HomeMy Public PortalAbout2024-01-25_Human Resources PROCEDURES FORMS.pdf
HUMAN
RESOURCES
FORMS
Contents
Form 1-1 Confirmation of Receipt of Human Resources Policies & Procedures
Form 2-3 Job Description Review Form
Form 3-1 Request for Workplace Accommodation
Form 3-5 Corrective Action
Form 4-1 Salary Adjustment Form
Form 4-4a Flexible Work Arrangement Request
Form 4-4b Flexible Work Arrangements Agreement
Form 4-4c Remote Work Self Assessment & Safety Checklist
Form 5-1a Performance Appraisal
Form 5-1b Performance Improvement Action Plan
Form 5-2a Individual Development Plan
Form 5-2b Training and Development Request
Form 6-8 Request for Leave of Absence
Form 7-1 Notice of Competition
Form 7-2a New Employee Orientation Checklist
Form 7-2b Agreement of Confidentiality
Form 7-3 Probationary Employee Progress Report
Form 7-4a Termination of Employee Checklist
Form 7-4b Resignation of Employee Checklist
Form 7-4c Exit Interview Form
Form 1-1
Confirmation of Receipt of Human Resources Policies & Procedures
Form 1-1
Confirmation of Receipt of Human
Resources Policies & Procedures
This will confirm that I have been provided with the following information:
☐ Personnel Policy & Procedures Manual _______ (Initial)
☐ Internet Policy _______ (Initial)
☐ Cell Phone Policy _______ (Initial)
☐ Location of Occupational Health & Safety Policy & Act _______ (Initial)
☐ A copy of the Joint Occupational Health & Safety Act and Policy are available in each department and the
location has been identified to me. _______ (Initial)
__________________________________ _________________________________
Signature of Employee Date
__________________________________ _________________________________
Signature of Department Head Date
__________________________________ _________________________________
Signature of HR Designate Date
__________________________________ _________________________________
Signature of CAO Date
Form 2-3
Job Description Review Form
Form 2-3
Job Description Review Form
This form to be completed at the time of an employee’s Annual Review if the procedures and responsibilities
outlined in the Employee’s Job Description has changed significantly.
Employee
Department
Job Title
Date
☐ Attach current Job Description
☐ Attach any Relevant Previous Job Description
Since the existing job description has been prepared are there any changes in the content of the job that necessitate
a change in the existing job description?
Yes ☐ No ☐
Explanation:
Attach an additional sheet as necessary
This ☐ will result in a position reclassification request.
☐ will not result in a position reclassification request.
Date Employee Signature
Date Department Head/Supervisor Signature
Date CAO Signature
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Form 3-1
Request for Workplace Accommodation
Form 3-1
Request for Workplace Accommodation
The Municipality must not discriminate against employees based on protected characteristics, such as disability or
gender. In fact, an employer has what is called a “duty to accommodate." This means they must do what is
reasonable to allow a person to get, or keep, a job. Workplace accommodation refers to the Municipality’s obligation
under the Nova Scotia Human Rights Act to prevent and remove barriers and provide reasonable accommodation to
the point of undue hardship for protected characteristics such as creed/religion, disability, family status and sex
(including pregnancy and gender identity).
Sometimes, our rules, practices, standards, or policies can create barriers that we didn’t intend. If the
accommodation you are requesting is related to one of our rules, practices, standards, or policies, please tell us
which one so we can review it. A review will tell us if there is a bona fide requirement (meaning it is necessary to
keep it in the document) or if it can be updated. This review is in addition to the expectation that accommodation will
be provided for individual needs that remain.”
The purpose of this form is to gather the information required to initiate and facilitate the accommodation process in
a timely manner under one or more grounds of the Act. Please submit the completed form via email to your
immediate supervisor. Your supervisor will then contact Human Resource designate to facilitate the accommodation
process. As with all personnel matters, the Municipality will maintain the confidentiality of the information related to
an accommodation request. By submitting this form, you consent to disclosing the information provided in this form
to the parties that need to be engaged in the accommodation process (i.e., supervisor, Human Resources, etc.).
Each accommodation request will be considered on an individual, case-by-case basis in order to determine the most
reasonable and appropriate accommodation based on the employee’s individual circumstances.
Please refer to the Personnel Policy 3.1 Accommodation for an overview of the workplace accommodation process
including the responsibilities of Human Resources, supervisors, and the employee.
Should you have any questions or need assistance completing the form, please reach out to your supervisor or the
Human Resource designate.
Employee
Department
Job Title
Date
1. Which Human Rights ground(s) is your accommodation request related to?
☐ Disability and/or medical condition ☐ Religion
☐ Marital or family status ☐ Not sure
☐ Other (please specify):
Form 3-1
Request for Workplace Accommodation
2. What workplace limitations are you currently experiencing? Please provide as much detail as you
believe is relevant.
3. Referencing the workplace limitations, you noted above, what specific parts of your assigned job responsibilities
are difficult to perform? Please attach a copy of any supporting documentation from your medical provider, if
applicable.
4. Please describe as completely and specifically as possible the workplace accommodation(s) that you are
requesting.
5. Please provide the duration of the requested workplace accommodation(s).
6. Please describe how the workplace accommodation(s) will assist you in performing your job responsibilities?
7. If the need for accommodation arises from an organizational rule, practice, standard or policy – this should be
assessed to make sure that it is a bona fide requirement (BFR). This means that it must be inclusively designed and
incorporate the concept of accommodation – this is in addition to the expectation that accommodation will be
provided for individual needs that remain. Attach additional pages if necessary.
a. Rule or standard to be evaluated
Form 3-5
Corrective Action
Form 3-5
Corrective Action
Employee
Department
Job Title
Date
VC = Verbal Counselling WR = Written Reprimand
EAP = Request consideration of referral to Employee Assistance Plan S =
Suspension T = Termination
Z = From verbal warning to dismissal depending on the nature of the offense.
