Doe Ohr 600 004 Form – Fill Out and Use This PDF

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: _____________________________

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

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

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

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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

Professional Certification

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

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."

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

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

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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.

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

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