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.

Application for Employment  (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.

EMPLOYEE BENEFITS –

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.

EMPLOYEE BENEFIT SUMMARY DOCUMENTS:

  • Administrators
  • Teachers
  • Calendar Year Support Staff
  • School Year Support Staff

HEALTH INSURANCE:

Health Plan Information/Resources – became effective 1-1-2018

Health Insurance Forms – 2019

  •   VEHI 2018 Employee Election Form
  •   Declaration of Health Care Form

FLEXIBLE SPENDING ACCOUNT (FSA)/HEALTH REIMBURSEMENT ARRANGEMENT (HRA)/HEALTH SAVINGS ACCOUNT (HSA) information and forms:

  • Flexible Spending Account (FSA)
  • Dependent Care Account (DCAP)
  • Health Reimbursement Arrangement (HRA)
  • Health Savings Account (HSA) – (Non-Union Employees Only)

DENTAL:

 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:

Life Insurance Beneficiary Change Form –
Beneficiary Change/Designation form

Privacy Notice

Life Certificates by employee class

Long-Term Disability Certificates by employee class

Short Term Disability Certificates by employee class

403(b) ANNUITY PLAN:

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

2019 Annual Compliance Notices:

    • 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 4 – 6
    • Women’s Health & Cancer Rights Act of 1998; page 6
    • Newborns’ and Mothers’ Health Protection Act of 1996; page 7
    • Important Notice About Your Prescription Drug Coverage and Medicare; pages 7 – 8
  • Health Care Reform: General Information
      • Summary of Benefits and Coverage (“SBC”) and Uniform Glossary; page 8
    • Notice Regarding the Health Insurance Marketplace; pages 8 – 9

EMPLOYMENT INFORMATION & FORMS – 

Payroll Information & Forms –
Direct Deposit form
W-4 Federal
W-4 VT – NEW 2019
Pay period dates

School Year Absence Day Guidelines before/after school breaks

Hourly employee time card guidelines

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)

District Web-Based Transfer Preference Form (“Dream List”)–STA Members Only

For travel beginning January 1, 2017
Mileage Reimbursement – 2017

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