Employee Handbook - Hudson Valley Community College

Employee
Handbook
December 2014
Employee Handbook Table of Contents Calendars
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1
5
Instructional Calendar College Calendar 
Mission of The College Major Campus Policies and Judicial Procedures  Anti Discrimination/Sexual Harassment Policy and complaint procedure  Computer Policy/Email Policy  Identity Theft Prevention Program  Judicial System 6
10
22
25
32
47
49
51
54
American with Disabilities Act [ADA] Fair Labor Standards Act [FLSA] Family and Medical Leave Act [FMLA] Family Educational Rights and Privacy Act [FERPA] Public Employment Safety and Health Act [PESHA] 
56
HVCC Emergency Information 61
73
Security and Privacy of Protected Health Information [HIPAA] Workers’ Compensation 
Accident/Injury Report example NYS Workers’ Compensation Board Claimant Information Packet
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Employee Benefits 
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Health Insurance > Plan Parameters > Rates Flexible Spending Account Dental Insurance > Schedule of Allowances > Claim Form Long‐Term Disability Insurance Employee Assistance Program Retirement Savings Programs > NYS Pension Plans > Tax Deferred Programs Employee Time and Attendance 
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110
116
Tuition Waivers Training 
College Services Available to Employees 
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Standard Work Day Leave Accruals Leave for Cancer Screening Jury Duty Summer Hours 
Professional Development Opportunities 
83
84
88
92
93
97
102
103
106
107
Dental Hygiene Clinic Recreational Facilities Employee Discounts Automotive Lab 118
Instructional Calendar 2015-2016
Fall 2015
Thursday
Monday
August 27
August 31
New Faculty Orientation
Instruction Begins – Day classes
Monday
Tuesday
Monday
Monday
September 7
September 8
September 14
September 21
Labor Day - College Closed
Evening On-Campus Classes Begin
Continuing Education Classes begin Off-Campus
All College Meeting 2 p.m.
County List Census Date
Monday
Monday
October 12
October 26
No Classes – Columbus Day
Mid-Semester Grades Due 10:00 a.m.
Sprint Classes Begin
Friday
Wednesday
Thursday
Friday
Saturday
November 20
November 25
November 26
November 27
November 28
Last day to withdraw from classes
Holiday - College closed
Holiday - College closed
Holiday - College closed
Holiday - College closed
Thursday
Friday
Saturday
Monday
Tuesday
Wednesday
December 17
December 18
December 19
December 21
December 22
December 23
Last day of instruction
Final Exams
Final Exams
Final Exams
Final Exams
Examination Snow Day
Thursday
Friday
December 24
December 25
Holiday – College Closed
Holiday – College Closed
Monday
December 28
Final Grades Due 10:00 a.m.
Thursday
Friday
December 31
January 1
Holiday – College Closed
Holiday – College Closed
Instructional Days
Monday
14
Tuesday
16
Wednesday
15
Thursday
15
Friday
14
Total
74
Page 1
Instructional Calendar 2015-2016
Intersession 2015
Monday
Thursday
Friday
Monday
Friday
Monday
Tuesday
Wednesday
Thursday
Sunday
December 28, 2015
December 31, 2015
January 1, 2016
January 4, 2016
January 8, 2016
January 11, 2016
January 12, 2016
January 13, 2016
January 14, 2016
Classes Begin
Holiday – College Closed
Holiday – College Closed
Classes Resume
Last day to withdraw
Classes End
Final Exams
Snow Day
Grades Due – 10 a.m.
Monday
12/28
9 a.m. – Noon
1 p.m. – 3 p.m.
Tuesday
12/29
9a.m. – Noon
1 p.m. – 3 p.m.
Wednesday
12/30
9a.m. – Noon
1 p.m. – 3 p.m.
Thursday
12/31
Holiday
College Closed
Friday
1/1
Holiday
College Closed
1/3
1/4
9 a.m. – Noon
1 p.m. – 3 p.m.
1/5
9 a.m. – Noon
1 p.m. – 3 p.m.
1/6
9 a.m. – Noon
1 p.m. – 3 p.m.
1/7
9 a.m. – Noon
1 p.m. – 3 p.m.
1/8
9 a.m. - Noon
1 p.m.– 3 p.m.
1/10
1/11
9 a.m. – Noon
1 p.m. – 3 p.m.
1/12
1/13
9a.m. – 11 a.m. Snow Day
Final Exams
1/14
Grades Due
10 a.m.
1/15
Saturday
1/2
1/9
Week 1 – 15 hours
Week 2 – 25 hours
Week 3 – 5 hours
Total hours – 45 hours + 2 hour final exam
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Instructional Calendar 2015-2016
Spring 2016
Monday
January 18
No Classes – Martin Luther King, Day
Tuesday
January 19
Monday
January25
Monday
February 8
Instruction Begins
All day & evening On-Campus Classes
Continuing Education Classes begin
Off-Campus
All College Meeting – 2:00 p.m.
Monday
Wednesday
February 8
February 10
County List Census Date
Faculty Workshop Day - No classes
Monday
March 14
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Monday
Tuesday
Wednesday
March 21
March 22
March 23
March 24
March 25
March 26
March 28
March 29
March 30
Mid-semester Grades Due 10:00 a.m.
Sprint Classes Begin
Spring Break – No Classes
Spring Break – No Classes
Spring Break – No Classes
Spring Break – No Classes
Holiday – College Closed
Holiday – College Closed
Holiday – College Closed
Holiday – College Closed
Classes Resume
Friday
April 15
Last day to withdraw from classes
Thursday
May 12
Last day of instruction
Faculty Honors Convocation 4:30 p.m.
Monday
Tuesday
Wednesday
Thursday
Saturday
Monday
May 16
May 17
May 18
May 19
May 21
May 23
Final Exams
Final Exams
Final Exams
Final Exams
Commencement
Final Grades Due 10:00 a.m.
Instructional Days
Monday
14
Tuesday
15
Wednesday
15
Thursday
16
Friday
15
Total
75
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Summer Sessions 2016
No Classes/College Closed Monday, May 30
No Classes/College Closed Monday, July 4
Summer Session 1 (3 weeks)
Monday
Friday
May 23
June 10
Classes Begin
Classes End
Summer Session 2 (6 weeks)
Monday
Friday
May 23
July 1
Classes Begin
Classes End
Summer Session 3 (12 weeks)
Monday
Friday
May 23
August 12
Classes Begin
Classes End
Summer Session 4 (5 weeks)
Tuesday
Friday
May 31
July 1
Classes Begin
Classes End
Summer Session 5 (3 weeks)
Tuesday
Friday
July 5
July 22
Classes Begin
Classes End
Summer Session 6 (6 weeks)
Tuesday
Friday
July 5
August 12
Classes Begin
Classes End
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HUDSON VALLEY COMMUNITY COLLEGE CALENDAR
2013/2014 ACADEMIC YEAR
Monday
August 26
Classes Begin
Monday
September 2
Labor Day
Monday
September 16
All College Meeting
Monday
October 14
Columbus Day
No Classes College Open
Wednesday November 27
Holiday
College Closed
Thursday
November 28
Thanksgiving
College Closed
Friday
November 29
Holiday
College Closed
Friday
December 13
Classes End
Tuesday
December 24
Holiday
College Closed
Wednesday December 25
Holiday
College Closed
Tuesday
Holiday
College Closed
Wednesday January 1
Holiday
College Closed
Monday
January 20
Martin Luther King Day
No Classes College Open
Tuesday
January 21
Classes Begin
Monday
January 27
All College Meeting
Friday
April 18
Holiday
College Closed
Monday
April 21
Holiday
College Closed
Tuesday
April 22
Holiday
College Closed
Friday
May 9
Classes End
Saturday
May 17
Commencement
Monday
May 26
Memorial Day
Monday
June 2
Summer Hours Begin
Friday
July 4
Holiday
Friday
August 8
Summer Hours End
December 31
College Closed
College Closed
College Closed
Through consultation with bargaining units, the Wednesday before Thanksgiving and the Thursday before Good
Friday or Tuesday following Easter may be holidays instead of Columbus Day and Washington’s Birthday.
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Statement of Commitment
Hudson Valley Community College is committed to providing caring, personal, high-quality
service at a reasonable cost to support students' success in reaching and raising their goals.
Mission Statement
Hudson Valley Community College’s mission is to provide dynamic, student-centered,
comprehensive, and accessible educational opportunities that address the diverse needs of
the community.
Historical Preamble
The college was created to respond to the needs of Rensselaer County and other nearby
counties following World War II, and after the closing of the Veteran's Vocational School in
1953. At first, the college’s programs were largely technical, but by 1960 the first science,
business, and liberal arts programs were added. In the decades since, the college has steadily
increased its offerings, both in degree and certificate programs, so that it is now
comprehensive in its majors and mission.
Since its inception in 1953, Hudson Valley Community College has been sponsored by
Rensselaer County under the supervision of the State University of New York. As one of the
30 community colleges in the state, all of its programs are registered and approved by the
New York State Department of Education* with the authority to award certificates and
associate degrees in arts, science, applied science, and occupational studies.
Hudson Valley Community College is accredited by the Commission on Higher Education of
the Middle States Association, an institutional accrediting agency recognized by the U.S.
Secretary of Education and the Commission on Recognition of Postsecondary Accreditation.
Many of the college’s academic programs also are accredited by specialized national
professional accrediting associations.
In 1966, the college began administering the Capital District Educational Opportunity Center
to better serve the needs of the community.
*New York State Education Department
Office of Higher Education and the Professions
Cultural Education Center, Room 5B28
Albany, NY 12230 (518) 474-5851
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Goals and Objectives
1. To enhance and promote excellence in teaching and learning.
1.1 To institute an integrated academic and administrative infrastructure that makes
optimal employee support a priority.
1.2 To support faculty with the necessary resources for professional and personal
development.
1.3 To develop effective teaching and learning methods that will assist the college in
adapting to changing student academic needs.
1.4 To increase and strengthen articulation agreements with educational institutions and
affiliations with educational partnerships.
1.5 To explore thoroughly all aspects of new educational delivery systems prior to
implementation.
1.6 To create an academic atmosphere that encourages and supports innovation in the
teaching and learning environment.
1.7 To assess effectiveness in the teaching and learning environment.
1.8 To ensure that the goals and standards of the college's academic programs are
achieved.
1.9 To provide and maintain a classroom environment that is conducive to teaching and
learning.
2. To develop and support a student centered collegial environment.
2.1
2.2
2.3
2.4
2.5
2.6
To promote and provide friendly, informative and supportive services for students.
To develop a systematic and integrated approach to student persistence and success.
To provide effective academic advising for all students.
To develop and maintain a student scheduling system that is driven by student needs.
To increase awareness of student support services, policies and campus events.
To foster and promote student responsibility and involvement in his/her education.
3. To promote the integration of pluralism within the college community.
3.1 To develop and promote institutional programs and processes that embrace diversity.
3.2 To promote affirmative action and equal employment opportunities to increase the
number of faculty and staff members from under-represented groups.
3.3 To increase the recruitment, retention, success and transfer of students from underrepresented groups.
4. To create and sustain a technological environment that is supportive of academic and
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administrative needs.
4.1 To provide for continuous review and upgrading of technology as it serves academic
and administrative applications.
4.2 To promote computer competency for students, faculty and staff.
4.3 To maintain an administrative information system that is useful, integrated and user
friendly.
4.4 To provide a supportive environment for the development and implementation of
distance learning opportunities.
5. To maintain and improve administrative services.
5.1 To develop and maintain an integrated institutional planning process.
5.2 To regularly assess the effectiveness of all areas under administrative services.
5.3 To promote communication, cooperation and shared decision making among
administrative and academic departments.
5.4 To ensure fair and equitable performance evaluation, promotion and compensation
systems for all faculty and staff.
5.5 To support the staff with the necessary resources for professional and personal
development.
5.6 To implement a non-adversarial and collaborative approach to the bargaining process.
5.7 To provide a clean, safe and accessible environment which meets the needs of
students, faculty and staff.
5.8 To promote fiscal responsibility and accountability.
6. To develop and foster beneficial relationships with the community.
6.1 To enrich and increase administrative and academic partnerships with businesses and
the community.
6.2 To promote and support the departmental efforts that generate external revenue.
6.3 To develop a comprehensive enrollment management system to achieve and maintain
effective recruitment and retention of students.
6.4 To promote the maximum achievable graduation rate for students.
6.5 To promote Hudson Valley Community College as an exemplary educational institution
through an institution-wide marketing focus, that highlights the merits of all programs.
6.6 To promote a spirit of community service among students, faculty and staff.
6.7 To serve as a cultural resource for internal and external communities through both
curricular and non-curricular programs and activities.
6.8 To cultivate relationships with external funding sources and actively pursue financial
support for programming, goods and services not supported by the college budget.
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Community Bill of Rights and Responsibilities
Hudson Valley Community College serves residents of the Capital Region and other areas in
appropriate and diverse ways, striving always to improve their quality of life by offering affordable
education, training and service. As a full-opportunity college dedicated to teaching and learning,
Hudson Valley Community College makes it possible for every applicant to pursue an appropriate
program of study. In the spirit of its mission, the Community Bill of Rights and Responsibilities states
that:
All members of the college community have the right and responsibility to work and learn in
a collegial setting:
Where all members of the college community are treated with courtesy and respect;
That has clear ethics and conduct codes with fair and consistently enforced
consequences for non-compliance;
That is safe, orderly and drug free;
That has clearly stated, high academic standards and the instructional materials and
equipment necessary to implement rigorous academic programs;
Where the college’s mission statement drives all academic and administrative
operations and functions.
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Anti-Discrimination And Harassment Policies And Complaint Procedure
Administered by: The Office of Affirmative Action & Human Resources Development
INTRODUCTION
Hudson Valley Community College has established an Equal Employment Opportunity Policy
and a Sexual/Discrimination Harassment Policy that is consistent with Federal and State antidiscrimination legislation. The policies which are set forth below represent the College’s ongoing commitment to providing an environment in both education and employment that is
free from such unlawful discrimination and harassment on the basis of race, color, national
origin, religion, age, sex, sexual orientation, disability, veteran status or marital status. In order
to equitably and uniformly enforce these policies, the College must seek to balance the
interests of those individuals or groups of individuals allegedly victimized by unlawful
discrimination or harassment with the due process rights of the accused. To this end, the
College has established a complaint procedure for the review of allegations of unlawful
discrimination and harassment. It is the goal of the College that these procedures serve as a
mechanism through which the College may fairly and equitably identify, respond to and/or
prevent incidents of unlawful discrimination and harassment on its campus and permit, if
possible, the resolution of alleged acts of unlawful discrimination or harassment without
resorting to the often expensive and time-consuming procedures of State and Federal
enforcement agencies or courts.
The procedures set forth below are applicable to both employees and students of the College.
Employee grievance procedures established through negotiated contracts, academic grievance
review committees, student disciplinary grievance boards and any other procedures defined by
contract shall continue to operate as before. It is important that neither the student nor the
employee is required to pursue resolution of their complaints through the College’s internal
procedure. Rather a Complainant may, at his or her discretion, file a complaint with a court of
competent jurisdiction or with an outside enforcement agency, such as the New York State
Division of Human Rights, the Equal Employment Opportunity Commission, the Office for Civil
Rights of the United States Department of Education or the Office of Federal Contract
Compliance of the United States Department of Labor. As of the date of this Policy, the
following deadlines apply:
New York State Division of Human Rights - 365 days after the latest act of alleged
unlawful discrimination;
Court of Competent Jurisdiction in New York State - 3 years from the accrual date of the
action;
Equal Employment Opportunity Commission - 365 days after the latest act of alleged
unlawful discrimination and generally 90 days after receiving a “right to sue” from the
Equal Employment Opportunity Commission with a Federal court;
Office for Civil Right of the United States Department of Education - 180 days after the
latest act of alleged unlawful discrimination; and
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The Office of Federal Contract Compliance (OFCCP) of the United States Department of
Labor.) - Depending on the nature of the complaint, 180 or 300 days.
Note: The deadlines referenced herein are provided only as general guidance and do
not constitute legal advice, legal opinion, or legal counsel and do not create any legal
relationship between the College and its students or employees. It is the Complainant’s
responsibility to seek legal counsel and to file his/her actions with any outside agency
or court of competent jurisdiction in a timely manner should he/she decide to forego
utilizing the College’s internal procedures. Once a Complaint arising from the same set
of facts and circumstances is lodged with such outside agencies or a court of competent
jurisdiction, the internal procedures set forth herein will not be applicable and the
student/employee will have no redress through the College.
The Affirmative Action Officer or the Affirmative Action/Sexual Harassment Advisory Council
shall receive all complaints of alleged unlawful discrimination and/or harassment; he/she shall
assist the Complainant in the use of the complaint form defining the charge(s); and he/she
shall provide the Complainant with information about the various options the Complainant has
in terms of where a complaint may be filed. While the Affirmative Action Officer or member of
the Affirmative Action/Sexual Harassment Advisory Council will provide, to the best of his/ her
knowledge, information concerning the processes relevant to outside agencies or courts,
he/she is not an attorney at law and can provide no advice as to a Complainant’s procedural or
substantive rights with regards to agencies or courts, including deadlines for filing.
Equal Employment Opportunity Policy Compliance Statement from the President
It is the policy of the Board of Trustees of Hudson Valley Community College to ensure that
persons associated with the College receive the fair and equal treatment prescribed within the
tenets of equal employment opportunity and affirmative action. All employment decisions are
made and will continue to be made on the job-related, objective bases or merit, qualifications,
competence and business necessity. Hudson Valley does not discriminate with regard to race,
color, religion, age, sex, national origin, marital status, disability, qualified special disabled
veterans, veterans of the Vietnam era, recently separated veterans, and other protected
veterans, sexual orientation, and all other categories covered by law.
The Board of Trustees has entrusted me with the overall responsibility for equal employment
opportunity and affirmative action. I expect the support of all employees in attaining and
maintaining our goals for a workplace free of discrimination. Equal employment opportunity is
not accomplished at the expense of any group or individual, but rather it is good business
practice and it contributes to an organization enriched by diversity and excellence. As
President, I am committed to ensuring that HVCC acts affirmatively in developing avenues of
entry, retention and mobility for persons in all job titles. The Affirmative Action Plan serves as
the foundation for the College’s good faith effort to ensure that a wider net is cast for
protected group members as the vehicle by which the pool of applicants for vacancies is
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expanded. The Plan applies equally to all appointments of the Board of Trustees.
HVCC recognizes that an effective affirmative action plan articulates specific results-oriented
procedures to which good faith effort is applied. The goal of such procedures, in combination
with good faith efforts, is equal employment opportunity; for procedures without effort to
make them work are meaningless and effort, absent specific and meaningful procedures, is
inadequate.
Employees of and applicants to the College will not be subject to harassment, intimidation,
threats, coercion, or discrimination because they have engaged or may engage in filing a
complaint, assisting in a review, investigation, or hearing or have otherwise sought to obtain
their legal rights related to any Federal, State, or local law regarding EEO for qualified
individuals with disabilities or qualified protected veterans.
To this end, the President has entrusted Hudson Valley’s Affirmative Action Officer with
responsibility for implementation and maintenance of the Plan. The Officer may be contacted
in Fitzgibbons Hall, Room 207, or by telephone at 518-629-8110.
The Affirmative Action Officer is responsible for monitoring the affirmative action plan and
reporting periodically to the President. The Officer should be contacted in the event an HVCC
employee or prospective applicant perceives that he or she has not been treated in accord
with the Equal Employment Opportunity Policy of the College.
As President, I wish to add my personal note of commitment to assuring that our College
carries out our Equal Employment Opportunity policy and fulfills the obligations of our
Affirmative Action Plan.
Dr. Andrew J. Matonak
President, Hudson Valley Community College
SEXUAL HARASSMENT POLICY
Sexual harassment is a violation of Title VII of the Civil Rights Act of 1964 and Title IX of the
Education Amendments of 1972. Hudson Valley Community College is committed to providing
an environment that is non-discriminatory, humane and respectful; one that supports and
rewards employees and students on the basis of relevant considerations like merit, effort,
competence, qualifications and business/academic necessity, and deters inappropriate
conduct that occurs in the College’s activities or operations.
Sexual harassment is unacceptable and in conflict with the mission and interests of the College.
Sexually harassing conduct between supervisors and staff members or between faculty and
students unfairly exploits the power inherent in the supervisor or faculty’s role. Through salary
increases, performances appraisals, academic advisement and academic evaluation, a
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supervisor or faculty member can have a decisive influence on a staff member’s career or a
student’s academic development. Sexual harassment in this context exhibits a lack of decency
and integrity, and is considered an abuse of power.
While sexual harassment typically occurs in situations where positions of power differentials
exist between individuals, this policy also recognizes that sexual harassment can occur
between individuals where no such power differential exists, such as in faculty-faculty or
student-student interaction.
Either men or women can be sexual harassers and either men or women can be the victims of
sexual harassment. Sexual harassment can also occur between members of the same sex.
Employees and students of either gender may make a claim of sexual harassment under this
policy.
The College will not tolerate sexual harassment. The College will act promptly and equitably,
within the framework of due process, to investigate alleged sexual harassment and to affect a
remedy when such allegations are determined valid. Further, this Sexual Harassment Policy
and the complaint procedures provided herein, shall be distributed campus-wide and internal
training sessions may be made available to employees and students pertaining to sexual
harassment.
Recognizing Sexual Harassment
Sexual harassment takes many forms, ranging from sexual innuendoes made in the context of
humor to physical assault. The key to determining whether a conduct constitutes sexual
harassment is determining whether the behavior is unwelcomed and/or unreasonably
interferes with an employee or student’s performance or creates a hostile, intimidating or
offensive environment. Examples may include:
Verbal: Sexual innuendo, suggestive comments, sexual propositions, etc.
Non-Verbal: obscene gestures, suggestive or degrading sounds, etc.
Physical: Unwanted contact, such as groping, pinching, grabbing, etc.
Visual: Pin-up calendars, sexually suggestive or explicit cartoons, pictures, objects, etc.
Threatening: Demands for sexual favors, stalking, rape, etc.
Who You Can Go To For Help
For information, assistance in using the informal procedure or to file a Complaint of Unlawful
Discrimination or Harassment, a student, faculty or staff member of the college may contact
any member of the Affirmative Action/Sexual Harassment Advisory Council or
Room 140
Administration Building
(518) 629-4552
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Title IX Compliance Statement
Title IX (Department of Education Amendment 1972) prohibits sex discrimination in any
education program or activity receiving Federal financial assistance, such as a Federal grant or
loan. It encourages recipients to take affirmative action to overcome effects of conditions,
which may have resulted in exclusion of women from participation in specific education
programs or activities. Title IX applies to student admissions and student affairs policy and the
employment of staff in connection with the recipient’s education programs/activities. It
mandates the designation of a responsible employee to coordinate compliance with its
provision, as well as the establishment of a complaint procedure to resolve student and
employee complaints alleging unlawful discrimination.
It is the policy of the Board of Trustees of Hudson Valley Community College to ensure that
persons associated with the College receives the fair and equal treatment prescribed within
the tenets of equal opportunity. All decisions are made and will continue to be made on the
job-related, objective bases of merit, competence, qualifications and business or academic
necessity. Hudson Valley Community College does not discriminate with regard to race, color,
national origin, religion, age, sex, sexual orientation, disability, veteran status, or marital status
or any other category protected by civil statute or regulation.
