Doe Ohr 600 004 Form PDF Details

For individuals interested in contributing to the education system as substitute teachers, understanding the intricacies of the DOE OHR 600 004 form is essential. Last revised on 06/27/2012, this form serves as both an application and a renewal for prospective and current substitute teachers within the Department of Education. It requires detailed personal, educational, and professional information to ensure that candidates are eligible and adequately prepared for the role. Applicants have the opportunity to specify their availability and preferences, including the grade levels and subjects they are willing to teach, as well as the school districts where they prefer to work. Additionally, the form includes sections for outlining qualifications, with a particular focus on educational background, teaching certifications, and professional teaching experience. Compliance with legal employment documentation is stressed, indicating a necessity for valid proof of the ability to work in the United States. Furthermore, the form addresses personal conduct and professionalism, asking candidates to disclose past employment terminations, military service discharges, arrests, or convictions, as well as any history of professional licensure issues. The application process is thorough, reflecting the Department's commitment to maintaining a high standard of education and ensuring the safety and well-being of students. As such, the DOE OHR 600 004 form is not just a procedural requirement but a critical step in vetting and selecting individuals who will shape the educational experiences of students.

QuestionAnswer
Form NameDoe Ohr 600 004 Form
Form Length4 pages
Fillable?Yes
Fillable fields217
Avg. time to fill out22 min 14 sec
Other namesformer doe form, hi doe application renewal, hawaii substitute renewal online, hawaii substitute application

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SUBSTITUTE TEACHER APPLICATION

AND RENEWAL

DOE OHR 600-004

Last Revised: 06/27/2012

Former DOE Form(s): 104, 204

DEPARTMENT OF EDUCATION

Office of Human Resources

T-SEAS Unit

P.O. Box 2360 Honolulu, HI 96804

Mark one:

New Application*

Annual Renewal - School Year __________ -

__________

 

 

YYYY

YYYY

*Valid documentation showing your ability to legally work in the United States may be required (i.e., Employment Authorization Document, Permanent Resident Card, unexpired foreign passport, etc.).

I. EMPLOYEE / APPLICANT INFORMATION

Name: _______________________________________________________________

Last 4 digits of SSN: _____________________

Last

First

M.I.

 

Mailing Address (Required): ____________________________________________________________________________________

City: _______________________ State: _________ Zip: _________________

Permanent Tel#: ________________________

Mailing Preference (please mark one):

USPS Mail

E-Mail

If e-mail, please provide: _____________________________

Mark if applicable

Change in Permanent Tel# (Written above)

Change in Preferences (Read and complete Section IV, as applicable)

Classification Change- Class _______ to Class _______ (Attach official transcripts, copy of teaching lic. and/or grade rpts.)

District Transfer - Effective Date: _______________________, Transfer from: _________________ District

MM/DD/YYYY

II. GENERAL INFORMATION

You are restricted to teaching in only ONE (1) Home District (Please mark the District):

HON

CEN

LEE

WIN

HAW

MAUI

KAU

PUBLIC CHARTER SCHOOLS

You are on at least one school priority list. Name of School: ___________________________________________________________

Principal/Designee Signature: ___________________________________________________

Date: _______________________

 

 

MM/DD/YYYY

Principal/Designee Name (Print): ________________________________________________

Title: _______________________

You completed the annual Bloodborne Training requirement within ONE (1) YEAR of the date on this application.

Exact date completed: _______________________

Location/Channel Viewed: __________________________________

MM/DD/YYYY

 

 

Did you complete the 30-Hour Substitute Teacher Course?

Yes; Date: ___________________, Location: ________________________

Anticipated

No; Completion Date: ________________

MM/DD/YYYY

MM/DD/YYYY

Did you complete the Re-Certification Class? (Note: Class I and Class II substitutes must have completed the 30-hour Substitute

Teacher Course before taking the Re-Certification Class.)

Yes; Date: ___________________, Location: ________________________

MM/DD/YYYY

Anticipated

No; Completion Date: ________________

MM/DD/YYYY

PERSONAL DATA

YES

NO

1. Have you at any time been suspended, fired, terminated, dismissed, discharged or asked to resign from employment? If yes, please explain:

2. Have you at any time separated from military service under conditions other than honorable? If yes, please explain:

3. Have you at any time been arrested and/or convicted?

If arrested, please specify what you were arrested for: ____________________________________________________________

If arrested, were you charged?

If charged, please specify what you were charged with and the disposition (outcome) of the charge:

4. Have you at any time had a professional license or certification (for example, attorney, nurse, psychologist, teacher, school administrator, etc.) suspended, revoked, denied or not renewed?

If yes, please explain:

(Note: Conviction or termination from employment will not necessarily disqualify an applicant)

Distribution: 1. Original - Personnel Regional Office; 2. Copy - School

(Page 1 of 4)

DOE OHR 600-004

 

 

 

Last Revised: 06/27/2012

 

 

 

Former DOE Form(s): 104, 204

Name: _______________________________________________________________

Last 4 digits of SSN: _____________________

Last

First

M.I.

 

III.QUALIFICATIONS - New Applicants: please complete this section. Existing substitute teachers: please complete only if there are any changes to your educational and professional training record.

