Springfield School District

Employee Forms, Benefit, Payroll, and Employment Information

Below you will find a list of employee forms, benefit, payroll, and employment information.

For the convenience of Springfield School District employees, several forms are now available to print from this page and through the links attached to this page, in PDF format.  Please call the Central Office with any questions.  Thank you.


Employment Application  (to be completed by all employees new to the district):
Please print, complete, and send to the School or Department to which you are applying.



Springfield School District values its employee community and has put together a comprehensive, affordable benefits package that is designed to support your physical, financial, and emotional well-being.  Choose from the links below to learn more.

Please contact Human Resources for questions or additional information on any of the benefits listed herein at 802-885-5127 or pcavicchi@ssdvt.org.  Thank you.

Compliance Notices – 2017

  • The Health Insurance and Portability and Accountability Act of 1996 (HIPAA); page 1
  • Continuation Coverage Rights Under COBRA; pages 1-3
  • Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP); pages 3-6
  • Women’s Health & Cancer Rights Act of 1998; page 6
  • Newborns’ and Mothers’ Health Protection Act of 1996; page 6
  • Important Notice About Your Prescription Drug Coverage and Medicare; pages 6-7
  • Health Care Reform: General Information
    • Summary of Benefits and Coverage (“SBC”) and Uniform Glossary; page 7
    • Notice Regarding the Health Insurance Marketplace; pages 7-8

403b Yearly Employee Notice May 2017

Right to Add Dependent up to Age 26 notice 2017

Employee Benefit Summaries –

Outline of benefits offered to those eligible, by employee type.

Health Insurance Information & Forms –
Enrollment/Change form

Declaration of Health Care Coverage form
Summary of Benefits & Coverage (SBC) for each plan offered
Health Insurance Certificates for each plan offered

Information on 2018 Health Plan Changes – effective 1-1-2018

Dental Insurance Information & Forms –
Enrollment/Change form
Waiver of Coverage form
Outline of Coverage by employee type
HOW (Health through Oral Wellness) information
Vision Discount information

Life Insurance Beneficiary Change Form –
Beneficiary Change/Designation form

Flexible Spending Plan Information & Forms –
Reimbursement form
Summary Plan Description

403(b) Annuity Plan (Pre-tax & Post-tax options) –
Contact information
Contribution Change form
Beneficiary Designation/Name & Address Change Form


Payroll Information & Forms –
Direct Deposit form
W-4 Federal
W-4 VT
Pay period dates
Hourly employee time card guidelines
Employee holiday list

Communication from Supt McLaughlin re:
Exceeding absence days (all employees)
Appropriate use of Floating Holiday & Vacation days (Calendar year employees covered by SSSA Master Agreement)

Leave Request Information & Forms –
Request for Leave of Absence form (all employees must complete this form for an absence of 5 or more days)
Teacher Absence Leave Bank Request form
– Family Medical Leave Act (FMLA)
– Vermont Parental Family Leave (VPFL)


For travel beginning January 1, 2017
Mileage Reimbursement – 2017


Contact us

We're not around right now. But you can send us an email and we'll get back to you, asap.

Questions, issues or concerns? I'd love to help you!

Click ENTER to chat