The College prohibits discrimination in all programs, policies, standards and activities,
maintains an established complaint procedure and assigns compliance responsibility to the
Affirmative Action Officer.
EQUAL EMPLOYMENT/SEXUAL HARASSMENT COMPLAINT PROCEDURES
COVERAGE: Employees, students, and prospective applicants of the College may use these
procedures if they believe that they have been the victims of any unlawful discrimination or
harassment at the College.
PURPOSE: The complaint procedure is provided for the review of complaints alleging unlawful
discrimination or harassment in any Hudson Valley Community College policy or program when
the alleged Unlawful discrimination or Harassment is perceived to be based on the
complainant’s race, color, national origin, religion, age, sex, sexual orientation, disability,
veteran status, or marital status or any category protected by civil statute or regulation.
DEFINITIONS:
Affirmative Action/Sexual Harassment Advisory Council – Representatives of all levels of the
College who advise the President and the Affirmative Action Officer on matters relating to
Equal Employment Opportunity, Affirmative Action, and Diversity. They are appointed by the
President. They serve as the pool of persons from which the Tri-partite Council will be selected
Page 14
in the formal stage of the complaint process.
Complainant - An employee, applicant for employment, or student of the College who believes
that he or she has been the victim of unlawful discrimination or harassment, and submits a
complaint.
Equal Employment Opportunity - The standard by which decisions that pertain to a person’s
employment or academic affairs with the College are made.
Discriminatory Harassment - Discriminatory harassment is based on race, color, national origin,
religion, age, sex, sexual orientation, disability, veteran status, or marital status or other
protected characteristics, which is oral, written, graphic or physical conduct. The actions must
be sufficiently severe, pervasive, or persistent so as to interfere with or limit the ability of an
individual to participate in or benefit from the College’s programs or activities. Such activities
include actions that derogate or humiliate a person or group because of actual or supposed
traits. Examples include, but are not limited to, ethnic or racial slurs or jokes, which have the
purpose or effect of creating an offensive environment.
Sexual Harassment - Under Title VII of the Civil Rights Act (1964), sexual harassment is cited as
unwelcome sexual advances, requests for sexual favors, or other verbal or physical conduct of
a sexual nature when (1) Submission to such conduct is made explicitly an employment term or
condition [or a condition on which one’s academic standing is predicated]; or (2) Submission to
or rejection of such conduct is used as a basis for employment [or academic] decisions; or (3)
Such conduct has the purpose or the effect of unreasonably interfering with one’s [academic]
or work performance, or creating an offensive, intimidating or hostile [academic] or work
environment.
Respondent - An individual or entity that answers in a complaint alleging unlawful
discrimination or harassment or the person(s) accused of alleged unlawful discrimination or
harassment.
Unlawful Discrimination - consists of:
harassment on the basis of race, color, national origin, religion, age, sex, sexual
orientation, disability, veteran or marital status;
employment decisions based on stereotypes or assumptions about the abilities, traits,
or performance of individuals of a certain race, color, national origin, religion, age, sex,
sexual orientation, disability, veteran or marital status; or
retaliation against an individual for filing a charge of discrimination, participating in an
investigation, or opposing discriminatory practices.
APPLICABILITY - This complaint procedure does not supplant nor duplicate any existing
complaint procedure. It does not deprive the complainant the right to file with outside
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government agencies, such as the New York State Division of Human Rights (DHR); U.S. Equal
Employment Opportunity Commission (EEOC); U.S. Office of Civil Rights of the Department of
Health, Education and Welfare (OCR); the Office of Federal Contract Compliance (OFCCP) of
the United States Department of Labor (DOL); or with a court of competent jurisdiction.
The procedure may not be used if a complaint based on the same facts and circumstances is
filed with a State or Federal agency or with a court of competent jurisdiction, or if a complaint
has been filed under any collective bargaining agreement. Any investigation underway will
terminate, without conclusion, at the time a complaint is filed with a state or federal agency or
a collective bargaining representative, or a court action is initiated on the same complaint. It is
the responsibility of the complainant to be aware of any filing deadlines for any outside agency
or court even in the event he/she initially chooses to attempt to resolve the complaint through
the College’s internal procedures. It is also the responsibility of the complainant to inform the
Affirmative Action Officer of any previous, pending or initiated actions filed with a state or
federal agency or court. While the Affirmative Action Officer of the College will make
reasonable attempts to notify the complainant of general time limitations, neither the
Affirmative Action Officer, the Affirmative Action/Sexual Harassment Advisory Council, nor the
College shall be held responsible for any failure on the part of the complainant to meet any
filing deadline.
RIGHT TO COUNSEL
Both the complainant and the respondent shall have the right to be assisted by an attorney at
all stages of both the informal and formal stages of the College’s internal complaint process.
CONFIDENTIALITY
Unlawful discrimination or Harassment complaints will be handled as confidentially as possible
while enabling the College to fully investigate the complaint. Information about the complaint
will only be divulged to individuals who have a legitimate need to know. All records pertaining
to complaints shall be kept and maintained by the Affirmative Action Officer.
SANCTIONS
Persons who are found to have engaged in unlawful discrimination and/or harassment may be
subject to sanctions that are reasonably calculated to end the unlawful discrimination and
prevent its reoccurrence. Sanctions that may be imposed include, but are not limited to,
written warnings; letter of reprimands; suspensions; change of job or class assignments;
termination; or expulsion.
RETALIATION
Reprisal actions and encouraging others to retaliate against anyone involved in the
investigation of an Unlawful discrimination or harassment complaint is prohibited. This
includes anyone who reports, is thought to have reported or cooperates in the investigation
process. The College considers retaliation to be a violation of College policy and may be subject
Page 16
to sanctions as provided herein.
FALSE CHARGES OF DISCRIMINATION
Filing a false charge of unlawful discrimination or harassment is a serious offense. If an
investigation reveals that a complainant knowingly filed false charges, appropriate actions and
sanctions as provided herein may be taken.
WHERE TO FILE A COMPLAINT OF DISCRIMINATION
For information, assistance in using the informal procedure and/or to file a formal complaint
any student, employee or applicant for employment, may contact the Affirmative Action
Officer.
Affirmative Action Officer
Human Resources
Room 140
Administration Building
(518) 629-4552
ADDITIONAL RESOURCES
For personal counseling: Center for Counseling and Transfer, Campus Center, Room 260, (518)
629-7320
For medical services: College Health Services, Fitzgibbons Hall, Room 146, (518) 629-7468
For escort service: Public Safety/Security, Campus Center, Room 170, (518) 629-7210
PROCEDURE FOR FILING A COMPLAINT OF DISCRIMINATION
PART A: Informal Resolution
1. The Affirmative Action Officer shall receive initial inquiries, reports and requests for
consultation and counseling. Assistance will be available whether or not a written
complaint is contemplated. It is the responsibility of the Affirmative Action Officer to
respond to all such inquiries, reports and requests as promptly as possible and consider
all such facts in an objective manner and in a manner appropriate to the particular
circumstances.
Note: It is the responsibility of the complainant to be certain that any complaint filed is
filed within the 60 calendar day period that is applicable under this paragraph.
2. Complaints or concerns that are reported to an administrator, manager or supervisor
concerning an act of discrimination or harassment shall be immediately referred to the
Affirmative Action Officer for investigation and resolution. Complaints may also be
made directly to a member of the Affirmative Action/Sexual Harassment Advisory
Council who will refer the case to the Affirmative Action Officer for investigation and
Page 17
resolution.
3. A written complaint must be filed with the Affirmative Action Officer within 60 calendar
days following the last act or occurrence of an alleged unlawful discriminatory act or
act of harassment. All such complaints must be submitted on the forms provided by the
College (see Appendix A). This form will be used for both the initiation of complaints
under the informal procedure and the conversion of the complaint to the formal
procedure.
4. If the Affirmative Action Officer is the respondent in a complaint of discrimination, the
President of the College shall designate a person to investigate and attempt to resolve
the complaint. That person shall carry out the duties and responsibilities of the
Affirmative Action Officer in that specific complaint.
5. The complaint shall contain:
(a) The name, local and permanent address(es), and telephone number(s) of the
Complainant.
(b) A statement of facts explaining what happened and what the complainant believes
constituted the unlawful discriminatory act(s) in sufficient detail to give each
respondent reasonable notice of what is claimed against him/her. The statement
should include the date(s), approximate time(s) and place(s) where the alleged act(s) of
unlawful discrimination or harassment occurred. If the act(s) occurred on more than
one date, the statement should also include the last date on which the acts occurred as
well as detailed information about any prior acts. The names of any potential witnesses
should be provided, if appropriate.
(c) The name(s), address(es) and telephone number(s) of the respondent(s), i.e., the
person(s) claimed to have committed the act(s) of unlawful discrimination.
(d) Identification of the status of the person(s) charged, whether faculty, staff, or
student.
(e) A statement indicating whether or not the complainant has filed or reported
information concerning the incidents referred to in the complaint with a non-college
official, court, or agency, under any other complaint or complaint procedure. If an
external complaint has been filed, the statement should indicate the name of the court,
person, department, or agency with which the information was filed and its address or
to which it was reported.
(f) Such other or supplemental information as may be requested.
6. If the complainant brings a complaint beyond the period in which the complaint may be
addressed under these procedures, the Affirmative Action Officer may terminate any
further processing of the complaint or advise the complainant of the alternative forums
(see Appendix B for a list of alternative forums).
7. If a complainant elects to have the matter dealt with in an informal manner, the
Page 18
Affirmative Action Officer will attempt to reasonably resolve the problem to the mutual
satisfaction of the parties.
8. In seeking an informal resolution, the Affirmative Action Officer shall attempt to review
all relevant information, interview pertinent witnesses, and bring together the
complainant and the respondent, if desirable. If a resolution satisfactory to both the
complainant and the respondent is reached within 14 calendar days from the filing of
the complaint, through the efforts of the Affirmative Action Officer, the Affirmative
Action Officer shall close the case, sending a written notice to that effect to the
complainant and respondent. The written notice, a copy of which shall be attached to
the original complaint form in the Affirmative Action Officer’s file, shall contain the
terms of any agreement reached by complainant and respondent, and shall be signed
and dated by the complainant, the respondent and the Affirmative Action Officer.
9. If the Affirmative Action Officer is unable to resolve the complaint to the mutual
satisfaction of the complainant and respondent within 14 calendar days from the filing
of the complaint, the Affirmative Action Officer will so notify the complainant. The
Affirmative Action Officer shall again advise the complainant of his or her right to
proceed to the next step internally and/or the right to separately file with appropriate
external enforcement agencies.
.
NOTE: The time limitations set forth above in paragraphs 7 and 8, may be extended by mutual
agreement of the complainant and respondent with the approval of the Affirmative Action
Officer the complainant and respondent.
10. At any time, subsequent to the filing of the complaint form in Appendix A under the
informal procedures provided in Part A above, the complainant may elect to proceed
under the Formal Complaint Procedure as specified in Part B of this document and
forego the informal resolution procedure.
11. Resolution of informal complaints can include an apology by the harasser, monitoring
treatment of the complainant to ensure that s/he is not subjected to retaliation by the
alleged harasser or others because of filing a complaint, training or counseling of the
alleged harasser or monitoring of the alleged harasser, or other resolutions which the
parties may agree.
PART B: The Formal Complaint Procedure
The Formal Complaint Procedure is structured in a way to promote the timely and fair
resolution of a complaint filed hereunder. While the College will make every effort to strictly
comply with the timeframes set forth herein, its failure to do so shall not constitute a waiver or
otherwise nullify the procedures set forth herein. Moreover, in the event that it is necessary to
undertake immediate measures before completing an investigation to ensure that further
Harassment or Unlawful discrimination does not occur, a recommendation may be made to
the President of the College or his/her designee to make scheduling changes so as to avoid
contact between the parties, transferring the respondent or placing the respondent on nondisciplinary leave with pay pending the conclusion of the investigation.
Page 19
1. The formal complaint proceeding is commenced by the filing of a complaint form as
described in Part A(4). The 60 calendar day time limit also applies to the filing of a
formal complaint.
2. If the complainant first pursued the informal process and subsequently wishes to
pursue a formal complaint, he/she may do so by checking the appropriate box, and
signing and dating the complaint form.
3. If an informal resolution was not pursued, the Affirmative Action Officer shall notify the
complainant 14 calendar days from the filing of the complaint.
4. Upon receipt of a complaint, the Affirmative Action Officer will provide an initialed,
signed, date-stamped copy of the complaint to the Complainant. As soon as reasonably
possible after the date of filing of the complaint, the Affirmative Action Officer will mail
a notice of complaint and a copy of the complaint to the respondent(s). Alternatively,
such notice with a copy of the complaint may be given by personal delivery, provided
such delivery is made by the Affirmative Action Officer (or designee) and, that proper
proof of such delivery, including the date, time and place where such delivery occurred
is entered in the records maintained by or for the Affirmative Action Officer.
5. Within 7 calendar days of receipt of the complaint, the Affirmative Action Officer shall
send notification to the complainant, the respondent and the College President that a
review of the matter shall take place in the form of a hearing by a Tripartite Panel to be
jointly selected by the complainant and the respondent from a pre-selected pool of
eligible participants (see Appendix C).
6. The Tripartite Panel shall consist of one member of the pre-selected pool chosen by the
complainant, one member chosen by the respondent and a third chosen by the two
designees. The panel members shall choose a Chairperson amongst themselves.
Selection must be completed and written notification of designees submitted to the
Affirmative action Officer no later than 7 calendar days after the complainant, the
respondent and the President received notice under Paragraph 6 above.
If the President is the respondent, then the third member of the panel shall be selected by the
College Board of Trustees.
7. In the event that the procedural requirements governing the selection of the Tripartite
Panel are not completed within 7 calendar days after notification, the Affirmative
Action Officer shall complete the selection process.
8. The Tripartite Panel shall review all relevant information, interview pertinent witnesses
and, at their discretion, hear testimony from and bring together the complainant and
the respondent, if desirable. Both the complainant and the respondent(s) shall be
entitled to submit written statements or other relevant and material evidence and to
provide rebuttal to the written record compiled by the Tripartite Panel.
9. Within 24 calendar days from the completion of the Tripartite Panel’s review, including
a hearing, the Chairperson of the Tripartite Panel shall submit a summary of its findings
and the Tripartite Panel’s recommendation(s) for further action or sanctions, if any, on
a form to be provided by the Affirmative Action Officer, to the President. If the
Page 20
President is the respondent, the findings and recommendation shall be submitted
concurrently to the Sponsor of the College, namely Rensselaer County, and to the
Chancellor.
10. Within 7 calendar days of receipt of the written summary, the President or his/her
designee shall issue a written statement to the complainant and respondent, indicating
what action the President proposes to take, if any. The action proposed by the
President or designee may consist of:
(a) A determination that the complaint was not substantiated.
(b) A determination that the complaint was substantiated and will either uphold,
reverse or modify the recommendation.
If the President is the respondent, the College Sponsor, namely Rensselaer County, and
the Chancellor shall concurrently issue a written statement to the complainant and
respondent indicating what action the College Sponsor, namely Rensselaer County, and
the Chancellor proposes to take. The College Sponsor, namely Rensselaer County, and
the Chancellor’s decision shall be final for purposes of this discrimination procedure.
11. If the complainant is dissatisfied with the President’s or the College Sponsor, namely
Rensselaer County, and the Chancellor’s decision, the complainant may elect to seek
reconsideration of the decision to the Chairperson of the College Board of Trustees, for
reconsideration within 7 calendar days of the decision. The decision shall be reversed,
amended, or upheld. The decision shall be final. If the complainant is unsatisfied with
the result, nothing precludes the complainant from filing a complaint with state and/or
federal agencies or a court of competent jurisdiction. (see Appendix B) The Affirmative
Action Officer will provide to the best of his/her knowledge, general information
concerning the processes relevant to outside agencies or courts but since he/she is not
an attorney at law, he/she can provide no advice as to procedural or substantive rights
concerning these agencies, or courts, including deadlines for filing.
FILING A COMPLAINT WITH AN EXTERNAL (N.Y. STATE OR FEDERAL) AGENCY OR COURT OF
COMPETENT JURISDICTION
Students or employees of the college may file a complaint of unlawful discrimination with the
appropriate state or federal agencies listed in Appendix B.
Filing a complaint with a state or federal agency, or a court of competent jurisdiction on the
same facts or circumstances as provided in a complaint filed pursuant to the College’s AntiDiscrimination and Harassment Complaint Procedure will terminate the latter procedures for
processing a complaint of unlawful discrimination. The Affirmative Action Officer will send a
letter to the complainant of the termination, immediately after confirming that the complaint
has been filed with a state or federal agency, or with a court of competent jurisdiction.
Page 21
Computer Use Policy
The goals of Hudson Valley Community College are to provide computer users with state-ofthe-art computing facilities and to keep the number of restrictions on individuals to a minimum,
while maintaining excellent service for all users, students in pursuit of their academic goals and
employees to conduct assigned work activity.
To assist the College in achieving these objectives, users themselves must observe reasonable
standards of behavior in the use of these facilities and maintain an atmosphere of civility,
mutual respect and high ethical standards. Proper use includes compliance with the following
guidelines:
•
•
No attempt will be made to modify or destroy system software components such as
operating systems, compilers, utilities, applications or other software residing on any
College computer, except the user's own files.
No attempt will be made to electronically transmit or post any material which is
considered harmful, abusive, threatening, defamatory, derogatory, harassing, vulgar,
obscene, sexually explicit, hateful, or racially, ethnically or otherwise objectionable.
•
No attempt will be made to access, read, modify or destroy files belonging to another
user without complete authorization from that user to do so.
•
No attempt will be made to connect to or use College computers with a user ID which
was not assigned to you by the College. Use of another person's user ID or password is
prohibited.
•
No attempt will be made to gain access to a password belonging to another person or
place a password other than your own in a file on a College computer. In addition, no
attempt will be made to install, run or place software designed for this purpose on any
College computer.
•
No attempt will be made to bypass or otherwise defeat system security to gain access to
programs, files or other computer data or to install, run or place software designed for
this purpose on any College computer.
•
No attempt will be made to copy, store, post or distribute computer software, files or
any other material in violation of trademark, copyright or confidentiality laws or when
you do not have a legal right to do so.
•
No attempt will be made to interfere with proper operation of a computer or interfere
with another person's use of a computer, including for example, the electronic
transmission or posting of files or programs containing viruses or any other content
intended to interfere with proper operation of a computer.
Page 22
•
No attempt will be made to impersonate any person, including other Hudson Valley
Community College students and employees. No attempt will be made to disguise the
origin of any electronically transmitted or posted material. No attempt will be made to
make unauthorized use of someone else's electronic signature.
•
No unauthorized attempts to use, modify, connect or disconnect computer equipment,
peripherals, communication equipment and cables.
•
No unauthorized attempt will be made to use any College computer to electronically
transmit chain letters, junk mail, pyramid schemes or any other unsolicited mass
mailings to multiple recipients with the exception of employees conducting College
business and students completing required College course assignments.
•
No unauthorized attempt will be made to connect to and/or gain access to information
being transported by computer networks, or to install, run or place software designed
for this purpose on any College computer. Installation or use of any network
communication software not approved by the College is prohibited.
•
No user will make their password known to anyone other than an employee of the
College authorized to assist employees or students with computer related problems.
•
No food or drink is permitted in any computer classroom or computer learning center
with the exception of the Computer Café in the Campus Center.
•
Users of College computers will comply with all local, state, federal and international
laws relating to the use of computers and any other electronic communication services
provided by the College.
•
Use of College computers for commercial, business purposes or personal profit is
prohibited without specific authorization from the College for such use. Commercial or
business purposes include advertising the sale of goods and services not directly related
to Hudson Valley Community College or campus based organizations.
•
Use of College computers to falsify or modify documents in a manner which is
unauthorized, is a violation of the rights of owners, is a violation of copyright laws or is
not properly attributed is prohibited.
•
Use of College computers and network services for local or remote game playing is
prohibited unless specifically required as part of a course in which a student is currently
registered or a faculty member is currently teaching. In addition, the installation,
uploading, downloading or storage of any game software on College computers is
prohibited.
•
Use of College computers and network services for IRC (Internet Relay Chat) or any
other form of interactive chat communication is prohibited unless specifically required
Page 23
for communication as part of a course in which a student is currently registered or a
faculty member is currently teaching.
•
Web site services for the entire campus community are provided on a centralized server
by the Office of Computer Services. Use of any other College computer for the purpose
of serving a web site is prohibited.
The Computer Services department regularly monitors all computer systems usage. All
occurrences of computer usage abuse, which interfere with other users or with proper
functioning of the computer system will be investigated "in depth." When placing files on the
College's computer systems, users should be aware that Computer Services has access to their
files and may review the contents of their account at any time when investigating problems or
suspected computer usage abuse. Findings of each investigation are forwarded to the Vice
President for Student Services. In addition, Hudson Valley Community College reserves the right
to remove or otherwise restrict access to material stored on any College computer system in
violation of the College's computer policy as stated above.
All instances of unethical or irresponsible use of computing facilities are grounds for disciplinary
action by the College's Regulations Review Board (see section in the College Catalog on Campus
Regulations for Students, Visitors and College Personnel and Organizations). Instances of abuse
may result in civil and/or criminal proceedings. The College expects that all users of computing
facilities will observe reasonable standards of behavior.
Page 24
Identity Theft Prevention Program for Hudson Valley Community College
Program Adoption
Hudson Valley Community College developed this Identity Theft Prevention Program
(“Program”) in order to comply with the Federal Trade Commission’s Red Flags Rule (16 CFR
681.2). The Board of Trustees determined that this Program was appropriate for Hudson Valley
Community College, and therefore approved this Program on April 23, 2009.
Purpose
The purpose of the Identity Theft Prevention Program is to prevent frauds committed by the
misuse of identifying information. The Program is designed to detect, prevent and mitigate
identity theft in connection with covered accounts, and to provide for continued administration
of the Program. The Program shall include reasonable policies and procedures to:
1. Identify relevant red flags for covered accounts and incorporate those red flags into the
Program;
2. Detect red flags;
3. Respond appropriately to any red flags that are detected; and
4. Review and update the Program periodically to consider and incorporate changes in
risks.
Definitions
Account:
A relationship established with an institution by a student, employee, or
other person to obtain educational, medical, or financial services.
Covered Account:
An account that permits multiple transactions or poses a reasonably
foreseeable risk of being used to promote an identity theft.
Identity Theft:
A fraud committed or attempted using the identifying information of
another person without authority.
Red Flag:
A pattern, practice, or specific activity that indicates the possible
existence of identity theft.
Responsible Staff:
Personnel who regularly work with Covered Accounts and are responsible
for performing the day-to-day application of the Program to a specific
Covered Account by detecting and responding to Red Flags.
Program Administrator:
The individual designated with primary responsibility for
oversight of the Program.
Page 25
Covered Accounts; Responsible Staff; Red Flags; Responses:
Covered Account:
Student Refund Checks
Responsible Staff:
Cashier
Background:
Students are required to present either a Hudson Valley Community
College Identification Card, or a driver’s license or other government
issued photo identification when picking up a check. All checks are either
mailed to students, or picked up by student in the Cashier’s Office.