Educational and Professional Training

Please list your degree(s), bachelor's degree and above, and the college and/or university at which the degree(s) was earned. The information should be complete and the official college and/or university transcript showing degree(s) granted and/or credits earned must be submitted. Timely transcript submittal is required to verify your proper classification and certification status since this may affect your assigned pay rate and priority for day-to-day employment. (Note: Transcripts submitted become the property of the Hawaii State Department of Education and will not be returned to applicant.)

College/University

Location (City/State)

From

To

Sem. Hrs.

Degree

Date

Major

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Student Teaching and/or Intern Teaching

From

To

Subject/Grade Level

Name and Address of School

Name of Cooperating Teacher

Sem. Hrs.

Professional Certification

Type of Teaching Certificate

State

Date Issued

Expiration Date

Professional Experience in Hawaii (Please list your most recent experience, if any)

Name of School

Location (City/State) Grade/Subject

From

To

Type of Employment (Contract or Substitute)

Reason for Leaving

IV. PREFERENCES - continued on page 3

CLASS I SUBSTITUTE TEACHERS: If you are a Class I substitute teacher, the T-SEAS computer will only call you for jobs at your priority schools. DO NOT complete Section IVa.- IVc.

CLASS II & CLASS III SUBSTITUTE TEACHER PREFERENCES for the T-SEAS computer: If you DO NOT want the T-SEAS computer to call you, go directly to Section IVd. - SPECIAL PREFERENCES and check the box marked "PRE-ARRANGED ASSIGNMENTS ONLY."

*Preferences marked in this section will be input into T-SEAS and serve as a basis for computerized call-outs. Offers from T-SEAS will be restricted to your priority list(s) and the complex areas and grade levels you select.

*Your subject preferences will also be considered, however, there may be days when you are needed for subjects you have not selected. Please keep an open mind and prepare to accept these assignments as well.

*Communication with T-SEAS requires a touch-tone phone. Answering machines, cordless phones, cellular phones, pagers, or pulse-generated phones are neither reliable nor compatible with T-SEAS. DOE/T-SEAS is not responsible for any missed job offers or miscommunication arising from their use.

Distribution: 1. Original - Personnel Regional Office; 2. Copy - School

(Page 2 of 4)

DOE OHR 600-004

 

 

 

Last Revised: 06/27/2012

 

 

 

Former DOE Form(s): 104, 204

Name: _______________________________________________________________

Last 4 digits of SSN: _____________________

Last

First

M.I.

 

IV. PREFERENCE - continued from page 2

IVa. COMPLEX PREFERENCE: Based on the ONE (1) Home District you selected in Section II., mark the corresponding complexes (listed directly under the District below) where you are willing and able to work. Keep in mind that you are restricted to teaching in your Home District only and cannot select complexes in other districts. If you DO NOT want the T-SEAS computer to call you, go directly to Section IVd. - SPECIAL PREFERENCES and check the box marked "PRE-ARRANGED ASSIGNMENTS ONLY."

HONOLULU

CENTRAL

LEEWARD

WINDWARD

HAWAII

DISTRICT

DISTRICT

DISTRICT

DISTRICT

DISTRICT

11 FARRINGTON

21 MOANALUA

31 PEARL CITY

41 KAILUA

51 HILO

12 MCKINLEY

22 RADFORD

32 WAIPAHU

42 KALAHEO

52 KAMUELA

13 ROOSEVELT

23 AIEA

33 CAMPBELL

43 CASTLE

53 HAMAKUA

14 KAIMUKI

24 MILILANI

34 NANAKULI

44 KAHUKU

54 PUNA

15 KALANI

25 LEILEHUA

35 WAIANAE

 

55 KONA

16 KAISER

26 WAIALUA

36 KAPOLEI

 

56 KOHALA

 

 

 

 

57 KAU/PAHALA

MAUI

DISTRICT

61BALDWIN

62MAUI

63LAHAINALUNA

64HANA

65MOLOKAI

66KEKAULIKE

67LANAI

KAUAI

DISTRICT

71 HANALEI

72 KAUAI

73 WAIMEA

74 KAPAA

IVb. GRADE LEVEL PREFERENCES: Mark the grade level codes you are willing and able to teach:

02 PRIMARY (K-3)

03 UPPER ELEM (4-6)

 

04 MIDDLE/INTER

 

 

 

 

05 HIGH SCHOOL

Ivc. SUBJECT PREFERENCES: Mark the subject area codes you are willing and able to teach:

06 LANGUAGE ARTS

07READING

08ENGLISH

09 ENGLISH AS A SECOND LANGUAGE (ESL)

16 SOCIAL STUDIES

20 COMPUTER

22AGRICULTURE

23ART

26 BUSINESS EDUCATION

27 HOME ECONOMICS

43 CHINESE

44 FILIPINO

45 FRENCH

46 GERMAN

47 HAWAIIAN

48 JAPANESE

49 KOREAN

50 LATIN

51 RUSSIAN

52 SPANISH

54 SPECIAL EDUCATION -

 

880 REGISTRAR

SPEECH LEARNING IMPAIRED

 

