Public Partnerships Form – Fill Out and Use This PDF

Employment Packet Forms Checklist

Forms Required from Interventionists for each Child Served

____ Application for Employment: This form is the standard application for employment for a

potential employee under the ATAP program.

____ ATAP Child Relationship Information Form: This form identifies family members

providing services. Both the interventionist and the authorized representative need to sign the form.

____ PPL Nevada Employment Agreement: This form is a joint agreement between PPL

Nevada (employer of record), the Authorized Representative (supervisor) and the Interventionist (employee) for the terms of services.

____ATAP Ethics Form: Guidelines for Interventionists: Outlines expected standards

in Professionalism, Confidentiality, Limitations of Training, Treatment Delivery, Data Requirements, Attendance, Staff Relations and performance.

Forms Required from Interventionists for only the FIRST Client served (you

are only required to turn these forms in once)

____ Security and Confidentiality Policy for Protected Data Form: All PPL Nevada

employees are expected to read, understand and sign this form which confirms that the employee will follow PPL Nevada’s policies and procedures regarding security and confidentiality.

____ Criminal Background Check Authorization Form: This form provides PPL Nevada all

the necessary demographic information to run the mandatory criminal background check.

____ USCIS Form I-9: Department of Homeland Security - Employment Eligibility

Verification. This form is used to confirm your immigration and US citizenship information. The form contains instructions developed by the USCIS. Your supervisor must certify and sign Section 2 of the I-9 Form in order to hire you as his/her employee. Copies of the documents used for verification must be submitted to PPL Nevada along with this form. Documents that verify your identity are your Driver’s License, Passport, Birth Certificate, along with many others. These are listed on page 21.

____ IRS Form W-4: Employee’s Withholding Allowance Certificate. This form is used to

calculate your federal tax withholding. The form contains instructions developed by the IRS.

____ Employee Driver’s License and Auto Insurance Verification Form: This form provides

PPL Nevada with a copy of a valid driver’s license and proof of valid auto insurance, which is required if you plan to use your vehicle within the scope of your employment. NOTE: Only required if using vehicle within scope of employment.

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Informational & Optional Forms to Keep

You will use these for the Program

Requirements for Criminal Background Check: This form provides a list of crimes that are considered barrier crimes to employment. Any potential employee convicted of one of these crimes may not provide services under the ATAP program.

ATAP Authorized Representative Acceptance of Responsibility for Employment: When an employee is convicted of a crime the authorized representative may choose to still hire that employee, however they must sign an acceptance of responsibility form.

Employees convicted of crimes which fall under the barrier crimes list are not eligible for employment.

Interventionist Rate Change Form: If an Authorized Representative decides to change a previously agreed upon rate, they must do so by submitting this form. Forms must be submitted 7 days in advance of the pay period in which the changed rate will take effect. This is the ONLY way to change rates.

Interventionist Change or Separation from Employment Form: This is a two part

form: The first half is to be used if an Interventionist’s demographic information changes. PPL Nevada needs the most current information as soon as possible to ensure that any mailings are sent to the appropriate location. The second part of this form should be submitted if an interventionist no longer works for the Child.

Payroll Schedule: Follow this schedule to complete timesheets and submit them to PPL Nevada twice per month. Properly completed and approved timesheets must be received by the payroll deadline in order for you to be paid according to the payroll schedule.

EFT Application: This form is used to establish direct deposit of your paycheck by PPL Nevada. Direct Deposit is highly recommended by PPL because it is the most dependable and quickest way to receive pay checks.

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What should I expect as an interventionist in the ATAP program?

Before you are eligible to provide services to a participating child, you must:

•Complete and submit to PPL Nevada all applicable forms as identified in the employment packet checklist listed under “Forms Required from Interventionist.”

•Submit to a Criminal Background Check and if charges are identified on your Criminal Background Check the authorized representative that you serve has the option to sign an “Acceptance of Responsibility Form” if he/she still wants to hire you.

•Receive your Employee ID number which will serve as notification from PPL Nevada that all documents have been properly completed and you are authorized to begin providing services.

After you start working for a participating child, you will:

•Submit time worked to the Authorized Representative for approval,

•Receive a paycheck from PPL Nevada, based on properly submitted timesheets twice per month.

•Receive a W-2 Wage Statement from PPL Nevada every year.

Who is responsible for submitting timesheets to PPL Nevada?

The Child’s Authorized Representative and the assigned Care Manager will approve your timesheets and submit them directly to PPL Nevada twice per month according to the pay schedule. Timesheets must always be approved by all parties before PPL Nevada will be able to process them. PPL provides a convenient online method using the PPL Web Portal that is the preferred method.

What is the U.S. Citizenship and Immigration Services (USCIS) Form I-9?

The USCIS Form I-9 is your employment eligibility verification. You must bring this form, and the documents listed on page 3 of the I-9 to the Authorized Representative. The Authorized Representative will review the documents, confirm your identity and verify your identity by signing this form. Documents that verify your identity are your Driver’s License, Passport, Birth Certificate, along with many others. These are listed on page 21. You are only required to complete this once and supply it to PPL. Detailed instructions are also included with this form in your packet. Copies of the documents used for verification must be submitted to PPL

Nevada along with this form.

What taxes will be withheld? Will I see them on my paycheck stub?

PPL will withhold Social Security, Medicare (FICA), state taxes and federal income taxes from your paycheck as applicable. A summary of all tax withholdings will appear on your paycheck stub throughout the calendar year. PPL Nevada will also mail you a W-2 form each January.

You will need this W-2 form to file your individual tax return by April of each year. The Authorized Representative will receive regular reports from PPL Nevada about your total hours worked.

If you have any additional questions as you review this packet please feel free to call our

customer service number: 1-888-805-1074

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