Red Flag 1:
Insufficient or suspicious identification is presented by a student who is
trying to pick up a check.
Response:
Withhold check unless or until the student’s identity has been established
through acceptable means.
Covered Account:
Hudson Valley Community College Identification Card
Responsible Staff:
ID Card Equipment Operators
Background:
Students are required to present a driver’s license or other government
issued photo identification in order to obtain a Hudson Valley Community
College identification card.
Red Flag 1:
Insufficient or suspicious identification is presented by a student who is
trying to obtain an identification card.
Response:
Do not issue Hudson Valley Community College identification card unless
or until the student provides acceptable documentation of identity.
Covered Account:
Student Accounts
Responsible Staff:
Cashier
Background:
Students must present a Hudson Valley Community College identification
card or other government issued photo identification to obtain
information about their student account.
Red Flag 1:
Insufficient or suspicious identification is presented by a student who is
trying to obtain information regarding a student account.
Page 26
Response:
Do not provide information regarding student account unless or until the
student provides acceptable documentation of identity.
Covered Account:
Student WIReD (Banner Self-Service via Web)
Responsible Staff:
Computer Services
Background:
Students are assigned a username and password to access their student
records via web using Banner Self-Service.
Red Flag 1:
The student notifies Computer Services that he or she believes that
someone else has gained access to his or her student records via Banner
Self-Service.
Response:
Notify student that he or she should change his/her password. If student
does not want to change his/her own password, have student contact the
Computer Learning Center. If student provides proper identification, inperson, Computer Learning Center will reset password and provide the
student with a new password. If student provides sufficient identification
over the telephone, Computer Learning Center will cause a new
password to be mailed to the student’s current address on file.
Red Flag 2:
A college office notifies Computer Services that it appears that someone
else has gained access to records of a student via Banner Self-Service.
Response:
Computer Services will investigate. If Computer Services agrees that this
is a reasonable assumption, Computer Services will disable the student’s
computer access to prevent further unauthorized access. The student
will need to be provided with a new password before computer access
may be restored.
Covered Account:
Student E-mail
Responsible Staff:
Computer Services
Red Flag 1:
The student notifies Computer Services that he or she believes that
someone else has gained access to his/her college e-mail account.
Page 27
Response:
Notify student that he or she should change his/her password. If student
does not want to change his/her own password, have student contact the
Computer Learning Center. If student provides proper identification, inperson, Computer Learning Center will reset password and provide the
student with a new password. If student provides sufficient identification
over the telephone, Computer Learning Center will cause a new
password to be mailed to the student’s current address on file.
Red Flag 2:
A college office notifies Computer Services that it appears that someone
else has gained access to a student’s e-mail account.
Response:
Computer Services will investigate. If Computer Services agrees that this
is a reasonable assumption, Computer Services will disable the student’s
computer access to prevent further unauthorized access. The student
will need to be provided with a new password before computer access
may be restored.
Covered Account:
Employee WIReD (Banner Self-Service via Web)
Responsible Staff:
Computer Services
Background:
Employees are assigned a username and password to access their own
records and records of their students via web using Banner Self-Service.
Red Flag 1:
The employee notifies Computer Services that he or she believes that
someone else has gained access to his/her records via Banner Self-Service
by using his/her username/password.
Response:
Notify employee that he or she should change his/her password. If
employee does not want to change his/her own password, Computer
Services will reset it. If employee provides proper identification, inperson, Computer Services will reset password and provide the employee
with a new password. If employee provides sufficient identification over
the telephone, Computer Services will mail a new password to the
employee’s current address on file.
Red Flag 2:
A college office notifies Computer Services that it appears that someone
else has gained access to records via Banner Self-Service using a
username/password assigned to an employee.
Page 28
Response:
Computer Services will investigate. If Computer Services agrees that this
is a reasonable assumption, Computer Services will disable the
employee’s computer access to prevent further unauthorized access.
The employee will need to be provided with a new password before
computer access may be restored.
Covered Account:
Employee E-mail
Responsible Staff:
Computer Services
Red Flag 1:
The employee notifies Computer Services that he or she believes that
someone else has gained access to his/her college e-mail account.
Response:
Notify employee that he or she should change their password. If
employee does not want to change his/her own password, Computer
Services will reset it. If employee provides proper identification, inperson, Computer Services will reset password and provide the employee
with a new password. If employee provides sufficient identification over
the telephone, Computer Services will mail a new password to the
employee’s current address on file.
Red Flag 2:
A college office notifies Computer Services that it appears that someone
else has gained access to an employee’s e-mail account.
Response:
Computer Services will investigate. If Computer Services agrees that this
is a reasonable assumption, Computer Services will disable the
employee’s computer access to prevent further unauthorized access.
The employee will need to be provided with a new password before
computer access may be restored.
Covered Account:
Student Record
Responsible Staff:
Staff in the following offices: Admissions, Community Education,
Continuing Education and Summer Sessions, Human Resources, Registrar
Red Flag 1:
A change of address request occurs under suspicious circumstances.
Page 29
Response:
Ask student to come in and personally verify address and any suspicious
usage activity.
Red Flag 2:
A change of name request occurs without appropriate identification
and/or documentation.
Response:
Deny name change request until student’s identity has been established
through acceptable means and/or appropriate documentation is
provided.
Covered Account:
Financial Aid Accounts
Responsible Staff:
Financial Aid Staff
Background:
Students are required to present either a Hudson Valley Community
College Identification Card or a driver’s license or other government
issued photo identification when submitting financial aid paperwork
and/or discussing student financial aid account information.
Red Flag 1:
Insufficient or suspicious identification is presented by a student who is
trying to obtain financial aid information.
Response:
Withhold information until the student’s identity has been established
through acceptable means.
Red Flag 2:
Department of Education selects student’s FAFSA for verification.
Response:
Students are required to submit all requested supplemental information
and resolve any conflict between the FAFSA and supplemental
information provided.
Red Flag 3:
Student submits multiple FAFSAs containing conflicting information.
Response:
Contact student to resolve conflicting information and verify information.
Program Administration and Oversight
The Executive to the President for Institutional Effectiveness and Strategic Planning will be the
Program Administrator and will be responsible for overseeing the administration of this
Program. The Program Administrator may designate additional staff of the College to
Page 30
undertake responsibility for training personnel, monitoring service providers, and updating the
Program, all under the supervision of the Program Adminstrator.
Staff Training
The Program Administrator or his or her designees shall train responsible staff, as neceessary,
in the detection of Red Flags, and the responsive steps to be taken when a Red Flag is detected.
Responsible staff are expected to notify the Program Administrator of any incidents of identity
theft.
Updating The Program
The Program will be reviewed annually, or if and when a problem arises, to ensure the
effectiveness of the procedures in place, and to update the Program based on new events,
institutional changes or changes in risks.
Oversight of Service Provider Arrangements
The Program Administrator will ensure that the activity of a service provider is conducted in
accordance with reasonable policies and procedures designed to detect, prevent, and mitigate
the risk of identity theft whenever the organization engages a service provider to perform an
activity with one or more covered accounts.
Page 31
Judicial System
1.1
2.1
2.2
3.1
3.2
3.3
3.4
ARTICLE I.
PREAMBLE
Hudson Valley Community College (“College”) is primarily concerned with academic
achievement, the personal integrity of its students and the wellness and safety of the
members of its community. In addition, the College is committed to preserving peace,
supporting a moral and just climate, maintaining a community where people are treated
with courtesy and respect, meeting its contractual obligations, and protecting its
property and that of its community members. The College, therefore, has established
this Code of Conduct to communicate its expectations of students, visitors, college
personnel and organizations.
ARTICLE II.
PURPOSE AND INTENT
The purpose of the College’s having codes and adjudication procedures is to enforce
standards of conduct and curtail inappropriate behavior as well as to assist the
individual in resolving problems in an institutionally acceptable manner. The
adjudication procedure provides a framework for the review of the substance of any
alleged violation of the Code of Conduct. The individual is not absolved of the
responsibility for his or her own behavior. Each individual is responsible for accepting
the fact that rights come with concomitant responsibilities and that violations of the
codes may result in discipline.
The student is charged with the responsibility of becoming familiar with the codes and
regulations and the procedures for enforcing them and acting accordingly.
ARTICLE III.
DEFINITIONS
“Campus Coordinator” means the Coordinator of the College Judicial System. This is the
person appointed by the College who is charged with the responsibility of ensuring that
the procedures provided herein are adhered to in the processing and adjudication of
complaints under the Code of Conduct. Campus Coordinator may also mean a designee
of that office.
“Code of Conduct” means the list of prohibited conduct established by the College, as
more fully set forth in Article V herein, which includes behavior that violates the
College’s Academic Ethics, Computer Ethics and Campus Regulations, and also includes
the procedures for enforcing the Code of Conduct.
“College” means Hudson Valley Community College, with its main campus located at 80
Vandenburgh Avenue in Troy, New York.
“College premises” means all buildings or grounds owned, leased, operated, controlled
Page 32
3.5
3.6
3.7
3.8
3.9
3.10
3.11
3.12
3.13
3.14
4.1
4.2
or supervised by the College including any buildings or grounds that are located off
campus.
“College-sponsored activity” means any activity on or off campus which is initiated,
aided, authorized or supervised by the College.
“College Official” means any full-time or part-time administrator or security guard or
security officer.
“College Personnel” means all employees of the College who work either on the
campus or on other property used for educational purposes by the College.
“Faculty Member” means any full-time or part-time faculty member.
“Organization” means any group of individuals recognized or otherwise licensed by the
College, which includes student groups, faculty groups or any group existing outside of
the College community which seeks to utilize the College Premises for its own
organizational purposes.
“President” shall mean the President of the College.
“Vice President” or “Vice President for Enrollment Services and Student
Development” means the Vice President for Enrollment Management and Student
Development or his/her designee.
“Student” means a person, including College Personnel, either enrolled in or auditing
credit or non-credit courses at the College, on either a full-time or part-time basis.
Reference to any “Time Limits”, days shall be defined as any day the College is open for
business and shall EXCLUDE Saturdays and Sundays, any holiday the College has
published as "College closed," and emergency closings. Time limits may be waived for
just cause under conditions that are set forth under the procedure affected.
“Visitor” means any individual who is not a Student nor otherwise affiliated with the
College but who is on the College Premises for a legitimate purpose.
ARTICLE IV.
JURISDICTION
Generally, College jurisdiction and discipline will be applied to conduct which occurs on
College Premises, during off-campus activities related to the College, or which violates
federal, state or local laws on or off the College Premises. Jurisdiction and discipline
may also be applied at the discretion of the College to conduct which occurs off-campus
and which adversely affects the College, the College community or the interests and
mission of the College. Students are responsible for the conduct of their guests, and
may be subject to discipline for the conduct of their guests.
College disciplinary proceedings may be instituted against a Student or an Organization
charged with conduct that potentially violates both the criminal law and the College’s
Code of Conduct (that is, if both possible violations result from the same factual
situation) without regard to the pendency of civil or criminal litigation in court or
criminal arrest and prosecution. Proceedings under this Code of Conduct may be carried
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out prior to, simultaneously with, or following civil or criminal proceedings off campus.
Determinations made or sanctions imposed under this Code of Conduct shall not be
subject to change because criminal charges arising out of the same facts giving rise to
violation of the College’s Code were dismissed, reduced, or resolved in favor of or
against the criminal law defendant. The College has the obligation to cooperate with all
police authorities. When the protection of life and property and the regular, orderly
operation of the College require it, the assistance of these agencies will be requested as
a matter of policy.
ARTICLE V.
CODE OF CONDUCT
5.1
ACADEMIC ETHICS
Hudson Valley Community College expects all members of the College community to
conduct themselves in a manner befitting the tradition of scholarship, honor and
integrity. They are expected to assist the College by reporting suspected violations of
academic integrity to appropriate faculty and/or other College Personnel. These
guidelines define a context of values for individual and institutional decisions
concerning academic integrity. It is every Student's responsibility to become familiar
with the standards of academic ethics at the College. Claims of ignorance, unintentional
error, or academic or personal pressures do not excuse violations.
The following is a list of the types of behavior which breach the College Academic Ethics
guidelines and are therefore unacceptable. Commission of such acts, or attempts to
commit them fall under the term academic dishonesty and are subject to penalty. No
set of guidelines can, of course, define all possible types or degrees of academic
dishonesty; thus, the following descriptions should be understood as examples of
infractions rather than an exhaustive list. Individual Faculty Members and the College
Committee on Ethics and Conduct will continue to judge each case according to its
particular circumstance.
PROHIBITED CONDUCT
5.1.1
PLAGIARISM. Plagiarism is a form of academic dishonesty that is considered a
serious offense and carries severe penalties ranging from failing an
assignment to suspension from school. A Student is guilty of plagiarism any
time s/he attempts to obtain academic credit by presenting someone else's
ideas as her/his own without appropriately documenting the original source.
Appropriate documentation requires credit to the original source in a current
manuscript style that is appropriate to the assignment and the discipline.
Examples of someone else's ideas may include the following:
-Language, words, phrases, symbols
-Style (written, oral or graphic presentation)
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5.1.2
5.1.3
5.1.4
5.1.5
5.1.6
5.1.7
5.1.8
-Data, statistics
-Evidence, research
-Computer programs, creative projects, artwork
-Intellectual ideas such as theories and lectures
-Web sites, digital forms of communication such as e-mail, chat room, and
instant messaging
-Photographs, video, audio
CHEATING ON EXAMINATIONS. Giving or receiving unauthorized help before,
during, or after an examination. Examples of unauthorized help include
collaboration of any sort during an examination (unless specifically approved
by the instructor); collaboration before an examination (when such
collaboration is specifically forbidden by the instructor); the use of notes,
books, or other aids during an examination (unless permitted by the
instructor); arranging for another person to take an examination in one's
place; looking on someone else's examination during the examination period;
the unauthorized discussion of test items during the examination period; and
the passing of any examination information to Students who have not yet
taken the examination. There can be no conversation while an examination is
in progress unless specifically authorized by the instructor.
MULTIPLE SUBMISSION. Submitting substantial portions of the same work for
credit more than once, without the prior explicit consent of the instructor to
whom the material is being (or has in the past been) submitted.
FORGERY. Imitating another person's signature or mark on academic or other
official documents (e.g., the signing of a Faculty Member's name to a College
document).
SABOTAGE. Destroying, damaging, or stealing of another's work or working
materials (including lab experiments, computer programs, term papers, or
projects).
UNAUTHORIZED COLLABORATION. Collaborating on projects, papers, or other
academic exercises which is regarded as inappropriate by the instructor(s).
Although the usual Faculty assumption is that work submitted for credit is
entirely one's own, standards on appropriate and inappropriate collaboration
vary widely among individual Faculty. Faculty Members are, therefore,
expected to establish explicit expectations and standards. Students who want
to confer or collaborate with one another on work receiving academic credit
should make certain of the instructor's expectations and standards.
FALSIFICATION. Misrepresenting materials or fabricating information in an
academic exercise or assignment (for example, the false or misleading citation
of sources, the falsification of experimental or computer data, etc.).
THEFT, DAMAGE, OR MISUSE OF LIBRARY OR COMPUTER RESOURCES.
Removing uncharged materials from the Library Building, defacing or
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5.2
damaging materials, intentionally displacing or hoarding materials within the
Library Building for one's unauthorized private use, or other abuse of reservebook privileges. Or, without authorization, using the College's or another
person's computer accounts, codes, passwords, or facilities; damaging
computer equipment; or interfering with the operation of the computer
system of the College. The College and the computer center has established
specific rules governing the use of computing facilities. The rules appear under
Computer Ethics. It is every Student's responsibility to become familiar with
them.
CAMPUS REGULATIONS FOR STUDENTS, VISITORS, COLLEGE PERSONNEL AND
ORGANIZATIONS
The College is charged by its sponsoring agency and by the State University to attain its
stated objectives. To properly discharge these responsibilities and to ensure a desirable
relationship with the community as well as the protection of all Students, Visitors,
guests, College Personnel, and Organizations, certain regulations have been established.
Students enrolling in the College’s education programs and Visitors, guests, College
Personnel and Organizations that are associated with or use the College facilities do so
subject to the Code of Conduct. In cases where there is an alleged violation of the Code
of Conduct, it is the policy of the College to afford each Student and Organization
associated with the College the right to adjudicate the allegation in accordance with the
adjudication procedures as set forth in this Code. However, in cases where the Vice
President for Enrollment Management and Student Development or his/her designee
deems the conduct, condition, or infraction to be of such nature that the alleged
violator poses a present or future threat to the health, safety and welfare of himself or
herself or the College or its community, he/she may take immediate action to suspend
the Student or disband any Organization associated with the College prior to the
initiation of the formal adjudication procedures. Visitors, guests and organizations not
affiliated with the College, while subject to these regulations, do not have rights to
adjudicate any decision made which results in their removal from the College Premises.
PROHIBITED CONDUCT
5.2.1
The obstruction or disruption of any College function or activity, including the
classroom instructional environment, administration of the parking program
or service functions and activities is prohibited. This includes obstruction of
the free flow of pedestrian or vehicular traffic, or the free access to, or exit
from any part of the College Premises as well as the unauthorized use or
occupation of College buildings or College Premises.
5.2.2
Harassment of a Student or Students, Faculty Member, College Personnel,
College Official, Visitor, or the College as an institution by Student or Students,
or by a non-student or non-students is prohibited. Harassment includes any
threat, in any way expressed or implied, to the person or property, or any
obstruction or attempted obstruction of any individual’s authorized
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5.2.3
5.2.4
5.2.5
5.2.6
5.2.7
5.2.8
5.2.9
5.2.10
5.2.11
5.2.12
movement on the College Premises. Harassment may also include the
persistent use of abusive or offensive language or any language or action that
may promote physical violence or physical or psychological intimidation.
The display of any inflammatory or incendiary signs, posters, or banners or the
distribution of literature which encourages or promotes any actions that are
prohibited under these Campus Regulations.
No firearms of any kind (including pellet, B-B guns, handguns, and rifles),
explosives (including firecrackers and fireworks), live ammunition of any kind,
noxious bombs or any other devices which are illegal under city, town, county,
state or federal ordinance or law may be brought, possessed, or used on the
College Premises. Duly authorized peace officers or police officers are
exempted.
No cutting instruments, knives, blades nor any other weapon is allowed on
College Premises except folding pocket knives two inches or under or those
instruments needed for legitimate school purposes.
Possession, transportation, and/or the use of any illegal drug on the College
Premises is prohibited.
(a) No alcoholic beverage may be brought, possessed, or consumed on
College Premises.
(b) No person who may appear to be intoxicated or affected by an illegal drug
is allowed on the College Premises.
Gambling of any kind is prohibited.
Unauthorized use of the College’s duplicating or reproduction equipment,
public address systems, email or radio station is prohibited. Authorization for
such use may be granted only by the College President or his designee.
Any and all official information related to the College and its operation shall
be transmitted to news media only through the College’s Public Information
Office. Arrangements for reporters and/or radio or television station
representatives to report or televise events on the College Premises shall be
made only by the Public Information Office. Any other arrangements are
unauthorized and the College reserves the right to bar (or remove) from the
College Premises unauthorized news media representatives.
Defacing, damaging, or maliciously destroying any College, Faculty, or Student
property is prohibited.
(a) All Visitors must be on the College Premises for a legitimate purpose. The
College reserves the right to determine whether the purpose is legitimate.
If it is not, Visitors will be asked to leave.
(b) Visitors are required to show identification when requested to do so by
security or administrative officers. Failure to do so, or to leave when
requested will result in such Visitors being considered as trespassers
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5.2.13
5.2.14
5.2.15
5.2.16
5.2.17
5.2.18
5.2.19
5.2.20
5.2.21
5.2.22
5.2.23
5.2.24
subject to arrest.
Student Identification: All Students and College Personnel are required to
obtain and carry College identification cards at all times and to present them
upon request to any College Official, or Faculty Member. Other identification
must be shown if such a request is made and the person questioned does not
have an ID card in his/her possession.
Disorderly or unlawful behavior is prohibited and may be prosecuted by the
College under this procedure whether or not such behavior is the subject of
prosecution in any civil or criminal court.
Reckless or intentional actions which endanger mental or physical health are
prohibited. The forced consumption of liquor or drugs for the purpose of
initiation into or affiliation with any organization is prohibited.
Smoking or chewing tobacco is prohibited in all buildings on the College
Premises.
False alarms, bomb scares or any form of false reporting submitted to any law
enforcement or College agency involving alleged incidents or occurrences on
College Premises is prohibited.
Unlawful behavior that is motivated in the selection of the victim or
commission of an offense by a perception regarding the race, color, national
origin, ancestry, gender, religion, religious practice, age, disability, or sexual
orientation is prohibited and may result in the imposition of more severe
penalties.
Certain violations of the Academic Code of Ethics at the discretion of the Vice
President for Enrollment Management and Student Development can be
pursued as violations of Campus Regulations.
Willfully failing to comply with the directives of College Personnel is
prohibited.
Intentionally furnishing the College with false information is prohibited.
Any activity that would be a violation of any federal, state or local statute is
prohibited on College Premises.
Any retaliatory action of any kind taken against a person seeking redress
under these procedures is prohibited and shall be regarded as a separate and
distinct cause for complaint under these procedures.
Violation of published College policies or regulations, including, without
limitation the following:
(a) Parking and traffic regulations
(b) Smoking policy
(c) Alcohol and drug policy
(d) Any other published College policies, rules and regulations including those
related to the entry into and/or use of College rooms, buildings, grounds, and
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5.3
facilities.
COMPUTER ETHICS POLICY
Hudson Valley Community College seeks to provide computer users with state of the art
computing facilities and to keep the number of restrictions on individuals to a minimum,
while maintaining excellent service for all users, Students in pursuit of their academic
goals and College Personnel to conduct assigned work activity. To assist the College in
achieving these objectives, users themselves must observe reasonable standards of
behavior in the use of these facilities and maintain an atmosphere of civility, mutual
respect and high ethical standards.
PROHIBITED CONDUCT
5.3.1
No attempt will be made to modify or destroy system software components
such as operating systems, compilers, utilities, applications or other software
residing on any College computer, except the user's own files.
5.3.2
No attempt will be made to electronically transmit or post any material which
is sexually explicit, hateful, or deemed prohibited conduct under the Campus
Regulations as set forth in Article 5.2.
5.3.3
No attempt will be made to access, read, modify or destroy files belonging to
another user without complete authorization from that user to do so.
5.3.4
No attempt will be made to connect to or use College computers with a user
ID which was not assigned to you by the College. Use of another person's user
ID or password is prohibited.
5.3.5
No attempt will be made to gain access to a password belonging to another
person or place a password other than your own in a file on a College
computer. In addition, no attempt will be made to install, run or place
software designed for this purpose on any College computer.
5.3.6
No attempt will be made to bypass or otherwise defeat system security to
gain access to programs, files or other computer data or to install, run or place
software designed for this purpose on any College computer.
5.3.7
No attempt will be made to copy, store, post or distribute computer software,
files or any other material in violation of trademark, copyright or
confidentiality laws or when you do not have a legal right to do so.
5.3.8
No attempt will be made to interfere with proper operation of a computer or
interfere with another person's use of a computer, including for example, the
electronic transmission or posting of files or programs containing viruses or
any other content intended to interfere with proper operation of a computer.