1st
Offence
2nd
Offence
3rd
Offence
4th
Offence
Intoxicated during working hours EAP/S T
Using alcoholic beverages or illegal drugs during working hours Z
False/misleading statements on application T
Intentional reporting incorrect information or falsifying records Z
Stealing - either from fellow employees, or from the Municipality T
Refusal to do work assigned without a valid reason Z
Carrying or using firearms, fireworks, or any other weapon on
Municipal property (except in the course of performing duties) T
Willful destruction or defacing property of the Municipality or fellow
employees EAP/S T
Fighting during working hours Z
Abusive or threatening language to a fellow employee or member
of the public EAP/S T
Failure to report to your supervisor any accident you have while at
work Z
Horseplay, rowdiness, fooling around in a careless manner,
roughhousing in the workplace. Z
Insubordination (refusal to obey any reasonable request from
management) Z
Leaving place of work during working hours without permission EAP/VC WR S T
Repeated failure to report to work on time or leaving early EAP/VC WR S T
Unreported absence from work EAP/W
R S T
Vulgar and/or profane language EAP/VC WR S T
Interfering with work or fellow employees EAP/VC WR S T
Disobeying safety regulations and common-sense safety
precautions Z
Disorderly conduct Z
Immoral conduct or indecency on Municipal property Z
Form 3-5
Corrective Action
VC = Verbal Counselling WR = Written Reprimand
EAP = Request consideration of referral to Employee Assistance Plan S =
Suspension T = Termination
Z = From verbal warning to dismissal depending on the nature of the offense.
1st
Offence
2nd
Offence
3rd
Offence
4th
Offence
Sleeping during working hours EAP/VC WR S T
Speeding and/or careless driving or use of Municipal vehicles or
equipment EAP/S T
Willful neglect and/or mishandling of a machine or other equipment EAP/S T
Violation of Municipal policies outlined in Sections of the Personnel
Policy Manual Z
Harassment in the workplace that is in conflict with the Human
Rights Act of Nova Scotia (refer to Sexual Harassment Policy) Z
Willful and consistent denigration of fellow employees or
Department Heads/Managers EAP/VC WR S T
Other: Z
*The above are to be considered as guidelines for suggested courses of action
Description of offense
Does the employee have a previous record of disciplinary action?
Yes ☐ No ☐
Disciplinary action taken in regard to the above
Form 3-5
Corrective Action
_______________________________________ _________________________
Signature of Employee (confirming knowledge Date
and receipt of a copy of this report)
☐ I am requesting a review of a decision relating to the attached Verbal Warning/ Written
Warning/Suspension
_______________________________________ _________________________
Signature of Supervisor/Department Head Date
_______________________________________ _________________________
Signature of Witness to Discussion and or Date
Warning (if applicable)
_______________________________________ _________________________
Signature of Chief Administrative Officer Date
(for written warning, suspension, or dismissal only)
Attach to this report copies of written warnings, notices of suspension, termination slips or any other relevant
documents. This record is to be placed in the employee’s personnel file and remain there permanently. The
employee will also receive a copy of the report.
Action Taken
Date Completed
Original to Employee File (initial)
Copy to Employee (initial)
Form 4-1
Salary Adjustment Form
Form 4-1
Salary Adjustment Form
Employee
Department Job Title
Date of Hire
Current Salary Step Level
Recommended
Salary
Step Level
Effective Date
Department Head/Supervisor Signature Date
CAO Signature Date
Approved ☐ Not Approved ☐
Notes:
Distribution:
Original to Employee File
Copy to Employee
Scanned to Electronic File
OFFICE USE ONLY COMPLETED DATE INITIALS
Adjustment forwarded to Morneau Shepell
Adjustment made to Group Insurance Premium
Clerk - Note evaluation on Master File
Form 4-4a
Flexible Work Arrangement Request
Form 4-4a
Flexible Work Arrangement Request
Employee
Department
Job Title
Date
Confirm the following prior to initiating the request:
☐ I have considered my unit/department’s criteria for flexible work in making this request
☐ I acknowledge and accept the terms of the Flexible Work Policy
☐ I have completed the Remote Work Self Assessment & Safety Checklist (for work from home option)
Flexible Work Arrangement Requested
☐ Earned days off (EDO)
☐ Variable hours
☐ Work from Home
Current Schedule Proposed Schedule Location
Monday
Tuesday
Wednesday
Thursday
Friday
For EDO indicate day of EDO
*Must complete Flexible Work Arrangement Agreement at end of application.
Why are you requesting the proposed schedule?
Describe your plan for meeting the responsibilities of your position.
Form 4-4a
Flexible Work Arrangement Request
Consider how you will ensure ongoing collaboration with co-workers and your supervisor. How will you ensure
regular two-way communication occurs between employee and supervisor?
What team norms and agreements have you developed to ensure communication with team members?
How will you address team collaboration issues such as scheduling meetings, sharing documents and collaborating
on tasks or projects?
How will you jointly ensure appropriate work/home boundaries are maintained?
How will you create opportunities to participate in the informal interactions of the workplace?
What kind of check-ins should we put in place to ensure your health and well-being given we won’t be seeing each
other in person every day?
How have you ensured that internet connectivity and speed at the remote work location is sufficient for the needs of
the role?
What contingencies are in place for an unexpected internet outage?
What arrangements have been made to create an appropriate and ergonomic workstation?
How will this request positively impact unit operations and/or client service aspects of the role?
How will on-site tasks be distributed equitably among team members?
How will work assignments, goals and priorities be established and work reviewed?