Yes _____No
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Complete the following:
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What was the date of the incident? __________
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Explain the incident in detail:
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__________
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__________
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__________
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__________
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__________
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__________
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__________
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__________
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If more space is needed, use additional sheets of paper. Be
sure to number the sheets accordingly.
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To be completed by the City Clerk's office:
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Date of receipt by claimant: __________
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CITY OF ORONOGO
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REQUEST FOR APPEAL HEARING
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Before submitting this Request for Appeal Form, be sure the
following is completed.
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Claimant:__________
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Date: __________
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Supervisor: __________
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Department: __________
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Were you suspended_____ or dismissed _____
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Complete the following:
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What was the date of suspension or dismissal? __________
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Explain the incident in detail:
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__________
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__________
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__________
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__________
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__________
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__________
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__________
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__________
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If more space is needed, use additional sheets of paper. Be
sure to number the sheets accordingly.
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To be completed by the City Clerk's office:
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Date of receipt by claimant: __________
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Date of response to claimant: __________
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Date of Appeal Hearing: __________
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