5.3.9
No attempt will be made to impersonate any person, including other Students
and College Personnel. No attempt will be made to disguise the origin of any
electronically transmitted or posted material. No attempt will be made to
make unauthorized use of someone else’s electronic signature.
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5.3.10
5.3.11
5.3.12
5.3.13
5.3.14
5.3.15
5.3.16
5.3.17
5.3.18
5.3.19
5.3.20
No unauthorized attempt will be made to use, modify, connect or disconnect
computer equipment, peripherals, communication equipment and cables.
No unauthorized attempt will be made to use any college computer to
electronically transmit chain letters, junk mail, pyramid schemes or any other
unsolicited mass mailings to multiple recipients with the exception of
employees conducting College business and Students completing required
College course assignments.
No unauthorized attempt will be made to connect to and/or gain access to
information being transported by computer networks, or to install, run or
place software designed for this purpose on any College computer. Installation
or use of any network communication software not approved by the College is
prohibited.
No user will make their password known to anyone other than an employee of
the College authorized to assist College Personnel or Students with computer
related problems.
No food or drink is permitted in any computer classroom or computer learning
center with the exception of the Computer Cafe.
Users of College computers will comply with all local, state, federal and
international laws relating to the use of computers and any other electronic
communication services provided by the College.
Use of College computers for commercial, business purposes or personal
profit is prohibited without specific authorization from the College for such
use. Commercial or business purposes includes advertising the sale of goods
and services not directly related to Hudson Valley Community College or
campus based Organizations.
Use of College computers to falsify or modify documents in a manner which is
unauthorized, is a violation of the rights of owners, is a violation of copyright
laws or is not properly attributed is prohibited.
Use of College computers and network services for local or remote game
playing is prohibited unless specifically required as part of a course in which a
Student is currently registered or a Faculty Member is currently teaching. In
addition, the installation, uploading, downloading or storage of any game
software on College computers is prohibited.
Use of College computers and network services for IRC (Internet Relay Chat) or
any other form of interactive chat communication is prohibited except for use
by College Personnel in counseling, scheduling or admissions or where
specifically required for communication as part of a course in which a Student
is currently registered or a Faculty Member is currently teaching.
Web site services for the entire College community are provided on a
centralized server by the Office of Computer Services. Use of any other
College computer for the purpose of serving a web site is prohibited.
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ARTICLE VI.
INFORMAL PROCEDURES FOR PROCESSING VIOLATIONS OF THE CODE OF ACADEMIC ETHICS
6.1 Academic Ethics - A Student shall inform the Faculty Member responsible for the course
or program when he/she has knowledge of violations of the Code of Academic Ethics. In
addition, any College Official or a Faculty Member of a course or program for which
he/she is responsible who has information that a Student may have violated the
Academic Ethics Code, may follow the procedures established in this Article VI or, if
either party so chooses, proceed with the formal procedures set forth in Article VIII
whereby disciplinary sanctions, as articulated in Article VII may also be imposed.
6.2 When a Faculty Member has knowledge that a violation of the Code of Academic Ethics
has occurred, the Faculty Member should take appropriate action. If the Faculty
Member is not the instructor for the course involved, that instructor should be notified
immediately.
6.3
6.4
The course instructor should meet with the Student as soon as possible and discuss the
allegation. If, after the discussion, the Faculty Member feels the Student did violate one
or more of the provisions of the Code of Academic Ethics, the Faculty Member may
impose one of the following sanctions. (Cases of plagiarism should proceed to § 6.4
which follows.)
6.2.1
Warning without further penalty
6.2.2
Retaking a test or rewriting an assignment
6.2.3
Lowering a grade on a project, assignment or test
6.2.4
Issuing a failing grade on a project, assignment or test
6.2.5
Lowering a final grade
6.2.6
Issuing a failing grade for a course
6.2.7
Imposing a penalty uniquely designed for the particular infraction.
Whenever a Faculty Member sanctions a Student for a violation of the Code of
Academic Ethics, a memorandum should be forwarded to the Campus Coordinator
advising that office of the allegation, the sanction imposed and whether the Student
accepted the sanction.
Plagiarism
6.4.1
Level 1 Violation: A Student commits any act of plagiarism as determined by
the instructor.
6.4.2
Level 1 Consequence:
(a) The Student will receive a failing grade for the assignment; and
(b) The Student’s Name will be forwarded to the Vice President for Academic
Affairs, the Vice President for Enrollment Services and Student
Development, the Student’s Department Chair and the Campus
Coordinator.
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6.4.3
6.5
Level 2 Violation: A Student commits any significant act of plagiarism as
determined by the instructor. A significant act of Plagiarism may include but is
not limited to one of the following:
(a) The Student commits numerous acts of plagiarism with numerous sources
within one particular assignment;
(b) The Student plagiarizes a significant portion of his or her assignment from
one source; or
(c) The Student borrows, purchases, or steals an entire paper and submits it
as his/her own.
6.4.4
Level 2 Consequence:
(a) The Student will receive a failing grade for the course; and
(b) The Student’s name will be forwarded to the Vice President for Academic
Affairs, the Vice President for Enrollment Management and Student
Development, the Student’s Department Chair and the Campus
Coordinator.
6.4.5
Level 3 Violation: A Student commits any act of plagiarism as determined by
the instructor(s) or administrator(s) on multiple assignments at any time
during his/her tenure at the College.
6.4.6
Level 3 Consequence:
(a) The Student will receive a failing grade for the course;
(b) The Student’s name will be forwarded to the Vice President for Academic
Affairs, the Vice President for Enrollment Management and Student
Development, the Student’s Department Chair and the Campus
Coordinator; and
(c) The Student may be suspended from the College for one semester.
The sanction imposed by the Faculty Member or College Official shall constitute a final
resolution of the matter unless the Student submits a request for a Hearing through the
office of the Campus Coordinator as set forth in Article VIII within five (5) days from the
date the sanction was imposed.
ARTICLE VII.
PROCEDURE FOR PROCESSING COMPLAINTS INVOLVING ALLEGED VIOLATIONS OF CAMPUS
REGULATIONS AND COMPUTER ETHICS.
7.1 Campus Regulations for Students, Visitors, College Personnel and Organizations - In
cases of alleged violations of Computer Ethics and/or Campus Regulations, any College
Personnel or Student shall notify the College’s Office of Public Safety or the Vice
President and the complaint shall be processed consistent with the procedures set forth
in Article VII or Article VIII. However, although College Personnel are subject to and
must abide by Campus Regulations, they shall have no right to a hearing or appeal
under this Code of Conduct and they shall utilize other applicable mechanisms to
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7.2
7.3
7.4
7.5
7.7
7.8
contest adverse actions.
All charges must be submitted in writing and signed.
It is strongly recommended that any party exercising his/her rights under this system or
any party accused of violating any of the Codes of Conduct consult with the Campus
Coordinator as soon as possible so rights, remedies and procedures can be explained.
The Student shall meet with the Vice President within five (5) days of receiving notice of
charges.
The Vice President for Enrollment Management and Student Development may also
meet with the complainant, security officers and/or any witnesses at the Vice
President’s discretion.
If, at the conclusion of the Vice President’s investigation, s/he finds the accused
individual did violate one or more provisions of the Campus Regulations and/or
Computer Ethics, the Vice President may impose one of the following sanctions:
7.6.1
Letter of Warning.
Letter of Warning to be placed in an individual’s permanent record file for a
7.6.2
stated period of time.
7.6.3
Restitution.
7.6.4
Community Service
7.6.5
Counseling Services provided by the College.
7.6.6
Mandatory Course requirements (in civility, human relations, anger
management, race or gender relations or a similar course designed to raise
consciousness or awareness).
7.6.7
Disciplinary Removal from a Curriculum.
7.6.8
Disciplinary Probation.
7.6.9
Disciplinary Suspension (Current or deferred, subject to conditions)
7.6.10 Disciplinary Dismissal.
7.6.11 Disciplinary Expulsion – Termination of Student status without the possibility
of readmission
7.6.12 Restricted Access to classrooms or buildings
7.6.13 Restricted Access to or loss of Computer Accounts
7.6.14 Any other sanction uniquely designed for the particular infraction.
The sanction imposed by the Vice President shall constitute a final resolution of the
matter unless the accused individual submits a request for a Hearing through the office
of the Campus Coordinator as set forth in Article VIII within five (5) days from the date
the sanction was imposed.
During the pendency of any proceeding under the Code of Conduct, the Vice President
may, in his or her sole discretion, have the accused individual removed from the College
Premises and enforce the restraint of the accused’s access to the College Premises in
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7.9
8.1
8.2
8.3
8.4
8.5
8.6
8.7
whole or in part, until his/her presence is required for the adjudication of the case if the
Vice President views the violation as jeopardizing property of the College or another
person or the individual’s safety or welfare or the physical or emotional safety or
welfare of others, or the orderly operation of the College.
Disciplinary suspension, dismissal, or expulsion from the College will most likely be
imposed for, among others, the following: (1) permitting or engaging in hazing (2)
setting fires or intentionally causing a false fire alarm (3) possession of or threats
involving weapons or explosives (4) possession or sale of illegal drugs (5) physical abuse,
violence, sexual assault or threats directed toward anyone on the College Premises or
any member of the College community off College Premises (6) serious forms of
computer misconduct (7) repeated violations of the College Code of Conduct.
ARTICLE VIII.
HEARING PROCEDURES UNDER THE CODE OF CONDUCT
In the event the accused timely files a written request for a Review Board hearing
(“Hearing”), the procedure set forth in this Article VIII shall apply.
Use of and Responsibility for Obtaining and Compensating an Advisor:
During the Hearing an advisor may be allowed but such advisor must be individually
obtained and compensated by the person(s) involved. An advisor may only serve in an
advisory capacity and may not speak or otherwise participate directly in the formal
procedure. An advisor may be a parent or child of the accused, a spouse or partner or a
member of the College community. A Student may bring a lawyer to the Hearing only as
an advisor and only if the allegations may also constitute a crime. The lawyer may not
participate in the Hearing, and participation is limited to advising the Student. If the
conduct of the lawyer is deemed to be inconsistent with the process, the Hearing may
be terminated or the lawyer excused for the remainder of the Hearing.
The Campus Coordinator, once advised by an accused that a Hearing has been
requested, shall immediately notify the Committee on Ethics and Conduct.
Within ten (10) days of the notification, a Hearing shall be held.
The Review Board will be comprised of three members of the Ethics and Conduct
Committee. It shall not contain more than one (1) administrator; one (1) Faculty
Member, one (1) non teaching professional or one (1) union employee and shall always
contain one (1) Student. If the dispute arose from a particular division or department,
no individual from that division or department is permitted to sit on the Review Board.
One of the members of the Review Board shall be designated as Chairperson and shall
have the responsibility of reporting the decision of the Review Board to the appropriate
College Official in writing.
If the accused does not appear for the Review Board Hearing and was properly notified
of its date, time and place, the accused individual shall be deemed to have forfeited
his/her right to a Hearing and the sanction imposed by the Vice President or Faculty
Member shall be automatically upheld and the accused individual will have no further
Page 44
recourse.
8.8 The Review Board shall not be bound by the technical rules of evidence but may hear
and receive any reports, documents, testimony, evidence or other information which is
relevant and material to the issues. The weight to be given such items shall be
determined solely by the Review Board.
8.9 The Review Board adjudication shall be transcribed or taped and those witnesses
appearing before the Review Board shall be sworn.
8.10 Only the primary parties in interest (and their advisors, if any), transcriber, the members
of the Review Board and the Coordinator of the Judicial System shall be present
throughout the Hearing. The Hearing shall be conducted in private. The advisors may
not speak for or take the place of a primary party in interest.
8.11 Conduct of the Hearing
8.11.1 The coordinator of the Judicial System may provide to the Review Board and
to the accused copies of documents to be considered by the Review Board in
advance of the Hearing, but no party shall be limited to such documents.
8.11.2 The Chairperson will read the charges.
8.11.3 Each party may make an opening statement, beginning with the individual
bringing the charge.
8.11.4 The person bringing the charge, whether by a Faculty Member or College
Official accusing a Student of violating the Code of Academic Ethics or the Vice
President accusing any Student, or Organization of violating the Campus
Regulations will read, summarize, or identify all of the material information
which has been submitted by witnesses, the Public Safety Office, or others.
Materials will usually consist of, but are not restricted to, a summary case
written by the Public Safety Office plus statements from witnesses or other
persons involved in the situation. Documents shall also be submitted at this
time. The Vice President may also give testimony, submit evidence or call
witnesses to give testimony or submit evidence or other information.
8.11.5 The other party and the members of the Review Board may ask questions of
any witness. After the submitted materials and evidence have been read, the
accused will have the opportunity to refute or explain the materials or
evidence or add information. The accused may choose to remain silent and
not make any statements or participate in the discussion. The accused may
call witnesses.
8.11.6 Each party will be provided an opportunity to give a summation of their
respective positions.
8.11.7 The Chairperson will conclude the Hearing when he or she is satisfied that all
information has been submitted.
8.11.8 The Review Board will then convene in closed session and consider only
information presented at the Hearing. If necessary, the Review Board may
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8.11.9
9.1
9.2
9.3
9.4
adjourn and reconvene, ask for further documentation, or call or recall
witnesses with the assistance of the Campus Coordinator, if required.
The decision of the Review Board as to whether the alleged infraction
occurred and whether the sanction imposed is appropriate shall be made
based on the information presented at the Hearing. The decision shall be in
writing and delivered to the parties by hand or via United States Mail within a
reasonable time after the Hearing. Deposit, postage prepaid, in an official
United States Postal Service receptacle shall be deemed delivery on the date it
is deposited.
ARTICLE IX.
APPEALS
Within seven (7) days of the delivery of the decision of the Review Board, either party
may appeal the decision, in writing, and submit the appeal to the Campus Coordinator.
S/he will forward the appeal to the other party who may submit a written response
which must be received within three (3) days of the receipt of the appeal. The opposing
party is under no obligation to respond to an appeal.
Within three (3) days of receiving the appeal the Campus Coordinator will present it to
the President.
The President, after receipt of such appeal, shall make a final adjudication and
determination in the matter. The accused individual, Vice President or appropriate
Faculty Member shall be notified of the final decision of the President by the Campus
Coordinator. There shall be no further appeals.
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American with Disabilities Act
This is a federal law which requires employers to “reasonably accommodate” disabled
employees who can perform the “essential tasks” of a job. Please note that employees are
also covered under the New York State Human Rights Disability Law. These laws require
employers to provide “reasonable” accommodations to qualified disabled employees who can
perform essential functions of the job.
Basic elements of the American with Disabilities act are as follows:
•
A disability is defined as a physical or mental impairment that substantially limits one or
more of the major life activities of such individual, a record of such impairment or being
regarded as having such impairment. While some temporary disabilities are covered,
temporary impairments which are excluded from coverage include:
o
o
o
o
•
Current illegal drug use
Common illnesses or injuries
Pregnancy
Personality traits
Employer makes reasonable accommodation to permit employee to perform essential
functions such as :
o Making facilities accessible
o Job restructuring
o Job reassignment
o Modifying work schedule
o Acquiring adaptive equipment
Employer need not suffer “undue hardship” in providing accommodation, defined as:
o Costly modifications/equipment
o Disruption of workflow
•
Enforced by EEOC with remedies including injunctive relief and monetary damages
Employees are also covered by the New York State Disability Law. The Human Rights law
defines a disabled individual as someone who has a physical, mental, or medical impairment
resulting from anatomical, physiological, genetic, or neurological conditions, which prevents the
exercise of a normal bodily function or is demonstrable by medically accepted, clinical, or
laboratory diagnostic techniques or record of such impairment or has a condition regarded by
others as such an impairment, provided however, that such an impairment shall be limited to
disabilities which upon the provision of reasonable accommodations, do not prevent the
Page 47
individual from performing in a reasonable manner the activities involved in the job or
occupation sought or held.
The College has a coordinator for ADA compliance. Contact the Office of Disability Resources
for assistance.
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Fair Labor Standards
The College is subject to many provisions of the Fair Labor Standards Act administered by the
NYS Department of Labor. The act applies to wage and hour issues and subjects of regulation
include: minimum wages, hours worked, overtime pay and equal pay for equal work. The act
allows eligible public employees, such as at the College, to receive compensatory time at a time
and one-half rate for overtime in lieu of cash payments, subject to choice by the employee.
Page 49
Page 50
Family and Medical Leave Act [FMLA] Federal law, which provides up to 12 weeks of job protected leave for:  Birth and care of a newborn child of employee;  Placement with an employee of a child for adoption or foster care;  Taking care of a spouse, child, or parent with a serious health condition; or  Taking medical leave when employee is unable to work because of a serious health condition  Exigency leave associated with a family member’s covered active duty service or call to covered service.  Taking care of a servicemember or veteran undergoing medical treatment, recuperation or therapy for serious injury or illness (up to 26 weeks in a 12 month period) Basic elements of the law are as follows:  Provides security for employees who have worked at least 1,250 hours for current employer in the last 12 months.  Child defined as biological, adopted or foster, step, legal ward who is under 18 or over 18 and incapable of self‐care because of mental or physical disability that limits one or more of the “major life activities.”  Parent does not include a parent “in law”.  Serious health condition is defined as an illness , injury, impairment, or physical or mental condition that involves either any period of incapacity or treatment connected with inpatient care ex; an overnight stay in a hospital, hospice, or residential medical care facility and any period of incapacity or subsequent treatment in connection with such inpatient care of continuing treatment by a health care provider, which includes any period of incapacity ex; the inability to work attend school, or perform other regular duties due to: o A health condition, including treatment therefore or recovery there from lasting more than three consecutive days and any subsequent treatment or period of incapacity relating to the same condition that also includes treatment two or more times by or under the supervision of a health care provider with a continuing regimen of treatment; or o Pregnancy or prenatal care; a visit to the health care provider is not necessary for each absence; or o A chronic serious health condition which continues over an extended period of time, requires periodic visits to a health care provider, and may involve occasional episodes Page 51

of incapacity; example asthma, diabetes, a visit to a health care provider is not necessary for each absence; or o A permanent of long term condition for which treatment may not be effective: example; terminal cancer. Only supervision by a health care provider is required, rather than active treatment; or o Any absence to receive multiple treatments for restorative surgery or for a condition which would likely result in a period of incapacity of more than three days if not treated; example, chemotherapy or radiation treatments for cancer. Serious injury or illness for a member of the armed forces (including a member of the National Guard or reserves) must have been incurred by the member in the line of duty on active duty in the armed forces and that may render the member medically unfit to perform the duties of the member’s office, grade, rank or rating or for a veteran who was a covered servicemember of the armed forces an injury or illness that was incurred by the member in the line of duty on active duty in the armed forces and that manifested itself before or after the member became a veteran. 


Health Care Provider means doctors of medicine or osteopathy authorized to practice medicine or surgery by the state in which that doctor practices; or podiatrists, dentists, clinical psychologists, optometrists, and chiropractors, authorized to practice and perform within the scope of their practice under state law or nurse practitioners, nurse midwives, and clinical social workers authorized to practice and perform within the scope of their practice and perform within the scope of their practice as defined by state law; or any health care provider recognized by the employer or the employer’s group health plan benefits manager. Time taken off work due to pregnancy complications can be counted against the 12 weeks of family leave. Spouses employed by the same employer are jointly entitled to a combined total of 12 work weeks of family leave for birth and care of the newborn child, for placement of a child for adoption or foster care, and to care for a parent who has a serious health condition. Leave for birth and care or placement for adoption or foster care if used intermittently is subject to the employer’s approval. There must be need for medical leave, as distinguished from voluntary treatments and procedures, and it must be that such medical need can be best accommodated to an intermittent or reduced leave schedule. Elective cosmetic treatments which are not medically necessary are excluded, such as orthodontia or acne. 
While the leave is unpaid, the employer may allow or mandate use of accrued leave to produce pay. 
Employer must maintain contribution to health insurance during absence. Page 52

Workers compensation leave can count against an employee’s FMLA leave entitlement, as they run together, if the reason for the absence is due a qualifying serious injury, and the employer properly notifies the employee in writing that the leave will be counted as FMLA leave. 
Upon return from FMLA leave, an employee must be restored to his or her original job or to an “equivalent” job, which means virtually identical to the original job in terms of pay, benefits, and other employment terms and conditions. 
An employer may require medical certification to qualify for leave and again for return to position. 
Employer may ask questions to confirm whether the leave needed or being taken qualifies for FMLA purposes and may require periodic reports on an employee’s status and intent to return to work after leave. 
Leave may be taken at once or intermittently during a rolling 12 month period which begins at point of first day of leave. 
Employer is not required to continue FMLA benefits or reinstate employees who would have been laid off or otherwise had their employment terminated had they continued to work during the FMLA period. 
FMLA does not require that employees on FMLA leave be allowed to accrue benefits or seniority. When use of leave for medical reasons is planned or known in advance the leave should be discussed with both your immediate supervisor and the Office of Human Resources to ensure all contractual and other legal rights are applied and understood. The administration of the FMLA tends to be based on the unique characteristics of each medical case. Early consultation with the Office of Human Resources is encouraged. When returning from an injury, hospitalization, any surgery or protracted illness, all employees must report first to the College Health Service to submit physician’s clearance to resume job duties. In some cases, the College Physician or Health Service Director may wish to discuss or examine the condition. This process is necessary to protect both college and employee. In general “light duty” is not allowed. Page 53
The Family Educational Rights and Privacy Act (FERPA)
The Family Educational Rights and Privacy Act (FERPA) affords students certain rights with
respect to their education records. In addition, parents are afforded the same rights as students
are, as long as the student is claimed as a dependent on either of their parent’s Federal Income
Tax return, and there is proper presentation of the dependency condition.
Please remember that students must present their Hudson Valley Community College Student
ID card or another type of photo identification in order to receive information about their
student record. This requirement helps to ensure privacy.
These rights are:
1. The right to inspect and review the student's education records within 45 days of the
day the college receives a request for access.
.
Students should complete the request form available in the Registrar's Office identifying
the record(s) they wish to inspect. The registrar will make arrangements for access and
notify the student of the time and place where the records may be inspected. If the
records are not maintained by the registrar, the student will be advised to whom the
request should be addressed.
2. The right to request the amendment of the student's education records that the student
believes are inaccurate or misleading.
.
Students may ask the college to amend a record that they believe is inaccurate or
misleading. They should complete the request form available in the Registrar's Office,
clearly identify the part of the record they want changed, and specify why it is
inaccurate or misleading.
.
If the college decides not to amend the record as requested by the student, the college
will notify the student of the decision and advise the student of his or her right to a
hearing regarding the request for amendment. Additional information regarding the
hearing procedures will be provided to the student when notified of the right to a
hearing.
3. The right to consent to disclosures of personally identifiable information contained in
the student's education records, except to the extent that FERPA authorizes disclosure
without consent.
.
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One exception which permits disclosure without consent is disclosure to school officials
with legitimate educational interests. A school official is a person employed, appointed
or hired by the college in an administrative, supervisory, academic or research, or
support staff position (including law enforcement unit and personal health staff); a
person or company with whom the college has contracted (such as an attorney, auditor,
or college agent); a person serving on the Board of Trustees; or a student serving on an
official committee, such as a disciplinary or grievance committee, or assisting another
school official in performing his or her tasks.
.
A school official has a legitimate educational interest if the official needs to review an
education record in order to fulfill his or her professional responsibility.