 

55 MATH

 

881 LIBRARIAN

62 MUSIC

 

882 COUNSELOR

63 BAND

 

83 SPECIAL EDUCATION - VISUAL

67 PHYSICAL EDUCATION

 

84 SPECIAL EDUCATION - HEARING

68 SPECIAL MOTIVATION PROGRAM

 

85 SPECIAL EDUCATION - MR/LD

69 SPECIAL EDUCATION -

 

86 SPECIAL EDUCATION - PRE-

ORTHOPEDIC HANDICAPPED

 

SCHOOL

70 HEALTH / SAFETY

 

87 SPECIAL EDUCATION -

 

 

EMOTIONALLY DISTURBED

73 SCIENCE

 

88 SPECIAL SCHOOL TEACHER

 

78 DORM COUNSELOR

 

89 SPECIAL EDUCATION - SEVERLY/

 

 

 

MULTIPLE HANDICAPPED

29 INDUSTRIAL ARTS

53 BILINGUAL/BICULTURAL

IVd. SPECIAL PREFERENCES (Mark only if applicable)

PRE-ARRANGED ASSIGNMENTS ONLY - By marking this box, you are choosing to ONLY accept assignments offered directly by schools or teachers. You will not be contacted by the T-SEAS computer (DO NOT select codes above if you choose this option).

SUBSTITUTES ON OAHU ONLY

ASSIGNMENTS AT THE HAWAII SCHOOL FOR THE DEAF AND THE BLIND (HSDB)

Your name will be forwarded to HSDB. If you are needed, you will be contacted directly.

 

* I can communicate in ASL at a proficiency rate of 50% or higher:

YES; If yes, what percentage? _____%

NO

Distribution: 1. Original - Personnel Regional Office; 2. Copy - School

(Page 3 of 4)

DOE OHR 600-004

 

 

 

Last Revised: 06/27/2012

 

 

 

Former DOE Form(s): 104, 204

Name: _______________________________________________________________

Last 4 digits of SSN: _____________________

Last

First

M.I.

 

Please read the following statements, then sign below to indicate understanding and acceptance. If you need clarification about any statement, check with your school administrator or Personnel Regional Officer.

1.I agree to comply with applicable state and federal laws as well as policies, regulations and procedures of the Hawaii State Department of Education and its Substitute Teacher Program.

2.I will refrain from illegal activities on campus or during school-related activities such as: corporal punishment; physical abuse/ harassment; racial and sexual abuse/harassment; smoking; possession, use or sale of alcoholic beverages or illegal drugs; releasing student records without authorization from school administration; using unprofessional language.

3.I will teach/treat all students with care, fairness, flexibility, and patience regardless of their race, color, national origin, gender, sexual orientation, religion or disability.

4.I will do my best to prevent or stop bullying and harassment by students and report such incidents to the school administration in order to maintain a safe and caring school environment.

5.I have reliable telephone communication that enables me to receive and accept assignment offers from schools, teachers,

and T-SEAS. I am aware that answering machines, cellular phones, pagers, cordless phones, or pulse-generated phones are neither reliable nor compatible with TSEAS. I will not hold DOE/TSEAS responsible for any missed job offers or miscommunication arising from their use.

6.I am available to accept assignments on an on-call, as needed basis. While I have indicated grade/subject level preferences, I may be asked to substitute for positions outside these subject areas when needed. Consistent, non-availability (i.e. declines, hang-ups, no answers) may result in removal from the substitute employment pool because it delays the calling and filling of assignments.

7.I have fulfilled the yearly bloodborne pathogen training requirement.

8.I have read and attached a signed copy of the "Hawaii State Department of Education Acknowledgement of General Confidentiality Expectations". Note: This form can be found at DOE website <http://tseas.hidoe.us>, Substitute Teacher link with the subject heading "Opening of the School Year".

Upon issuance of the DOE employment document, Form 5, I will be eligible to: 1) use T-SEAS; 2) be called for assignments, as

needed, for the school year, except between academic terms or during customary recesses, holidays, and intersessions; and 3) be certified for payroll processing. (Note: All materials submitted become the property of the Hawaii State Department of Education and will not be be returned to applicant.)

I hereby certify that all statements in this application are true, complete and correct. I understand that any willful omission or falsification of material facts in this application or breach of the Application Agreement will constitute sufficient reason for immediate dismissal.

Applicant's Signature: _______________________________________________________ Date: _______________________

MM/DD/YYYY

I hereby accept this applicant to be a substitute teacher in the District for the current school year.

Complex Area Superintendent or Designee's Signature

Acceptance (Today's Date)

MM/DD/YYYY

Effective Date of Form 5

MM/DD/YYYY

Reclassification Use Only (if applicable)

Class: _____________ Date: _______________________ Initial: ________

MM/DD/YYYY

Comments:

 

 

T-SEAS Use Only

 

 

EBC: _________________

VAX: _________________

VIP: _________________

MM/DD/YYYY

MM/DD/YYYY

MM/DD/YYYY

Comments:

 

 

Distribution: 1. Original - Personnel Regional Office; 2. Copy - School

(Page 4 of 4)

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