4. Hudson Valley Community College designates the following items as directory
information: student's name, dates of attendance, date of birth, enrollment status,
major, date of graduation, honors and awards received, and student campus e-mail
address. The college may disclose any of those items without prior consent, unless
notified in writing to the contrary within thirty days of the beginning of the term.
5. The right to file a complaint with the U.S. Department of Education concerning alleged
failures by State University to comply with the requirements of FERPA. The name and
address of the office that administers FERPA is:
.
Family Policy Compliance Office, U.S. Department of Education, 400
Maryland Avenue, SW., Washington, DC, 20202-4605
Page 55
PESHA (OSHA)
The College is subject to the Public Employment Safety and Health Act, the public sector version
of the Occupational Safety and Health Act, to provide for workplace safety and wellness
regulation. The act is administered by the NYS Department of Labor, which receives employee
complaints of unsafe conditions, investigates unsafe workplace situations and conducts
periodic inspections of the worksite for compliance.
Page 56
HVCC Emergency Information for Faculty, Staff & Students
1. To Call for assistance during ANY Emergency:
Dial 911 from a campus phone or
629-7210 from a cell phone
You will be connected with the College Department of Public Safety. Explain the
nature of the emergency and stay on the line for further instruction. Do not call
County 911 from your cell phone. This will delay the response time as the call is redirected to the College Department of Public Safety.
2. Communicating Emergencies to the Campus Community:
HVCC has instituted the SUNY NY-Alert system to warn students and college employees
of an impending or ongoing emergency, and provide timely emergency information to
the same groups to protect lives and minimize campus disruption. Participants need to
“opt in” to receive the Alerts. Messages can be received via cell phone (text and/or
voice), telephone, e-mail and fax. Find out more at:
https://www.hvcc.edu/nyalert/index.html
3. Fire Emergencies
a. When the fire alarm is sounded:
Everyone must leave the building. Even in a drill, it is a clear policy violation to
disregard alarms and such conduct may be pursued as a disciplinary matter. Do
not re-enter the building in alarm until the all clear is given by response officials.
b. If you observe fire or smoke:
Go to the nearest fire alarm pull station located in hallways and pull the handle
to activate the building alarm. Public Safety will notify the Fire Department and
dispatch an officer to the building. Report any information pertaining to the
emergency to Public Safety or the FD as soon as possible.
c. Fire Extinguishers:
Extinguishers are available in all buildings. Only attempt to extinguish a fire if
you know how to and it is safe to do so. You are not required to perform this
task.
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d. Fire Drills
Drills are held 3 times per year, as required by State law. Everyone must
evacuate during all alarms, whether it is a drill or not. Each building has a
number of Floor Marshals who will assist in the evacuation. Please follow their
instructions.
e. Mobility-impaired persons
If you can, please help assist mobility-impaired persons evacuate. Keep in mind
that elevators cannot be used in a fire emergency. People can safely exit by
going to an adjoining building and using that elevator or exit. Also, Public Safety
has “evac chairs” available if a person needs to be carried down the stairs. If
waiting for assistance, go to a location furthest from the fire and call Public
Safety and report your exact location and nature of the emergency.
4. Procedures for Medical Emergencies
Call the College Public Safety Office:
a.
b.
c.
d.
Dial 911 from a campus phone
Dial 629-7210 from a cell phone
Use a red emergency phones located in campus buildings
Use an outdoor emergency phone identified by the blue light
If possible, have someone else stay with the patient if you need to go to a
phone. Give Public Safety as much information as you can about the nature of
the emergency. Public Safety will dispatch an officer to the scene and will also
connect your call to the Rensselaer County 911 by conference call. You will
receive instructions on what to do until the Fire Department and EMTs arrive.
Data suggests that the average response time by the Troy Fire Department and
EMTs to emergency calls on campus has been in the range of 3 to 4 minutes.
Every effort will be made to keep this response time as short as possible.
5. AEDs (Automatic External Defibrillators)
AEDs are emergency medical units that may be used in cardiac emergencies to restore
heart beat.
AEDs are emergency medical units that may be used in cardiac emergencies to restore
heart beat. These devices are publicly accessible on campus at the following locations:
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BTC
Day Care
Fitz
HRC
Hudson
Jordan Road
LaPan
McDonough
Stadium Class
room
Main Lobby near elevator
2nd floor by room 134
Health Services -storage room 141
Inside Dental Clinic room 113 center of room
3rd Floor Corridor by Vending rm 329
Main hall way by rest rooms
2nd Floor lobby, Suite B
Main Hall way between Rest Rooms
Main Lobby by ticket booth
Trainers Room
Inside Room 107 , south wall of room
If you suspect a patient is in cardiac arrest, report this to Public Safety when calling. A
Public Safety Officer will respond with an AED.
6. Work Related Accidents and Injuries
If an injury or illness occurs on campus, go to the College Health Service in Fitzgibbons
146 for medical attention. An incident report will be completed while at the College
Health Service. No claim for worker’s compensation may be processed without such an
incident report which must, by law, be filed within 30 days of the incident. In the case
of a medical emergency where an ambulance is called, report to the College Health
Service upon return to work.
7. Employee Return from Illness/Injury/Hospitalization/Surgery
When returning from any protracted illness or injury, all employees must report first to
the College Health Service to submit a physician’s clearance to resume job duties. In
some cases, the College Physician or Health Service Director may wish to discuss or
examine the condition. This process is necessary to protect both college and employee.
In general, “light duty” is not allowed.
8. Reporting a Theft or Assault: During an emergency, if a theft or assault is in progress,
please call 911. After the incident has occurred, please call 629-7210 so that a Public
Safety staff member can be dispatched to take a report. In either case, please be certain
to report details such as descriptions of property and of suspects: i.e.: clothing,
height/weight, hair color, eye color, etc.
9. Reporting a Motor Vehicle Accident: Minor property damage car crashes/accidents, can
be reported directly to Public Safety by calling 629-7210. Injury accidents and more
serious property damage accidents can be initially reported to Public Safety. However,
we will then contact the appropriate Police Agency to take the report and investigate
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further.
10. Employee Rights and Responsibilities under State OSHA law: As an employee of the
College, you have the right to ask questions related to potential safety & health
conditions in your work area. Such issues should be directed to the Department of
Environmental Health & Safety (629-7163 or 7787). Or, you can report the issue to the
College Safety Committee through our web page:
https://www.hvcc.edu/ehs/safety_committee/index.html .
At a minimum, all College employees must have safety orientation training provided by
the Department of Environmental Health & Safety. Additional environmental health &
safety training may be required based on your job responsibilities and will be provided
by your department or Environmental Health & Safety.
11. Safety & Health Resources: The following College departments can provide you with
safety and health assistance:
a. Department of Public Safety https://www.hvcc.edu/public_safety/index.html
Located in the south end of the Campus Center, Public Safety’s mission is to
provide a safe, secure atmosphere. The office, located at the south end of the
Siek Campus Center is open 24 hours a day. Contact Public Safety for all
emergencies by dialing 911 from a campus phone or 629-7210 from a cell phone.
b. College Health Service https://www.hvcc.edu/healthsvcs/index.html Provides
staff and students with health information and medical attention. For
assistance, report to the Health Office in Fitzgibbons Hall, room146.
c. Department of Environmental Health & Safety
https://www.hvcc.edu/ehs/health/index.html Provides guidance and training
on all occupational safety and environmental health issues. Contact the
department at 629-7163 or 629-7787.
d. College Safety Committee
https://www.hvcc.edu/ehs/safety_committee/index.html With representatives
from across campus, the committee is responsible for promoting and
strengthening all aspects of safety and health on the campus. To contact the
committee, click on “reporting a safety issue” link on the web page.
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SECURITY AND PRIVACY OF PROTECTED HEALTH
INFORMATION
(CREATED 12/02)
Rationale: Hudson Valley Community College recognizes a duty to avoid
wrongful disclosure of Protected Health Information (PHI) of students, staff,
faculty and others. It is a requirement of the College that every effort be
made to protect the medical privacy of persons who have PHI on file with
the College. This is done by protecting paper and electronic records as well
as other health information through physical, administrative and
technological means directed at maintaining the integrity and security of
those records.
Goal: Secure and Protected Health Information
Objectives:
Training:
1. To maintain a training schedule for Health Science students to
meet the requirements of affiliated institutions
2. To maintain an annual security and privacy training schedule for
appropriate staff.
3. To update training modules as required.
Privacy and Security:
1. To maintain a secure environment wherever PHI is located, including
areas of use and storage of medical and other health records.
2. To ensure staff behavior will uphold the privacy and security of PHI.
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3. To maintain continuing review of security and privacy processes
within the College and to develop or amend policies and procedures
when necessary to protect PHI.
4. To maintain a program which allows for the transfer of Individually
Identifiable Health Information upon written request of the individual
and the revocation of that request as well.
5. To inform individuals submitting PHI of their privacy rights and to
maintain a process to allow for satisfaction of complaints concerning
the privacy and security of PHI.
6. To maintain accurate reporting, investigation and review of violations
of security or privacy policy and determine sanctions for such
violations.
7. To support a program which allows for amendments to medical and
other health records.
8. To maintain an accurate accounting of disclosures of PHI.
9. To document all aspects of the security and privacy program.
Guidance for Disclosure of Protected Health Information
General Guidelines:
Generally, every disclosure must be evaluated on an individual basis.
Identity of a requester of PHI must be appropriately verified.
Discussion for medical treatment, insurance processing and other
normal business operations is allowed. Incidental observations are not
appropriate.
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Sharing identifiable information with the risk manager in case of
possible liability, conversations with Human Resources Director or
his/her Designee regarding ability of an employee to perform assigned
duties, discussion of immunization information with Health Science
Department Chairs and affiliating hospitals are examples of allowed
communication because they fall under necessary disclosure for
normal business operations. The Privacy Officer will advise staff
with questions concerning disclosures of a questionable nature.
Policies:
Policy, Maintaining Physical Security of the PHI
The physical security of medical and other records containing Individually
Identifiable Health Information will be maintained at all times.
Procedures:
Records containing PHI will not be left unattended in any place accessible to
non-medical people.
Areas of location of Individually Identifiable Health Information must be
locked at all times when staff members are not present in the immediate area
to protect the security of PHI. Keys to such areas should be available only
to those who need access to the health information.
At the end of each working day, all records containing PHI will be put in
secure locked areas.
Records containing PHI will not be removed from their assigned location
without permission of the Privacy Officer.
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Policy, Staff Practices:
Staff will discuss or release PHI only for the purposes of treatment,
insurance processing or when necessary to maintain normal business
operations of the college and will take measures to avoid accidental release
of PHI by careless record handling or verbal indiscretions.
Violators of any privacy policies will be subject to disciplinary action that
ranges from reprimand to termination.
Procedures:
• Oral disclosures of information will be made only in emergency
situations and then written or witnessed verbal consent of the
concerned individual must be obtained if possible.
• Staff will never discuss an individual’s PHI with another staff
member within hearing distance of others.
• Staff will ensure identity of persons requesting PHI. SUNY card,
Drivers License or other picture ID is acceptable identification.
• When speaking to someone concerning their health information,
doors to an interview area should be closed. A TV, radio, CD or
tape player should be used as sound for masking during interviews
as well.
• Records containing PHI will not be left unattended and never be
left where anyone other than appropriate staff can see or touch
them.
Policy, College PHI Security and Privacy Committee:
A College PHI Security and Privacy Committee will be responsible for the
security and privacy policies, procedures and protocols. This does not
abrogate the responsibility of individual employees to be vigilant with
respect to any circumstances that may facilitate a breach of the security
and privacy system.
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• The College PHI Security and Privacy Committee comprised of
representatives from Health Services, Health Sciences, Human
Resources, Finance, and Computer Services and FSA will review the
security and privacy plan annually or more often if a need for policy
change becomes apparent or applicable changes to the law occur. The
Committee will make recommendations for change to the policy when
necessary.
• Minutes of these meetings will be kept permanently.
• If the committee makes recommendations that are not approved by
the relevant director or department chair, the recommendation must be
reviewed by the Privacy Officer and the appropriate Vice President
the ultimate decision concerning enactment of the recommendations
will be made by the appropriate Vice President.
• In keeping with other Health Service policy, all changes to policy will
be documented as revisions to the original policy and previous
policies will be maintained for a minimum of 10 years.
Policy, Staff Training:
All Staff who may come in contact with PHI while performing their duties
will be trained annually regarding HIPAA and HVCC policies and
procedures of security and privacy.
Procedure:
• In general training will be conducted as a web based activity.
Training will be developed the Privacy Officer or others as assigned.
• Any changes in policies or procedures will be disseminated and
explained to staff immediately. The training module will be updated
immediately upon change.
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• In keeping with other College policy, training in which each
individual staff member participates will be recorded in the Office of
Human Resource Development.
Policy, Release of Medical Information: (See Faxing Policy)
All written requests for release of health or medical information will be
reviewed and the minimum information necessary to meet the purposes
of the request will be released.
Research involving access to any individually identifiable student
information is prohibited.
health
Medical information will be released only upon written permission of the
patient, a judicial subpoena or other legal requirements. This includes all
information released to another medical office. Information regarding
medical history or treatment will not be shared with faculty or administration
unless the patient has requested such in writing (verbal permission is
acceptable in extreme emergency but must be given in presence of witness).
The exception to this is that accident reports will be faxed to the College
Risk Manager immediately upon completion.
Procedure:
• Subpoenas and other legal forms will be evaluated by the Privacy
Officer and/or the College Attorney, if necessary, before honoring the
legal request for transfer of records .
• A “Request for Disclosure” form should be completed by the patient
or his/her legal representative.
• Request for Disclosure forms must contain the following information:
Name, address, Social Security number, and relationship of
person requesting transfer,
Exact description of information to be transferred,
Purpose of disclosure,
Name, address and, if appropriate, fax number of where the
records should be sent,
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Signature of person requesting the transfer and date of
signature,
Witnessing signature of transfer request.
• All requests for disclosure must be examined carefully and with the
exception of a request for Immunization or Physical Exam
information that is signed by the student or staff member, all requests
will be reviewed by the Privacy Officer who will use discretion in
referring these requests to the College Attorney.
• Information disclosed will always be limited to the exact information
authorized.
• Written permission must be signed by the student/ patient unless that
person is under the legal age of consent, in which case the legal
guardian should sign the letter/form. Proof of legal guardianship will
be approved by the College Attorney.
• If a Request for Disclosure form or a letter of request is signed by
someone claiming to be a legal representative, the request must be
approved by the Privacy Officer or the College Attorney. The
documentation of representation must be attached to the form.
• The letter/form must specifically address what information is to be
released and cannot be used for more than one transfer of information.
• When the “Request for Disclosure” Form is completed the
information will be photocopied and mailed to the address indicated
or given to the individual requesting his/her records.
• The request will be retained with the Health information released and
in the Disclosure Log. A note that the copy was faxed and mailed or
given to the individual and the date will be noted on the request and, if
appropriate, on the Clinical notes of the patient’s record.
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• ONLY FORMS ORIGINATING AT HVCC OR AT THE REQUEST
OF HVCC CAN BE COPIED AND SHARED WITH OTHERS.
FORMS GENERATED AT OTHER PLACES CANNOT BE
TRANSFERRED.
Faxing of PHI:
Faxing of Protected Health Information will be done only after a request by
the subject of the PHI.
Procedure:
• Numbers to which information will be faxed may be accepted if given
by the subject of the PHI.
• Numbers which are researched by college staff must be verified by
calling the office to which the information is to be faxed.
• A cover sheet must accompany the information and the cover sheet
must have the standard information:
1. Name, telephone and fax number of the person the PHI is
being faxed to,
2. Name, address and telephone number of the person from
whom the PHI is being faxed, Date the fax is being
initiated,
3. Number of pages being faxed, including cover page,
4. Subject or topic of the fax.
5. The cover sheet should also contain a confidentiality notice.
The statement should include:
CONFIDENTIALITY NOTICE
INFORMATION ACCOMPANYING THIS FACSIMILE COVER SHEET CONTAINS PRIVILEGED AND
CONFIDENTIAL INFORMATION INTENDED SOLELY FOR THE USE OF THE INDIVIDIUAL OR ENTITY TO WHOM IT
IS ADDRESSED. IF THE READER OF THIS NOTICE IS NOT THE INTENDED ADDRESSEE, YOU ARE HEREBY
NOTIFIED THAT ANY DISSEMINATION, DISTRIBUTION OR COPYING OF THIS COMMUNICATION IS STRICTLY
PROHIBITED.
THE
IF YOU HAVE RECEIVED THIS FACSIMILE IN ERROR, PLEASE NOTIFY US BY TELEPHONE IMMEDIATELY AND
EITHER RETURN THE FAXED INFORMATION TO THE SENDER, BY US MAIL, AT THE ADDRESS LISTED ON THIS
FACSIMILE, OR DISPOSE OF THE DOCUMENT BY SHREDDING. THANK YOU
Page 68
• After a fax transmission is completed, the fax the number on the
transmittal form will be verified as the proper number to which the
information should have been faxed. The transmittal form will then
be attached to the cover sheet and a copy of the information that was
faxed. These papers will be kept in the medical record with the
original information.
Policy, Right to Revoke Authorization:
Each individual has a right to revoke an authorization previously signed by
completing an “Authorization Revocation Form”.
Procedure:
• After signing and witnessing of the “Authorization Revocation
Form” a copy shall be given to:
The patient requesting revocation
The Privacy Officer
A third will be filed with the health information
• The revocation will be entered in the revocation log.
Policy, Accounting of Disclosure of Protected Health Information:
A complete accounting of individual disclosures of protected health
information will be maintained on each individual record and in a disclosure
log. A separate record will be maintained by the Privacy Officer.
Procedure:
• Required information to maintain in the Disclosure Log for each
disclosure is as follows:
1. Date of disclosure
2. Name and address of person to receive the disclosed
information
3. Description of disclosed information
4. Statement of purpose of disclosure
5. Written accounting of disclosure will be provided to the
individual
6. Title of person who approved the disclosure
7. The disclosure log will be archived annually.
Page 69
Policy, Right to Request Restriction of Use and Disclosure of Protected
Health Information:
A person requesting restriction of use or disclosure of his/her protected
health information should be informed that the College may be unable to
restrict disclosure. Other restriction requests will be processed by the
Privacy Officer.
Procedure:
• Upon request for restriction of use or disclosure, the individual
will be given a request for restriction form.
• The Privacy Officer will process the request with in 10 working
days. During that time no PHI will be disclosed.
• If the request is denied, the requestor may appeal to the
appropriate Vice President by completing an appeal form. The
Vice President will notify the individual of the decision within 10
days.
• Upon approval of a “Request of Restriction of Use and Disclosure
Form”, a copy will be placed with the student’s health information
and a “Restriction” stamp will be applied on the outside of the
folder. If put in storage without a file jacket, the file will have a
red “Restricted” sticker put on the front page of the health
information.
Policy, Notice of Privacy Practice:
Every effort will be made to inform students and employees of the College
Privacy Practice.
Procedure:
A copy of the Notice of Privacy Practice will be placed in the College
Catalog, the Student Handbook and the Employee Orientation Packet.
Page 70
Policy, Processing of Complaints Regarding Privacy Policies
Students have a right to have complaints heard and responded to in a timely
manner.
Procedure:
• Upon request, the complainant will be given a Privacy Complaint
Form to complete.
• The completed form will be sent to the Privacy Officer at once.
• All complaints regarding privacy policy will be processed by the
Privacy Officer within 10 working days.
• Appeal of unsatisfied complaints will be sent to the Vice President
of Student Services upon completion of an Appeals Form.
Appeals Forms must be completed within 10 days of notification
of the Privacy Officer’s decision.
Policy, Investigations of Violations of Privacy Policy
All complaints of violations of privacy will be thoroughly investigated.
Procedure:
• Investigations of privacy violations will be directed by the Privacy
Officer and completed within 10 working days of the complaint.
• A complete report of any investigation will be given to the Vice
President of Student Services upon completion of the
investigation.
Page 71
Policy, Review and Amendment of protected Health Information:
Anyone wishing to review or amend his or her health information may apply
to do so.
Procedure:
• Persons wishing to review or amend their health information must
process a “Request for Review” or “Request for Amendment of
Medical Record” form that will be processed by the Privacy
Officer. These requests will be processed within 10 business
days.
Review and Amendment Decision:
The applicant will be notified of the Privacy Officers” decision concerning
the review/amendment request within 15 working days of the date of the
original request.
Procedure:
• If the review/amendment is approved the Privacy Officer will
direct the involved administrator to place the amendment in the
health information.
• If the review/amendment is denied, the Privacy Officer will
explain to the applicant in writing reasons for denial within 15
days of the application. The Privacy Officer will also explain the
process for appeal to the appropriate Vice President.
• The applicant may appeal a denial to the Vice President by filing
an appeal form within 10 working days of the decision.
• The Vice President will notify the applicant of his/her decision
within 10 working days of receiving the appeal.
• In the case of denial of the appeal, the Vice President will notify
the complainant of his/her right to complain to US Health and
Human Services.
• The Vice President may allow the involved administrator to file
an opposing view of the amendment in the health record.
Page 72
Workers Compensation
Job related injury or illness may qualify you for compensation for loss of income or leave
accruals. The college is a member of the Rensselaer County Workers Compensation Pool
administered by Rensselaer County and benefits are prescribed by NYS law. Basic operation of
the law includes:
•
•
•
•
•
The requirement that a case be initiated by the filing of an incident report with the college
through the College Health Service or the Public Safety Office [if Health Service is closed]
and Office of Human Resources to be forwarded to the current consultant, Benetech, Inc.
Need to report the claim in writing on forms provided by the college within thirty days of
occurrence.
Use of accrued sick leave ( or other leaves once sick leave is exhausted) to cover pay while
absent until the claim is adjudicated.
Awards resulting in restoration of leave accruals and or actual dollar awards in cases of
disabilities.
Compensation available directly from the system when college leaves are exhausted or
the injured individual so chooses.
When returning from an injury, hospitalization, any surgery or protracted illness, all
employees must report first to the College Health Service to submit physician’s clearance to
resume job duties. In some cases, the College Physician or Health Service Director may wish
to discuss or examine the condition. This process is necessary to protect both college and
employee. In general “light duty” is not allowed.
Page 73
PL
E
AM
EX
Page 74
STATE OF NEW YORK
WORKERS’ COMPENSATION BOARD
100 BROADWAY-MENANDS
ALBANY, NY 12241
(877) 632-4996
You were injured at work. What now?
The New York State Workers’ Compensation Board has received notice you suffered a
workplace injury or illness, so we’re preparing a workers’ compensation case in your
name. You may have already received medical treatment. If you haven’t, you should
seek medical care as soon as possible.
A Worker’s Responsibilities
 You must tell your employer, in writing, when, where and how you were injured.
Do this within 30 days of injury.
 Medical reports are necessary for your case. Advise your doctors that you have a workrelated injury, and give the name of your employer. Do not pay for your care
yourself or use other health insurance. Tell your doctor to file reports with the Board
and with your employer or its insurance carrier. If your case is disputed, the Board
needs a medical report on your injury to begin resolving your claim.
Starting a Case
Once your employer knows of your injury, it must notify this Board by filing a C-2
form. You should file an employee claim (C-3 form) reporting your injury as soon as possible.
(You must notify the Board of your injury or illness within two years.) If you injured the
same body part before, or had a similar illness, you must also file a Form C-3.3.
If you haven’t already filed a C-3 or C-3.3 (if necessary), there are three ways to do it.



Visit www.wcb.state.ny.us/content/main/onthejob/howto.jsp to complete the form.
Complete the enclosed paper forms, and mail them to the Board.
Call 1-866-396-8314. A Board employee will complete the form with you.
Health Care Bills
Do not pay your doctor or hospital. Those bills are paid by the insurer unless the Board
disallows your case. If your case is disputed, the providers are paid when the Board
decides your case. If the Board decides against you, or if you don’t pursue a case, you will
have to pay the doctor or hospital.
Your employer’s insurance covers medically necessary drugs and equipment your
doctor prescribes. You’re also entitled to carfare or necessary expenses incurred when
traveling for treatment. (Get receipts for those expenses.)
THIS AGENCY EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION
Page 75
Claimant Information Packet
Generally, you can choose any doctor authorized by the Board. You can also use
occupational health clinics. However, if your employer’s insurer has a preferred
provider organization to provide care for workers' compensation injuries, you must get
your initial treatment from those providers. If that insurer also has a pharmacy or
diagnostic network, you must get service within these networks. If the carrier uses these
networks, it must also tell you its service providers and how to use them.
Benefits for Lost Wages
You are entitled to a portion of your lost wages if your injury affects you in one or more
ways:
1. It keeps you from work for more than seven days;
2. Part of your body is permanently disabled;
3. Your pay is reduced because you now work fewer hours or do other work.
An employer or insurer can accept your claim and begin paying your lost wage benefit
promptly. Sometimes, employers and carriers dispute a claim. When that occurs, the
Board strives to resolve most cases within 90 days.
You may hire an attorney or licensed representative, who can be helpful with complex
or disputed claims, but it isn’t required. The Board sets their fees and they will be
deducted from your lost wages award. You or your family should not pay anything
directly to your attorney or licensed representative.
If your case is disputed, you may receive disability benefits while the case is heard.
You’d pay them back out of your lost wages award. To get a DB-450 form, visit
www.wcb.state.ny.us/content/main/forms/db450.pdf or a Board office, or call (800) 353-3092.
Help is Available
People sometimes need help getting back to work. Your employer may have a return to
work program that can get you back to work in light duty or an alternative position
while you heal. An injury can also cause family or financial problems. The Workers'
Compensation Board has rehabilitation counselors and social workers to help. Call (877)
632-4996 for more assistance.
What’s Next?
Your employer or its insurance carrier will contact you if your claim is accepted. When
that happens, your treatment will be paid and lost wage benefits begin. If your case is
challenged, the Board will notify you about resolving the case. If more information is
necessary, the Board will contact you and tell you how to file it.
Important Contact Information
Workers’ Compensation Board
Disability Benefits
NYS Bar Association Lawyer
Referral and Information Service
(877)632-4996
(800)353-3092
(800)342-3661
[email protected]
www.WCB.State.NY.US
[email protected]
NEW YORK STATE WORKERS' COMPENSATION BOARD
Page 76
Employee Claim
C-3
State of New York - Workers' Compensation Board
Fill out this form to apply for workers' compensation benefits because of a work injury or work-related illness. Type or
print neatly. This form may also be filled out on-line at www.wcb.state.ny.us.
WCB Case Number (if you know it):
A. YOUR INFORMATION (Employee)
1. Name:
2. Date of Birth: ______/______/______
First
3. Mailing address:
MI
Number and Street/PO Box
-
4. Social Security Number:
7. Do you speak English?
Last
City
-
Yes
State
Zip Code
5. Phone Number: (_____)_______________ 6. Gender:
Male
Female
No If no, what language do you speak?
B. YOUR EMPLOYER(S)
2. Phone Number: (_____)_______________
1. Employer when injured:
3. Your work address:
Number and Street
4. Date you were hired: _____/_____/_____
City
State
Zip Code
5. Your supervisor's name:
6. List names/addresses of any other employer(s) at the time of your injury/illness:
7. Did you lose time from work at the other employment(s) as a result of your injury/illness?
Yes
No
C. YOUR JOB on the date of the injury or illness
1. What was your job title or description?
2. What types of activities did you normally perform at work?_________________________________________________________________
3. Was your job? (check one)
Full Time
Part Time
Seasonal
4. What was your gross pay (before taxes) per pay period?
6. Did you receive lodging or tips in addition to your pay?
Volunteer
Other:____________________
5. How often were you paid?
Yes
No
If yes, describe:
D. YOUR INJURY OR ILLNESS
1. Date of injury or date of onset of illness: ______/______/______
2. Time of injury:
AM
PM
3. Where did the injury/illness happen? (e.g., 1 Main Street, Pottersville, at the front door)
4. Was this your usual work location?
Yes
No
If no, why were you at this location?
5. What were you doing when you were injured or became ill? (e.g., unloading a truck, typing a report) _______________________________
6. How did the injury/illness happen? (e.g., I tripped over a pipe and fell on the floor)
7. Explain fully the nature of your injury/illness; list body parts affected (e.g., twisted left ankle and cut to forehead):______________________
C-3.0 (8-09) Page 1 of 2
THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE
WITH DISABILITIES WITHOUT DISCRIMINATION
Page 77
www.wcb.state.ny.us
YOUR NAME:________________________________________________
First
MI
DATE OF INJURY/ILLNESS: ______/______/______
Last
D. YOUR INJURY OR ILLNESS continued
8. Was an object (e.g., forklift, hammer, acid) involved in the injury/illness?
Yes
9. Was the injury the result of the use or operation of a licensed motor vehicle?
your vehicle
If yes,
employer's vehicle
other vehicle
If yes, what?
No
Yes
No
License plate number (if known):
If your vehicle was involved, give name and address of your motor vehicle insurance carrier:
10. Have you given your employer (or supervisor) notice of injury/illness?
Yes
If yes, notice was given to: ____________________________________
11. Did anyone see your injury happen?
Yes
No
orally
No
in writing Date notice given: _____/_____/_____
Unknown If yes, list names:________________________________________
E. RETURN TO WORK
Yes, on what date? _____/_____/_____
1. Did you stop work because of your injury/illness?
2. Have you returned to work?
Yes
No
If yes, on what date? _____/_____/_____
3. If you have returned to work, who are you working for now?
regular duty
New employer
Same employer
4. What is your gross pay (before taxes) per pay period?
No , skip to Section F.
limited duty
Self employed
How often are you paid?
F. MEDICAL TREATMENT FOR THIS INJURY OR ILLNESS
None received (skip to question F-5)
1. What was the date of your first treatment? ______/______/______
2. Were you treated on site?
Yes
No
3. Where did you receive your first off site medical treatment for your injury/illness?
Doctor's office
Clinic/Hospital/Urgent Care
none received
Emergency Room
Hospital Stay over 24 hours
Name and address where you were first treated:
Phone Number: (_____)_______________
4. Are you still being treated for this injury/illness?
Yes
No
Give the name and address of the doctor(s) treating you for this injury/illness:
Phone Number: (_____)_______________
5. Do you remember having another injury to the same body part or a similar illness?
Yes
No
If yes, provide the names and addresses of the doctor(s) who treated
If yes, were you treated by a doctor?
Yes
No
you and COMPLETE AND FILE FORM C-3.3 TOGETHER WITH THIS FORM:
6. Was the previous injury/illness work related?
Yes
No
If yes, were you working for the same employer that you work for now?
Yes
No
I am hereby making a claim for benefits under the Workers' Compensation Law. My signature affirms that the information I am providing is true
and accurate to the best of my knowledge and belief.
Any person who knowingly and with INTENT TO DEFRAUD presents, causes to be presented, or prepares with knowledge or belief that it
will be presented to, or by an insurer, or self-insurer, any information containing any FALSE MATERIAL STATEMENT or conceals any
material fact, SHALL BE GUILTY OF A CRIME and subject to substantial FINES AND IMPRISONMENT.
Employee's Signature:
Print Name:
Date: _____/_____/_____
On behalf of Employee:
Print Name:
Date: _____/_____/_____
An individual may sign on behalf of the employee only if he or she is legally authorized to do so and the employee is a minor, mentally incompetent or incapacitated.
I certify to the best of my knowledge, information and belief, formed after an inquiry reasonable under the circumstances, that the allegations and other factual
matters asserted above have evidentiary support, or are likely to have evidentiary support after a reasonable opportunity for further investigations or discovery.
Signature of Attorney/Representative (if any):
Print Name:
ID No., if any: R
C-3.0 (8-09) Page 2 of 2
Date: _______/_______/_______
Title:
If Licensed Representative, License No.:
Expiration Date: _______/_______/_______
Page 78
C-3.3
Limited Release of Health Information
(HIPAA)
State of New York - Workers' Compensation Board
WCB Case No. (if you know it):___________________________
To Claimant: If you received treatment for a previous injury to the same body part or for an illness similar to the one described in your current
Claim, fill out this form. This form allows the health care providers you list below to release health care information about your previous injury/
illness to your employer's workers' compensation insurer. The federal HIPAA law (Health Insurance Portability and Accountability Act of 1996)
says you have a right to get a copy of this form. If you do not understand this form, talk to your legal representative. If you do not have a legal
representative, the Advocate for Injured Workers at the Workers' Compensation Board can help you. Call: 800-580-6665.
To Health Care Provider: A copy of this HIPAA-compliant release allows you to disclose health information. If you send records to the
employer's workers' compensation insurer in response to this release, also mail copies to the Claimant's legal representative. (If no legal
representative is listed below, send copies to the Claimant.) Health care providers who release records must follow New York state law and
HIPAA.
This release is:
Voluntary. Your health care provider(s) must give you the same care,
payment terms, and benefits, whether you sign this form or not.
Limited. It gives your health care provider(s) permission to release only
those health records that are related to the previous illness/condition you
describe below.
Temporary. It ends when your current claim for compensation is established
or disallowed and all appeals are exhausted.
Revocable. You can cancel this release at any time. To cancel, send a letter
to the health care provider(s) listed on this form. Also, send a copy of your
letter to your employer's workers' compensation insurer and the Workers'
Compensation Board. Note: You may not cancel this release with respect to
medical records already provided.
For records only. It gives your health care provider(s) listed on this form
permission to send copies of your health care records to your employer's
workers' compensation insurer.
This form does NOT allow your health care provider(s)
to release the following types of information:
HIV-related information
Psychotherapy notes
Alcohol/Drug treatment
Mental Health treatment (unless you check below)
Verbal information (your health care providers may
not discuss your health care information with anyone)
Any medical records released will become part of your workers' compensation file and are confidential under the Workers' Compensation Law.
A. YOUR INFORMATION (Claimant)
1. Name:__________________________________________________________________ 2. Social Security Number:______-_____-______
3. Mailing Address: _________________________________________________________________________________________________
4. Date of Birth: ______/______/______ 5. Date of the current injury/illness: ______/_______/_______
6. Current injury/illness, including all body parts injured:_____________________________________________________________________
______________________________________________________________________________________________________________
7. Your legal representative's name and address (if any):___________________________________________________________________
______________________________________________________________________________________________________________
Check here if you allow your health care provider(s) to release mental health care information.
B. YOUR HEALTH CARE PROVIDER(S) (List all health care providers who treated you for a previous injury to the same body part or similar
illness. If more than 2 providers attach their contact information to this form.)
1. Provider:__________________________________________________________________ 2. Phone Number: (______)_______________
3. Mailing Address: _________________________________________________________________________________________________
4. Other provider (if any):_______________________________________________________ 5. Phone Number: (______)_______________
6. Mailing Address:_________________________________________________________________________________________________
C. READ AND SIGN BELOW. I hereby request that the health care provider(s) listed above give my employer's workers' compensation
insurer copies of all health records related to any previous injury/illness, to all body parts, described above.
____________________________________________________________________________________________________________
Claimant's signature (ink only -- use blue ballpoint pen, if possible.)
Date
If the claimant is unable to sign, the person signing on his/her behalf must fill out and sign below:
______________________________________________________________________________________________________________
Your name
C-3.3 (12-09)
Relationship to Claimant
Signature (ink only -- use blue ballpoint pen, if possible.)
Versión en español al reverso de la forma.
Date
Page 79
www.wcb.state.ny.us
Divulgación limitada de información sobre la salud
(HIPAA)
Estado de NuevaYork - Junta de Compensación Obrera (WCB)
C-3.3
WCB Case No. (if you know it) (Número de caso WCB [si lo sabe])
Al reclamante: Si usted recibió tratamiento por una lesión anterior en la misma parte del cuerpo o por una enfermedad similar a la que motiva
ahora su reclamación, complete este formulario. Este formulario les permite a los proveedores de salud que usted señala a continuación divulgar
a la compañía de seguros de compensación obrera de su empleador la información sobre su salud relacionada con su lesión/enfermedad
anterior. La Ley federal HIPAA (Ley de portabilidad y responsabilidad del seguro de salud de 1996) establece que usted tiene derecho a recibir
una copia de este formulario. Si no comprende este formulario, hable con su representante legal. Si no tiene un representante legal, el
Representante de los obreros lesionados de la Junta de Compensación Obrera puede ayudarlo. Llame al 800-580-6665.
Al proveedor de salud: Una copia de esta divulgación, redactada según lo que establece la ley HIPAA, le permite divulgar información sobre la
salud. Si envía los registros al asegurador de compensación obrera del empleador en respuesta a la presente divulgación, también debe enviar
por correo copias al representante legal del reclamante. (Si a continuación no se especifica un representante legal, envíe las copias al
reclamante). Los proveedores de salud que divulgan los registros deben cumplir con las leyes del estado de Nueva York y la HIPAA.
Esta divulgación es:
Este formulario NO autoriza a su(s) proveedor(es) de
Voluntaria. Su(s) proveedor(es) de salud deben otorgarle la misma
salud a divulgar los siguientes tipos de información:
atención, condiciones de pago y beneficios, independientemente de que
usted firme este formulario o no.
Limitada. Le otorga a su(s) proveedor(es) de salud permiso para divulgar
Información relacionada con el VIH
únicamente los registros médicos que se relacionen con la enfermedad/
afección anterior que usted describe a continuación.
Notas de terapia psicológica
Temporal. Termina cuando se otorgue o desestime su actual reclamación
de compensación y se hayan agotado todas las apelaciones.
Revocable. Usted puede cancelar esta divulgación en cualquier momento.
Tratamientos por abuso de alcohol o drogas
Para hacerlo, envíe una carta al (a los) proveedor(es) de salud que se
indican en este formulario. Además, envíe una copia de su carta a la
compañía de seguros de compensación obrera de su empleador y a la Junta
Tratamiento de salud mental (a menos que usted lo
de Compensación Obrera. Nota: No podrá cancelar esta divulgación en lo
indique a continuación)
que se refiere a registros médicos que ya se hayan provisto.
Solamente para registros. Le otorga a su(s) proveedor(es) de salud que se
Información verbal (sus doctores no pueden hablar
indica(n) en este formulario permiso para enviar copias de sus registros de
con nadie sobre su información de salud)
salud a la compañía de seguros de compensación obrera de su empleador.
Los registros médicos divulgados se incorporarán a su expediente de compensación obrera y son confidenciales conforme a la
Ley de compensación obrera.
CONTESTA LAS SIGUIENTES PREGUNTAS, EN INGLÉS SI ES POSIBLE, EN LOS ESPACIOS PROVISTOS Y FIRMA
AL FRENTE DE LA FORMA.
A. YOUR INFORMATION (Claimant) INFORMACIÓN PERSONAL (Reclamante)
1. Name (Nombre)
2. Social Security Number (Número de seguro social)
3. Mailing Address (Dirección postal)
4. Date of Birth (Fecha de nacimiento)
5. Date of the current injury/illness (Fecha de la lesión/enfermedad actual)
6. Current injury/illness, including all body parts injured (Descripción de la lesión/enfermedad actual, incluyendo todas las partes del
cuerpo lesionadas)
7. Your legal representative's name and address (if any) (Nombre y dirección de su representante legal [si corresponde])
Check here if you allow your health provider(s) to release mental health care information. (Marque aquí si autoriza a su(s) proveedor(es) de
salud a divulgar información sobre tratamientos de salud mental.)
B. YOUR HEALTH CARE PROVIDERS (List all health care providers who treated you for a previous injury to the same body part or similar
illness. If more than 2 providers, attach their contact information to this form.
SU(S) PROVEEDOR(ES) DE SALUD (Enumere todos los proveedores de salud que le han tratado por lesiones previas a las mismas
areas del cuerpo ó por enfermedades semejantes.Si son más de 2 proveedores, adjunte su información de contacto a este formulario.)
1. Provider (Proveedor de salud)
2. Phone Number (No de teléfono)
3. Mailing Address (Dirección postal)
4. Other provider (if any) (Otro proveedor [si corresponde])
5. Phone Number (No de teléfono)
6. Mailing Adress (Dirección postal)
C. READ AND SIGN BELOW I hereby request that the health care provider(s) listed above give my employer's workers' compensation
insurer copies of all health records related to any previous injury/illness, to all body parts, described above. LEA Y FIRME A
CONTINUACIÓN. Por la presente solicito que los proveedores de salud aquí enumerados le provean al asegurador de compensación
obrera de mi patrono copias de todos los records médicos relacionados a cualquier lesión/enfermedad aquí enumeradas.
If the claimant is unable to sign, the person signing on his/her behalf must fill out and sign below: (Si el reclamante no puede firmar, la
persona que firme el formulario en su nombre y representación debe llenar y firmar a continuación)
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
Claimant's signature (Firma del reclamante ) use solo tinta - preferiblemente azul
Date (Fecha)
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
Your name (Su nombre)
Relationship to Claimant (Relación con el reclamante)
Signature(Firma)
Date(Fecha)
C-3.3 (12-09)
Page 80
www.wcb.state.ny.us
Instructions for Completing Form C-3, “Employee Claim”
Please complete this form and send it to your local Workers' Compensation Board district office (DO) to apply for workers'
compensation benefits. The addresses are listed at the bottom of these instructions. If you need additional help in completing
this form, contact the Worke rs' Compensation Board at 1-877-632-4996. You may also fill this form out online at: http://
www.wcb.state.ny.us/
If you do not have or know your Workers' Compensation Board Case Number, please leave this field blank. It is not
required to process your claim. Remember to enter your name and the date of your injury/illness on the top of page
two.
Section A - Your Information (Employee):
Item 1: Enter your full name, including first name, middle initial, and last name.
Item 2: Enter your date of birth in month/day/year format. Include the four digit year.
Item 3: Enter your mailing address, including P.O. Box, if applicable, city or town, state, and Zip code.
Item 4: Enter your Social Security Number. This is very important to help service your claim faster.
Item 5: Indicate the primary contact phone number, including area code. This may include a cell phone number.
Item 6: Indicate your gender (Male or Female).
Item 7: Check Yes if you can speak and understand English. If not, then check No and indicate which language you speak.
Section B - Your Employer(s):
Item 1: Indicate the employer you were working for at the time you were injured or became ill.
Item 2: Enter the phone number for this employer, either a primary contact number or the number for your supervisor.
Item 3: Enter the employer's address, including P.O. Box, if applicable, city or town, state, and Zip code.
Item 4: Indicate the date you were hired by this employer.
Item 5: Enter your direct supervisor's name, whom you report to on a regular basis.
Item 6: If you have more than one job, please indicate the names and addresses of all other employers you work for besides
the one you were injured at. Please attach a separate sheet if you need more room.
Item 7: Check Yes if you lost time from any of your other jobs as a result of your injury or illness; otherwise, check No.
Section C - Your Job on the Date of the Injury or Illness:
Item 1: Indicate your current job title or job description (e.g., warehouse worker).
Item 2: Indicate your typical work activities for this job (e.g., keeping inventory, unloading trucks, etc.).
Item 3: Check the type of job you had.
Item 4: Enter your gross pay (before taxes) per pay period.
Item 5: Indicate how often you received a paycheck (weekly, bi-weekly, etc.).
Item 6: Indicate if you received any tips or lodging in addition to your regular pay. If you did, describe them.
Section D - Your Injury or Illness:
Item 1: Enter the date when you were injured or the first date you noticed you became ill. Enter the date in month/day/year
format. Include the four digit year. If this is an illness or occupational disease, then skip item 2.
Item 2: Enter the time when the injury occurred. Check whether it was AM or PM.
Item 3: Indicate the location where the injury/illness occurred, including the address of the building and the physical
location in the building where the injury/illness happened.
Item 4: Check whether this was your normal work location. If it was not, explain why you were at this location.
Item 5: Describe in detail what you were doing at the time of the injury/illness (e.g., unloading boxes from a truck by hand).
This explains the events leading up to the injury.
Item 6: Describe in detail how the injury/illness occurred (e.g., I was lifting a heavy box off a truck). This should include all
people and events involved in the injury/illness.
Item 7: Indicate fully the nature and extent of your injury/illness, including all body parts injured. Be as specific as possible.
(e.g., I strained my back trying to lift a heavy box. It hurts to bend over or hold even lighter objects now.)
Item 8: Indicate if some object was involved in the accident OTHER THAN a licensed motor vehicle. Other objects may
include a tool (e.g., hammer), a chemical (e.g., acid), machinery (e.g., forklift or drill press), etc.
Item 9: Indicate if a licensed motor vehicle was involved in the accident. If so, check if the motor vehicle involved was
yours, your employer's, or a third party's. Include the license plate number (if known). If your vehicle was involved,
fill out the name and address of your automobile liability insurance carrier.
Item 10: Check if you gave your employer or supervisor notice of your injury or illness. If so, indicate who you gave notice
to as well as if it was orally or in writing. Include the date you gave notice.
Item 11: Check if anyone else saw the injury happen. If anyone did see it, include their name(s).
Section E - Return to Work:
Item 1: If you stopped working as a result of your work-related injury/illness, check Yes and indicate on what date you
stopped working. If you have not stopped working, check No and skip to the next section.
Page 81
C-3.0 (3-09)
Section E - Return to Work (cont):
Item 2: If you have since returned to work, check Yes. Also indicate on what date you started working again, as well as if you
have returned to your Normal Duties or if you are on Limited or Restricted Duty. (If you have not returned to your full
pre-injury or illness work duties, then you are on Limited Duty.)
Item 3: If you have returned to work, indicate who you are working for now.
Item 4: Enter your gross pay (before tax pay) per pay period for the job you are working at now. Indicate how often you are
receiving a paycheck (weekly, bi-weekly, etc.).
Section F - Medical Treatment for This Injury or Illness:
Item 1: If you did not receive medical treatment for this injury/illness, check None Received and skip to item 5. Otherwise,
enter the date you first received treatment for this injury/illness and complete the rest of this section.
Item 2: Check if you were first treated on the job for this injury or illness.
Item 3: Check the location where you first received off site medical treatment for your injury or illness. Include the name and
address of the facility as well as the phone number (including area code).
Item 4: If you are still receiving ongoing treatment for the same injury or illness, check Yes and indicate the name and
address of the doctor(s) providing treatment as well as the phone number (including area code); otherwise check No.
Item 5: If you believe you already had an injury to the same body part or a similar illness, check Yes and indicate if you were
treated by a doctor for this injury or illness. If you were treated by a doctor, indicate the name(s) and address(es) of the
doctor(s) whom provided care and complete and file Form C-3.3 together with this form.
Item 6: If you had a previous injury or illness, check if your previous injury or illness was work-related. If Yes, check if
the injury or illness happened while working for your current employer.
Sign Form C-3 in the place provided for "Employee's Signature on page 2, print your name, and enter the date you signed the
form. If a third-party is signing on behalf of the employee, that person should sign on the second signature line. If you have
legal representation, your representative must complete and sign the attorney/representative's certification section on the
bottom of page 2.
What Every Worker Should Do in Case of On-The-Job Injury or Occupational Disease:
1.
2.
3.
4.
5.
6.
Immediately tell your employer or supervisor when, where and how you were injured.
Secure medical care immediately.
Tell your doctor to file medical reports with the Board and with your employer or its insurance carrier.
Make out this claim for compensation and send it to the nearest Workers' Compensation Board Office. (See below.) Failure to file
within two years after the date of injury may result in your claim being denied. If you need help in completing this form, telephone or
visit the nearest Workers' Compensation Board Office listed below.
Go to all hearings when notified to appear.
Go back to work as soon as you are able; compensation is never as high as your wage.
Your Rights:
1.
2.
3.
4.
5.
6.
7.
Generally, you are entitled to be treated by a doctor of your choice, provided he/she is authorized by the Board. If your employer is
involved in a preferred provider organization (PPO) arrangement, you must obtain initial treatment from the preferred provider
organization which has been designated to provide health care services for workers' compensation injuries.
DO NOT pay your doctor or hospital. Their bills will be paid by the insurance carrier if your case is not disputed. If your case is
disputed,
the doctor or hospital must wait for payment until the Board decides your case. In the event you fail to prosecute your case or the
Board decides against you, you will have to pay the doctor or hospital.
You are also entitled to be reimbursed for drugs, crutches, or any apparatus properly prescribed by your doctor and for carfares or other
necessary expenses going to and from your doctor's office or the hospital. (Get receipts for such expenses.)
You are entitled to compensation if your injury keeps you from work for more than seven days, compels you to work at lower wages,
or results in permanent disability to any part of your body.
Compensation is payable directly and without waiting for an award, except when the claim is disputed.
Injured workers or dependents of deceased workers may represent themselves in matters before the Board or may retain an attorney or
licensed representative to represent them. If an attorney or licensed representative is retained, his/her fee for legal services will be
reviewed by the Board and if approved will be paid by the employer or insurance company out of any compensation benefits due.
Injured workers or dependents of deceased workers should not directly pay anything to the attorney or licensed representative
representing them in a compensation case.
If you need help returning to work, or with family or financial problems because of your injury, contact the Workers' Compensation
Board office nearest you and ask for a rehabilitation counselor or social worker.
This form should be filed by sending directly to the appropriate WCB district office (DO) at the address listed below:
Albany DO - 100 Broadway-Menands, Albany NY 12241 (866) 750-5157 (for accidents in the following counties: Albany, Clinton, Columbia,
Dutchess, Essex, Franklin, Fulton,Greene, Hamilton, Montgomery, Rensselaer, Saratoga, Schenectady, Schoharie, Ulster, Warren, Washington)
Binghamton DO - State Office Building, 44 Hawley Street, Binghamton NY13901 (866) 802-3604 (for accidents in the following counties: Broome,
Chemung, Chenango, Cortland,Delaware, Otsego, Schuyler, Sullivan, Tioga, Tompkins)
Buffalo DO - 369 Franklin Street, Buffalo NY 14202 (866) 211-0645 (for accidents in the following counties: Cattaraugus, Chautauqua, Erie, Niagara)
Rochester DO - 130 Main Street West, Rochester NY 14614 (866) 211-0644 (for accidents in the following counties: Allegany, Genesee, Livingston,
Monroe, Ontario, Orleans,Seneca, Steuben, Wayne, Wyoming, Yates)
Syracuse DO - 935 James Street, Syracuse NY 13203 (866) 802-3730 (for accidents in the following counties: Cayuga, Herkimer, Jefferson, Lewis,
Madison, Oneida, Onondaga,Oswego,St. Lawrence)
Downstate Centralized Mailing - PO Box 5205, Binghamton NY, 13902-5205 for all DO's in NYC (800) 877-1373; in Hempstead (866) 805-3630; in
Hauppauge (866) 681-5354; in Peekskill (866) 746-0552 (for accidents in the following counties: Bronx, Kings, Nassau, New York, Orange, Putnam,
Queens, Richmond, Rockland, Suffolk, Westchester)
Page 82
C-3.0 (8-09)
STATEWIDE FAX LINE: 877-533-0337
Health Insurance If you are employed in a qualifying position which includes health insurance as a benefit the following plan summaries and associated rates should provide sufficient information for decisions about appropriate coverage. If you decline the insurance coverage the College has a “waiver” or “opt‐out” payment of $50 per month which is paid out in December of each calendar year for the preceding January‐December period. The College currently offers four (4) different carriers: Capital District Physicians’ Health Plan [CDPHP], MVP, Community Blue, and Traditional Blue Shield Indemnity. Part‐time faculty teaching at least twelve (12) contact hours may enroll only in CDPHP at 102% of full premium cost. Health Insurance premium deductions are taken a month in advance i.e. January deductions pay for February coverage, February deductions pay for March coverage, etc… therefore as you begin your coverage, your first payroll deduction may be larger than a normal bi‐weekly amount in order to get you on schedule with your payments. The employee’s share of Health Insurance premium costs are established through the collective bargaining process. If you have any questions on your deductions please contact the Office of Human Resources. The following plan parameters are subject to change and any specific coverage questions should be directed to the Office of Human Resources or to our third party administrator: Capital Benefits Consulting. Prescription drug coverage is Creditable Coverage with respect to Medicare Part D for all plans. Page 83
BLUE SHIELD COMMUNITY BLUE 202 PLUS
This is a summary only. It is not intended to be a complete description of benefits which are governed by the Contract between the College and the
insurer.
In Network
Out of Network
None
$500 Individual/$1000 Family
Annual Deductible
Coinsurance
Annual Out of Pocket Maximum
Annual Maximum Benefit
Lifetime Maximum Benefit
Dependent Coverage
Inpatient Hospitalization
Outpatient Hospital Services
Outpatient Hospital Surgery
Well Child Care
Annual Gynecological Visit
Routine Mammograms
Maternity
Immunizations
Annual Physical Exam
Primary Care Physician Office Visit
Specialist Office Visit
Diagnostic Radiology
Diagnostic Laboratory Tests
Routine Vision Exam
Dental check-up routine (every 6 months)
Physical, Speech and Occupational Therapy
Chiropractic
Mental Health Inpatient
Mental Health Outpatient
Alcohol/Substance Abuse Inpatient
Alcohol/Substance Abuse Outpatient
Emergency Room Care
Ambulance*
Urgent Care
Durable Medical Equipment
Prescription Drugs (Retail) 30 day supply
Prescription Drugs (Mail Order) 90 day supply
Inpatient Hospitalization Precertification
Primary Care Physician Required
Specialty Referral Required
None
$6350 Individual/$12700 Family
Unlimited
Unlimited
to Age 26
Covered In Full
$10, $15 or $20 co-pay
$75 co-pay
Covered In Full
Covered In Full
Covered In Full
Covered In Full
Coverage Varies
Covered In Full
$0, $5 or $10 co-pay
$10, $15 or $20 co-pay
$10, $15 or $20 co-pay
Covered In Full
Once every 2 years, covered in full
$10, $15 or $20 co-pay
$10, $15 or $20 co-pay (30 visits combined)
$10, $15 or $20 co-pay
Covered In Full
$10, $15 or $20 co-pay
Covered In Full
$10, $15 or $20 co-pay
$50 co-pay
$50 co-pay
$10 co-pay
50% co-insurance
$10 Generic/$20 Brand/$40 Non-Formulary
$25 Generic/$50 Brand/$100 Non-Formulary
Yes
Yes
No
You pay 20%
$5,000 Individual/ $10,000 Family
Unlimited
Unlimited
to Age 26
Deductible and 20% Coinsurance
Deductible and 20% Coinsurance
Deductible and 20% Coinsurance
Covered In Network Only
Deductible and 20% Coinsurance
Deductible and 20% Coinsurance
Deductible and 20% Coinsurance
Covered In Network Only
Deductible and 20% Coinsurance
Deductible and 20% Coinsurance
Deductible and 20% Coinsurance
Deductible and 20% Coinsurance
Deductible and 20% Coinsurance
Not covered
Not covered
Deductible and 20% Coinsurance
Deductible and 20% Coinsurance
30 Days Deductible and Coinsurance
Deductible and 20% Coinsurance
Deductible and 20% Coinsurance
Deductible and 20% Coinsurance
$50 co-pay
$50 co-pay
$10 co-pay
Deductible and 50% Coinsurance
$10 Generic/$20 Brand/$40 Non-Formulary
N/A
Yes
No
No
NOTE*
The current 2015 Blue Shield plan option automatically includes out of network benefits.
You have a choice of Primary Care/Specialist co-pays: $10/$10; $0/$20 or $5/$15.
*Ambulance - Please note: Must be deemed a trul life threatening emergency
Prescription drug coverage is Creditable Coverage with respect to Medicare Part D.
Participating Provider information is available by visiting their website at www.bsneny.com. Your selection is binding for one year until the
next open enrollment period.
Page 84
MVP HEALTH PLAN
NY CO-PLAN 15 PLUS
This is a summary only. It is not intended to be a complete description of benefits which are governed by the Contract
between the College and the insurer.
In Network
Annual Deductible
Coinsurance
Annual Out of Pocket Maximum
Annual Maximum Benefit
Lifetime Maximum Benefit
Dependent Coverage
Inpatient Hospitalization
Outpatient Hospital Surgery
Well Child Care & Immunizations
Annual Gynecological Visit
Routine Mammograms
Maternity
Annual Physical Exam
Physician Office Visit
Specialist Office Visit
Diagnostic Radiology
Diagnostic Laboratory Tests
Dental - (Preventative for children)
Routine Vision Exam
Physical/Speech/Occupational Therapy
Chiropractic
Durable Medical Equipment
Mental Health Inpatient
Mental Health Outpatient
Alcohol/Substance Abuse Inpatient
Alcohol/Substance Abuse Outpatient
Emergency Room Care
Ambulance
Urgent Care
Prescription Drugs (Retail) 30 day supply
Prescription Drugs (Mail Order) 90 day supply
Inpatient Hospitalization Precertification
Primary Care Physician Required
Specialty Referral Required
None
None
Unlimited
Unlimited
Unlimited
to Age 26
Covered In Full
$15 co-pay
Covered In Full
Covered In Full
Covered In Full
Covered In Full
Covered In Full
$15 co-pay
$15 co-pay
$15 co-pay
Covered In Full
Exam & x-ray for children to age 19, $25 co-pay
One every 2 years, $15 co-pay
$15 co-pay (30 visits combined)
$15 co-pay
50% co-insurance
Covered In Full
$15 co-pay
Covered In Full
$15 co-pay
$50 co-pay
Covered in Full
$15 co-pay
$5 Generic/$20 Brand/$40 Non-Formulary
$12.50 Generic/$50 Brand/$100 Non-Formulary
Yes
Yes
No
Prescription drug coverage is Creditable Coverage with respect to Medicare Part D.
MVP is a traditional HMO. You must select a Primary Care Physician, however, effective 1/1/09 you no longer
need to obtain referrals for specialty care. There are no out-of-network benefits unless specifically authorized in
advance by MVP. Participating Provider information is available through their web site at
www.mvphealthplan.com.
Your selection is binding for one year until the next open enrollment period.
Page 85
CAPITAL DISTRICT PHYSICIANS
HEALTH PLAN (HMO)
This is a summary only. It is not intended to be a complete description of benefits which are governed by the Contract between the
College and the insurer.
2015 AVID CARE $25 In Network
Annual Deductible
Coinsurance
Annual Out of Pocket Maximum
Annual Maximum Benefit
Lifetime Maximum Benefit
Dependent Coverage
Inpatient Hospitalization
Outpatient Hospital Surgery
Well Child Care & Immunizations
Annual Gynecological Visit
Routine Mammograms
Maternity - (Physician Services)
Annual Physical Exam
Physician Office Visit
Specialist Office Visit
Diagnostic Radiology
Diagnostic Laboratory Tests
Dental
Routine Vision Exam
Physical & Occupational Therapy
Speech Therapy
Chiropractic
Durable Medical Equipment
Mental Health Inpatient
Mental HealthOutpatient
Alcohol/Substance Abuse Inpatient
Alcohol/Substance Abuse Outpatient
Emergency Room Care
Ambulance
Urgent Care
Prescription Drugs (Retail) 30 day supply
Prescription Drugs (Mail Order) 90 day supply
Inpatient Hospitalization Precertification
Primary Care Physician Required
Specialty Referral Required
None
None
$6600 Individual/$13200 Family
Unlimited
Unlimited
to Age 26
$240 Co-pay
$25 co-pay
Covered In Full
Covered In Full
Covered In Full
Covered In Full
Covered In Full
$25 co-pay
$25 co-pay
$25 co-pay, waived at preferred facilities
$25 co-pay,waived at preferred facilities
Not covered
One every 2 years, $25 copay
$25 co-pay, 120 days
$25 co-pay, 60 days
$25 co-pay
20% co-insurance
$240 co-pay
$25 co-pay
$240 co-pay
$25 co-pay/visit
$100 co-pay
$100 co-pay
$35 per visit
$5 Generic/$20 Brand/$35 Non-Formulary
$12.50 Generic/$50 Brand/$87.50 Non-Formulary
Yes
Yes
Yes
Reimbursement
Amount
$10
$10
$10
$10
$10
$10
$10
$10
$10
$10
$10
$50
$50
$10
NOTE*
You are eligible to receive reimbursement for the difference between the 2005 Avid 15 plan co-pays and the new 2015 Avid 25
plan co-pays. You must keep and submit all applicable receipts within 20 months of the date of service. Submission forms are
available on the Office of Human Resources website.
Prescription drug coverage is Creditable Coverage with respect to Medicare Part D.
CDPHP is a traditional HMO. You must select a Primary Care Physician and obtain referrals for specialty care. There are no outof-network benefits unless specifically authorized in advance by CDPHP. Participating Provider information is available by visiting
their web site at www.cdphp.com.
Your selection is binding for one year until the next open enrollment period.
Page 86
BLUE SHIELD/ENVISION INDEMNITY PLAN
This is a summary only. It is not intended to be a complete description of benefits which are governed by the
Contract between the College and the insurer.
$100 Individual/$300 Family for Major Medical Benefits
$240 Individual/$720 Family for IP&OP Hospital Benefits
20% of Usual & Customary
When 20% coinsurance reaches $500
Unlimited
Unlimited
to Age 26
Annual Deductible
Coinsurance
Lifetime Out of Pocket Maximum
Annual Maximum Benefit
Lifetime Maximum Benefit
Dependent Coverage
HOSPITAL COVERAGE
There is a $240 Deductible that is reimbursed by HVCC
Inpatient Hospitalization
Covered In Full - 365 days
Outpatient Hospital Services
Covered In Full
Outpatient Hospital Surgery
Covered In Full
Mental Health Inpatient
Covered In Full - 365 days
Alcohol/Substance Abuse Inpatient
Covered In Full
Maternity
Covered In Full
Diagnostic Radiology
Covered In Full
Diagnostic Laboratory Tests
Covered In Full
Emergency Room
Covered in Full
MEDICAL/SURGICAL COVERAGE
IN NETWORK
Covered In Full
Covered In Full
Covered In Full
Covered In Full
Covered In Full
Covered In Full
Diagnostic Radiology
Diagnostic Laboratory Tests
Maternity
Surgical Procedures
Routine Mammograms
Anesthesia
Medical/Surgical benefits for covered services received from out-of-network providers are paid at the in-network fee
schedule with any balances paid as a Major Medical Benefit subject to deductible and coinsurance.
MAJOR MEDICAL COVERAGE
Primary Care Physician Office Visit
Specialist Office Visit
Durable Medical Equipment
Urgent Care
Rehabilitation Services (PT,OT,ST)
Chiropractic
Dental
Routine Vision Exam
Deductible & Coinsurance
Deductible & Coinsurance
Deductible & Coinsurance
Deductible & Coinsurance
Deductible & Coinsurance
Deductible & Coinsurance
limited benefit
limited benefit
OTHER COVERAGE
Alcohol/Substance Abuse Outpatient
Mental Health - outpatient
Well Child Care & Immunizations
Annual Gynecological Visit
Adult Immunizations
Annual Physical Exam
Prescription Drugs
Inpatient Hospitalization Precertification
Primary Care Physician Required
Specialty Referral Required
*Mandates
Covered in Full*
Covered in Full*
Covered in Full*
Covered in Full*
Coverage varies*
Covered in Full*
$5 Generic/$20 Brand
No
No
No
Prescription drug coverage is Creditable Coverage with respect to Medicare Part D.
This is a traditional Indemnity Plan. It does not require selection of a Primary Care Physician nor do you need a referral
for specialty care. You may select any licensed provider. However, benefits are maximized if you use participating
providers. Physician visits are subject to deductible and coinsurance and you may need to submit claim forms in some
cases. Your selection is binding for one year until the next open enrollment period.
Page 87
Hudson Valley Community College Classified Staff
Are you a Classified Staff member covered under the NIEU Collective Bargaining Agreement first employed after August 14, 2014 in a
qualifying position which includes health insurance as a benefit?
Then your health insurance rates are:
Monthly
Monthly
Total Monthly
Per Pay Period
Employee Share Employer Share
Premium
86.67
173.34
982.24
1,155.58
Traditional Blue Shield Indemnity Individual Coverage
Traditional Blue Shield Indemnity Family Coverage
473.16
946.32
2,139.41
3,085.73
48.65
97.30
551.38
648.68
CDPHP Family Coverage
199.59
399.18
1,222.50
1,621.68
MVP Individual Coverage
52.77
105.54
597.99
703.53
CDPHP Individual Coverage
MVP Family Coverage
221.86
443.72
1,315.11
1,758.83
Community Blue Shield Individual Coverage
194.58
389.16
551.37
940.53
Community Blue Shield Family Coverage
318.44
636.88
1,734.09
2,370.97
Are you a Classified Staff member covered under the NIEU Collective Bargaining Agreement first employed after March 23, 2007 and
prior to August 14, 2014 who has been employed in a qualifying position which includes health insurance as a benefit?
Then your health insurance rates are:
Monthly
Monthly
Total Monthly
Per Pay Period
Employee Share Employer Share
Premium
57.78
115.56
1,040.02
1,155.58
Traditional Blue Shield Indemnity Individual Coverage
473.16
946.32
2,139.41
3,085.73
32.43
64.86
583.82
648.68
CDPHP Family Coverage
199.59
399.18
1,222.50
1,621.68
MVP Individual Coverage
35.18
70.36
633.17
703.53
221.86
443.72
1,315.11
1,758.83
Traditional Blue Shield Indemnity Family Coverage
CDPHP Individual Coverage
MVP Family Coverage
Community Blue Shield Individual Coverage
178.36
356.72
583.81
940.53
Community Blue Shield Family Coverage
318.44
636.88
1,734.09
2,370.97
Are you a Classified Staff member covered under the NIEU Collective Bargaining Agreement first employed prior to March 23, 2007
who has been employed in a qualifying position which includes health insurance as a benefit?
Then your health insurance rates are:
Monthly
Monthly
Total Monthly
Per Pay Period
Employee Share Employer Share
Premium
1,155.58
1,155.58
Traditional Blue Shield Indemnity Individual Coverage
Traditional Blue Shield Indemnity Family Coverage
473.16
946.32
-
-
CDPHP Family Coverage
199.59
399.18
MVP Individual Coverage
-
-
MVP Family Coverage
221.86
Community Blue Shield Individual Coverage
145.92
Community Blue Shield Family Coverage
318.44
CDPHP Individual Coverage
2,139.41
3,085.73
648.68
648.68
1,222.50
1,621.68
703.53
703.53
443.72
1,315.11
1,758.83
291.84
648.69
940.53
636.88
1,734.09
2,370.97
Page 88
Hudson Valley Community College Classified Staff
Are you a Classified Staff member covered under the UPSEU Collective Bargaining Agreement employed in a qualifying position which
includes health insurance as a benefit?
Then your health insurance rates are:
Monthly
Monthly
Total Monthly
Per Pay Period
Employee Share Employer Share
Premium
86.67
173.34
982.24
1,155.58
Traditional Blue Shield Indemnity Individual Coverage
Traditional Blue Shield Indemnity Family Coverage
473.16
946.32
2,139.41
3,085.73
48.65
97.30
551.38
648.68
CDPHP Family Coverage
199.59
399.18
1,222.50
1,621.68
MVP Individual Coverage
52.77
105.54
597.99
703.53
CDPHP Individual Coverage
MVP Family Coverage
221.86
443.72
1,315.11
1,758.83
Community Blue Shield Individual Coverage
194.58
389.16
551.37
940.53
Community Blue Shield Family Coverage
318.44
636.88
1,734.09
2,370.97
Page 89
Hudson Valley Community College Department Chairs
Are you a Department Chair first employed for or after 2009/2010 academic year not yet tenured in a qualifying position
which includes health insurance as a benefit?
Then your health insurance rates are:
Traditional Blue Shield Indemnity Individual Coverage
Per Pay
Monthly
Period Employee Share
86.67
173.34
Traditional Blue Shield Indemnity Family Coverage
473.16
946.32
2,139.41
3,085.73
48.65
97.30
551.38
648.68
CDPHP Family Coverage
199.59
399.18
1,222.50
1,621.68
MVP Individual Coverage
52.77
105.54
597.99
703.53
MVP Family Coverage
221.86
443.72
1,315.11
1,758.83
Community Blue Shield Individual Coverage
194.58
389.16
551.37
940.53
Community Blue Shield Family Coverage
318.44
636.88
1,734.09
2,370.97
CDPHP Individual Coverage
Monthly
Employer Share
982.24
Total Monthly
Premium
1,155.58
Are you a Department Chair first employed for or after 2009/2010 academic year, tenured in a qualifying position which
includes health insurance as a benefit?
Then your health insurance rates are:
Traditional Blue Shield Indemnity Individual Coverage
Per Pay
Monthly
Period Employee Share
57.78
28.89
Traditional Blue Shield Indemnity Family Coverage
473.16
946.32
2,139.41
3,085.73
CDPHP Individual Coverage
16.22
199.59
32.44
616.24
648.68
399.18
1,222.50
1,621.68
17.59
221.86
35.18
668.35
703.53
443.72
1,315.11
1,758.83
324.30
616.23
940.53
636.88
1,734.09
2,370.97
CDPHP Family Coverage
MVP Individual Coverage
MVP Family Coverage
Community Blue Shield Individual Coverage
Community Blue Shield Family Coverage
162.15
318.44
Monthly
Employer Share
1,097.80
Total Monthly
Premium
1,155.58
Are you a Department Chair first employed prior to September 1, 2009 in a qualifying position which includes health
insurance as a benefit?
Then your health insurance rates are:
Per Pay
Monthly
Monthly
Total Monthly
Period Employee Share Employer Share
Premium
Traditional Blue Shield Indemnity Individual Coverage
1,155.58
1,155.58
Traditional Blue Shield Indemnity Family Coverage
473.16
946.32
-
-
CDPHP Family Coverage
199.59
399.18
MVP Individual Coverage
-
-
MVP Family Coverage
221.86
Community Blue Shield Individual Coverage
Community Blue Shield Family Coverage
CDPHP Individual Coverage
2,139.41
3,085.73
648.68
648.68
1,222.50
1,621.68
703.53
703.53
443.72
1,315.11
1,758.83
145.92
291.84
648.69
940.53
318.44
636.88
1,734.09
2,370.97
Page 90
Educational Opportunity Center Alliance
Are you an EOC Alliance member (including Faculty & Counselors) employed after September 1, 2011 in a qualifying position
which includes health insurance as a benefit?
Then your health insurance rates are:
Per Pay
Monthly
Monthly
Total Monthly
Period Employee Share Employer Share
Premium
115.56
231.12
924.46
1,155.58
Traditional Blue Shield Indemnity Individual Coverage
473.16
946.32
2,139.41
3,085.73
64.87
129.74
518.94
648.68
CDPHP Family Coverage
199.59
399.18
1,222.50
1,621.68
MVP Individual Coverage
70.36
140.72
562.81
703.53
MVP Family Coverage
221.86
443.72
1,315.11
1,758.83
Community Blue Shield Individual Coverage
210.80
421.60
518.93
940.53
Community Blue Shield Family Coverage
318.44
636.88
1,734.09
2,370.97
Traditional Blue Shield Indemnity Family Coverage
CDPHP Individual Coverage
Are you an EOC Alliance member (including Faculty & Counselors) first employed subsequent to September 1, 2001 and prior
to September 1, 2011 and not yet tenured in a qualifying position which includes health insurance as a benefit?
Then your health insurance rates are:
Per Pay
Monthly
Monthly
Total Monthly
Period Employee Share Employer Share
Premium
231.12
462.24
693.34
1,155.58
Traditional Blue Shield Indemnity Individual Coverage
Traditional Blue Shield Indemnity Family Coverage
617.15
1,234.30
1,851.43
3,085.73
CDPHP Individual Coverage
129.74
259.48
389.20
648.68
CDPHP Family Coverage
324.34
648.68
973.00
1,621.68
MVP Individual Coverage
140.71
281.42
422.11
703.53
MVP Family Coverage
351.77
703.54
1,055.29
1,758.83
Community Blue Shield Individual Coverage
275.67
551.34
389.19
940.53
Community Blue Shield Family Coverage
474.19
948.38
1,422.59
2,370.97
Are you an EOC Alliance member (including Faculty & Counselors) first employed prior to September 1, 2011 and/or tenured
in a qualifying position which includes health insurance as a benefit?
Then your health insurance rates are:
Per Pay
Monthly
Monthly
Total Monthly
Period Employee Share Employer Share
Premium
1,155.58
1,155.58
Traditional Blue Shield Indemnity Individual Coverage
473.16
946.32
-
-
CDPHP Family Coverage
199.59
399.18
MVP Individual Coverage
-
-
MVP Family Coverage
221.86
Community Blue Shield Individual Coverage
Community Blue Shield Family Coverage
Traditional Blue Shield Indemnity Family Coverage
CDPHP Individual Coverage
2,139.41
3,085.73
648.68
648.68
1,222.50
1,621.68
703.53
703.53
443.72
1,315.11
1,758.83
145.92
291.84
648.69
940.53
318.44
636.88
1,734.09
2,370.97
Page 91
Hudson Valley Community College Faculty
Are you a Faculty member first employed for or after 2010/2011 academic year, in a qualifying position which includes health insurance benefits?
Then your health insurance rates are:
Per Pay Period
Traditional Blue Shield Indemnity Individual Coverage
Traditional Blue Shield Indemnity Family Coverage
CDPHP Individual Coverage
57.78
473.16
32.43
CDPHP Family Coverage
199.59
MVP Individual Coverage
35.18
MVP Family Coverage
221.86
Community Blue Shield Individual Coverage
178.36
Community Blue Shield Family Coverage
318.44
Monthly Employee Share
Monthly Employer Share
Total Monthly Premium
115.56
946.32
1,040.02
2,139.41
1,155.58
3,085.73
64.86
399.18
583.82
1,222.50
1,621.68
70.36
443.72
633.17
1,315.11
1,758.83
356.72
636.88
583.81
1,734.09
648.68
703.53
940.53
2,370.97
Are you a Faculty member first employed for or after the 2001/2002 academic year and prior to the 2010/2011 academic year and not yet tenured in a qualifying
position which includes health insurance as a benefit?
Then your health insurance rates are:
Traditional Blue Shield Indemnity Individual Coverage
Traditional Blue Shield Indemnity Family Coverage
Per Pay Period
Monthly Employee Share
Monthly Employer Share
86.67
173.34
982.24
1,155.58
473.16
946.32
2,139.41
3,085.73
-
-
CDPHP Family Coverage
199.59
399.18
MVP Individual Coverage
-
-
MVP Family Coverage
221.86
Community Blue Shield Individual Coverage
145.92
Community Blue Shield Family Coverage
318.44
CDPHP Individual Coverage
Total Monthly Premium
648.68
648.68
1,222.50
1,621.68
703.53
703.53
443.72
1,315.11
1,758.83
291.84
648.69
940.53
636.88
1,734.09
2,370.97
Are you a Faculty member first employed prior to the 2010/2011 academic year, tenured in a qualifying position which includes health insurance as a benefit?
Then your health insurance rates are:
Per Pay Period
Traditional Blue Shield Indemnity Individual Coverage
Traditional Blue Shield Indemnity Family Coverage
Monthly Employee Share
Total Monthly Premium
-
-
1,155.58
1,155.58
473.16
946.32
2,139.41
3,085.73
-
-
CDPHP Family Coverage
199.59
399.18
MVP Individual Coverage
-
-
MVP Family Coverage
221.86
Community Blue Shield Individual Coverage
145.92
Community Blue Shield Family Coverage
318.44
CDPHP Individual Coverage
Monthly Employer Share
648.68
648.68
1,222.50
1,621.68
703.53
703.53
443.72
1,315.11
1,758.83
291.84
648.69
940.53
636.88
1,734.09
2,370.97
Page 92
Hudson Valley Community College Non-Teaching Professionals
Are you a Non Teaching Professional covered under the NTP Collective Bargaining Agreement first employed after
November 6, 2014 in a qualifying position which includes health insurance as a benefit?
Then your health insurance rates are:
Per Pay
Monthly
Monthly
Total Monthly
Period Employee Share Employer Share
Premium
86.67
173.34
982.24
1,155.58
Traditional Blue Shield Indemnity Individual Coverage
Traditional Blue Shield Indemnity Family Coverage
473.16
946.32
2,139.41
3,085.73
48.65
97.30
551.38
648.68
CDPHP Family Coverage
199.59
399.18
1,222.50
1,621.68
MVP Individual Coverage
52.77
105.54
597.99
703.53
MVP Family Coverage
221.86
443.72
1,315.11
1,758.83
Community Blue Shield Individual Coverage
194.58
389.16
551.37
940.53
Community Blue Shield Family Coverage
318.44
636.88
1,734.09
2,370.97
CDPHP Individual Coverage
Are you a Non Teaching Professional covered under the NTP Collective Bargaining Agreement first employed prior to
November 6, 2014 in a qualifying position which includes health insurance as a benefit?
Then your health insurance rates are:
Per Pay
Monthly
Monthly
Total Monthly
Period Employee Share Employer Share
Premium
28.89
57.78
1,097.80
1,155.58
Traditional Blue Shield Indemnity Individual Coverage
473.16
946.32
2,139.41
3,085.73
16.22
32.44
616.24
648.68
CDPHP Family Coverage
199.59
399.18
1,222.50
1,621.68
MVP Individual Coverage
17.59
35.18
668.35
703.53
221.86
443.72
1,315.11
1,758.83
Traditional Blue Shield Indemnity Family Coverage
CDPHP Individual Coverage
MVP Family Coverage
Community Blue Shield Individual Coverage
162.15
324.30
616.23
940.53
Community Blue Shield Family Coverage
318.44
636.88
1,734.09
2,370.97
Are you a Non Teaching Professional not covered under the NTP Collective Bargaining Agreement employed less than 36
Months in a qualifying position which includes health insurance as a benefit?
Then your health insurance rates are:
Per Pay
Monthly
Monthly
Total Monthly
Period Employee Share Employer Share
Premium
144.45
288.90
866.68
1,155.58
Traditional Blue Shield Indemnity Individual Coverage
Traditional Blue Shield Indemnity Family Coverage
CDPHP Individual Coverage
CDPHP Family Coverage
473.16
946.32
2,139.41
3,085.73
81.08
162.16
486.52
648.68
202.71
405.42
1,216.26
1,621.68
87.95
175.90
527.63
703.53
MVP Family Coverage
221.86
443.72
1,315.11
1,758.83
Community Blue Shield Individual Coverage
145.92
291.84
648.69
940.53
Community Blue Shield Family Coverage
318.44
636.88
1,734.09
2,370.97
MVP Individual Coverage
Page 93
Hudson Valley Community College Non-Teaching Professionals
Are you a Non Teaching Professional not covered under the NTP Collective Bargaining Agreement employed more than 36
Months in a qualifying position which includes health insurance as a benefit?
Then your health insurance rates are:
Per Pay
Monthly
Monthly
Total Monthly
Period Employee Share Employer Share
Premium
1,155.58
1,155.58
Traditional Blue Shield Indemnity Individual Coverage
473.16
946.32
-
-
CDPHP Family Coverage
199.59
399.18
MVP Individual Coverage
-
-
MVP Family Coverage
221.86
Community Blue Shield Individual Coverage
Community Blue Shield Family Coverage
Traditional Blue Shield Indemnity Family Coverage
CDPHP Individual Coverage
2,139.41
3,085.73
648.68
648.68
1,222.50
1,621.68
703.53
703.53
443.72
1,315.11
1,758.83
145.92
291.84
648.69
940.53
318.44
636.88
1,734.09
2,370.97
Page 94
Flex Spending Accounts
A Flexible Spending Account (FSA) is a tax-favored program that allows employees to pay for
eligible out-of-pocket health care and dependent care expenses with pre-tax dollars. By using
pre-tax dollars to pay for eligible health care and dependent care expenses, an FSA gives you an
immediate discount on these expenses that equals the taxes you would otherwise pay on that
money.
•
•
The Medical Expense Flexible Spending Account can be used to pay for qualified medical
costs and health care expenses that are not paid by your health insurance plan or any
other insurance. PLEASE NOTE: This cannot be used to pay for any type of insurance
premiums, including long-term care insurance premiums.
The Dependent Care Flexible Spending Account is to pay for eligible dependent care
expenses such as child care for children under age 13 or day care for anyone who you
claim as a dependent on your Federal tax return who is physically or mentally incapable
of self-care so that you (and your spouse, if you are married) can work, look for work, or
attend school full-time.
Your participation in the Flex Spending Account is completely voluntary, and it’s important to
remember that unlike other benefits, your FSA election is only effective for one Benefit Period.
In other words, you must enroll each year that you choose to participate. If you do not enroll
during Open Enrollment [December 1-31], you will not participate in the next Benefit Period,
unless you experience a qualifying life event that allows you to make an election outside of
Open Enrollment. The Benefit Period will always run from January 1 of the current Benefit
Period through March 15 of the following year. This includes a 2 ½ month grace period from
January 1 through March 15 of the following year. During the grace period, eligible expenses
incurred from January 1 through March 15 of the following year can be applied towards your
prior year's balance. The intent is to help account holders avoid forfeiting any of the funds they
deposited in FSA accounts. It is important to carefully consider the amount you choose to elect.
Eligibility to participate is contingent on an employee’s funding source and employment status;
therefore please contact the Office of Human Resources to enquire about your ability to enroll.
Page 95
Dental Insurance
The Dental Benefits Plan described is made available to eligible employees.
HVCC’s Dental Benefits Program has been designed to encourage you to maintain good dental
care while keeping dental care expenses at a minimum. By visiting your dentist for check-ups
on a regular basis (at least once a year) and receiving prompt treatment of small disorders
when they are first discovered, you will be avoiding more serious dental problems from
developing at a later date. This makes good sense from both a health and financial standpoint.
The Dental Benefit Program allows you complete freedom of choice in the selection of any
licensed dentist.
In addition, you are not required to submit to a preliminary examination in order to establish
your eligibility or the Dental Benefits Program.
To determine if you are eligible for this Plan, please contact the Office of Human Resources.
ELEIGIBILITY
Benefits are available to all eligible employees on the effective date of the Dental Plan. The
Office of Human Resources will determine your eligibility.
New employees become eligible on the first day of the seventh month following the date of
active employment. There is no payroll contribution for individual coverage.
BASIC SCHEDULE OF ALLOWANCES
Schedule of Allowances is published on the Office of Human Resources website. For each
dental procedure listed, the plan will pay the Benefit Payable or the actual charge, whichever is
less.
TERMINATION OF BENEFITS
Dental benefits will cease on the same day of the month you are removed from the payroll, or if
you fail to make the required contributions, if any, toward the cost of your benefits. There are
no benefits for dental services performed after termination of coverage.
PARTICIPATING DENTISTS
Participating Dentists are those dentists in this area who will accept, as payment in full, the
Plan’s Schedule of Benefits. This service is made available as a convenience to you through
BENETECH, the Plan Administrator. The list of Participating Dentists is subject to change at any
time.
There are instances when a Participating Dentist may not be able to perform a particular
procedure for the prescribed maximum payment. In such cases, the Participating Dentist has
agreed to notify you or your eligible dependent of any dollar difference prior to the actual
commencement of treatment.
Page 96
YOUR DENTIST
The Dental Plan does not require that you go to a Participating Dentist for treatment. If you use
a nonparticipating dentist for treatment, then you will be responsible for paying any difference
between the amount charged by the dentist and the maximum payment under the Plan’s
Schedule of Benefits. It is not the intention of the College to disturb the dentist-patient
relationship, and the College will not, under ordinary circumstances, interfere with the free
exercise of professional judgment by the dentist as to the care provided.
There are instances when differences of opinion arise. If an employee disagrees with benefit
payments under the Plan, he may present his disagreement to the College’s Office of Human
Resources. If agreement is not reached, the disagreement will be presented to the Plan’s
Administrator for review by a dentist, if necessary. The Plan Administrator’s decision shall be
final.
EXCLUSIONS
The Dental Benefits Plan will not allow benefits for the following:
1) Loss or theft of a denture.
2) Extra duplicate prosthetic device.
3) Injuries, diseases or conditions, the treatment of which is available without cost to the
person treated under the laws enacted by the legislature of any State or the Congress of
the United States (such as Worker’s Compensation, Veteran’s Compensation, etc.)
4) Cosmetic dentistry.
5) Oral hygiene, dietary instructions, or education programs.
6) Any charge for failure to keep a scheduled appointment.
7) Orthodontics.
8) Any charges for appliances or restorations, other than full dentures, whose purpose is to
alter vertical dimension, stabilize periodontically involved teeth or restorative
occlusions.
9) Any charge for completing a claim form.
10) Services or supplies which do not meet accepted standards of dental practice or are
experimental in nature.
11) Dental disease or defect incurred or resulting from war, declared or undeclared, military
or naval service to any country, riot, civil disorder, insurrection or while committing a
felonious act.
12) Dental mechanic or denturist, unless practicing according to applicable dental practice
acts and related statutes.
13) Any service or appliance received from a dental or medical department maintained by
an employer, a mutual benefit association, labor union, trustee or other similar person
or group.
14) Any service unless rendered in connection with the care of an employee by a duly
licensed dentist, and any service or appliance for which the patient incurs no dentist’s
charge.
15) Any type of service or appliance not described in the Plan or in any Rider modifying the
Plan.
Page 97
CLAIM ADMINISTRATION
Whenever you have an appointment with the dentist, the following steps should be taken:
1) Obtain an Attending Dentist’s Statement (claim form) from either the Office of Human
Resources or your work location. Fully complete the form and sign the employee’s
section of the claim form, indicating your name as employee, the name of the patient,
your social security number, your complete home mailing address and fill in all the other
information requested. Remember, an incomplete claim form will be returned to you
for further information, which may cause a delay in processing the dental claim.
2) Give the claim form to the attending dentist. If dental work is anticipated to cost less
than $200.00, have the dentist full complete his portion of the form and return it to
BENETECH, PO Box 348, Wynantskill, NY, 12198-0348 once treatment has been
rendered.
If dental charges are anticipated to exceed $200.00, then ask the dentist to
submit a Pre-treatment Estimate before the actual treatment begins. Pre-treatment
Estimates will assist you and the dentist in determining what expenses are or are not
covered under the Dental Plan. This will be an aid in eliminating any uncertainty
regarding allowances payable and benefits remaining in the calendar year. BENETECH
will complete the Pre-treatment Estimate and will return it to the attending dentist. The
attending dentist will discuss the treatment and indicated benefits with you. While Pretreatment Estimates are not required, they certainly are recommended.
If the dentist you go to is participating in the Dental Benefits Plan, it will be
required that you inform the Participating Dentist of your enrollment in the College’s
Plan. Notification will be accomplished by presenting the Dental Benefits Identification
Card that has been issued to you.
3) BENETECH will pay the applicable benefit amount (for all completed dental work) to the
attending dentist or directly to you, as indicated on the claim form. However, benefits
are always payable to the dentist if such dentist is participating in the Plan.
4) For any dental work, it is a good idea to discuss the anticipated treatment plan and
estimated cost before treatment begins.
5) When another dental appointment has been scheduled, merely obtain a new claim form
for you and your dentist to complete.
6) The College reserves the right to deny payment of any claim submitted to the Dental
Plan more than 90 days following the last date of treatment indicated on the claim form.
COORDINATION OF BENEFITS
If you are entitled to receive benefits from another group plan, benefits under this plan will be
coordinated with the benefits from any of your other group plans so that up to 100% of the
“allowable expenses” incurred during a calendar year will be paid by the plans.
An “allowable expense” is any necessary, reasonable, and customary item of expense covered
in full or in part under any one of the group plans involved.
A “Plan” is considered to be any group insurance benefits or other arrangement of benefits for
individuals in a group which provides dental benefits or services on an insured or an uninsured
basis.
Page 98
The College reserves the right to obtain and exchange benefit information from any other
insurance company, organization, or individual to determine the applicability of the
Coordination of Benefits provisions. When an overpayment has been made, the College has
the right to recover the excess amount from the individual, insurance company, or organization
to whom payment has been made.
In order to obtain all of the benefits available, you should file claims under each plan.
DENTAL CLAIMS QUESTIONS
Dental claims will be processed and records stored at BENETECH’S Office.
If you have a question concerning the status of a claim, benefit coverage, who was paid, the
amount of payment, etc., then contact:
Claims Manager
BERNETECH
P.O. Box 348
Wynantskill, NY 12198-0348
(518) 283-8500
or the Office of Human Resources.
This communication is intended to explain dental benefits in a non-technical language. It does
not constitute the Master Agreement which is on file with the Office of Human Resources.
Page 99
HUDSON VALLEY COMMUNITY COLLEGE
DENTAL BENEFITS PLAN
SCHEDULE OF ALLOWANCES
PLAN ADMINISTERED BY DELTA DENTAL
Effective January 1, 2015
Annual Maximum for all services - $1200
CODE
DENTAL PROCEDURE
CLASS
DIAGNOSTIC
Clinical Oral Examinations (Not more than one examination of either type
in a 6 consecutive month period)
0120 PERIODIC ORAL EXAMINATION
0140 LIMITED ORAL EXAM - PROBLEM FOCUSED
0150 COMPHRENSIVE ORAL EVALUATION
Radiographs (includes examination and diagnosis)
0210 INTRAORAL FMS & BITEWINGS - limited to
one series in a 36 conseacutive month period
0220 INTRAORAL SINGLE FIRST FILM
0230 INTRAORAL EACH ADDITIONAL FILM
0240 INTRAORAL, OCCLUSAL, SGL FILM
0250 EXTRAORAL, SGL, FIRST FILM
0260 EXTRAORAL EACH ADDITIONAL FILM
0270 BITEWING - SINGLE FILM **
0272 XRAYS-BITEWINGS-2 FILMS**
0274 X-RAYS-BITEWINGS-4 FILMS**
** Bitewings are limited to one service in a
6 consecutive month period.
0290 POSTERIOR-ANTERIOR OR LATERAL SKULL/FACI
0321 TMJ JOINT SINGLE FILM/PER FILM
0330 PANOREX-MAX/MAND SINGLE FILM - limited
to one service in a 36 consecutive month period.
0340 CEPHALOMETRIC FILM SERIES
PREVENTATIVE
Dental Prophylaxis, not more than one in a 6 consecutive month period)
1110 PROPHYLAXIS-ADULT 'OVER 14'
1120 PROPHYLAXIS-CHILD 'UNDER 14'
Fluoride Treatments (limited to one service in a 12 month
1
1
1
$29.00
$29.00
$38.65
1
$58.00
1
1
1
1
1
1
1
1
$6.44
$6.44
$19.33
$12.88
$12.88
$11.27
$19.33
$35.43
1
1
1
$58.00
$58.00
$58.00
1
$48.32
1
1
$58.00
$38.65
1
$28.99
1
1
1
$144.95
$193.26
$96.63
2
2
2
2
2
2
2
$58.00
$77.30
$96.63
$96.63
$58.00
$77.30
$96.63
2
2
2
2
$67.64
$87.00
$96.63
$77.30
consecutive month period to persons under 19)
1203 TOPICAL APPLICATION OF FLUORIDE - CHILD
Space Maintainers (to replace permaturely lost teeth of
dependent child under age 14)
1510 SPACE MAINT, FIXED BAND TYPE
1515 SPACE MAINT, FIXED, S S CROWN TYPE
1525 SPACE MAINT - REMOVABLE
RESTORATIVE
Amalgam Restorations (inc. polishing)
2110 AMALGAM ONE SURFACE DECIDUOUS
2120 AMALGAM 2 SURFACE DECIDUOUS
2130 AMALGAM 3 SURFACE DECIDUOUS
2131 AMALGAM 4 SURFACE PRIMARY
2140 AMALGAM ONE SURFACE PERMANENT
2150 AMALGAM TWO SURFACE PERMANENT
2160 AMALGAM THREE SURFACE PERMANENT
Composite Restorations
2330 COMPOSITE RESIN ONE SURFACE
2331 COMPOSITE RESIN TWO SURFACE
2332 COMPOSITE RESIN THREE SURFACE
2335 RESIN-FOUR OR MORE SURFACES OR INCISAL ANGLE
Page 100
CODE
DENTAL PROCEDURE
2337 RESIN - BASED COMPOSIT CROWN ANT-PERM
2385 RESIN - ONE SURFACE POSTERIOR PERMANENT
2386 RESIN - TWO SURFACES POSTERIOR PERMANENT
2387 RESIN-THREE OR MORE SURFACES POSTERIOR
Gold Foil Restorations
2410 GOLD FOIL ONE SURFACE
2420 GOLD FOIL TWO SURFACES
2430 GOLD FOIL THREE SURFACES
Gold Inlay Restorations
2520 INLAY GOLD TWO SURFACE
2530 INLAY GOLD THREE SURFACE
2542 INLAY GOLD THREE SURFACE
2710 PLASTIC ACRYLIC CROWN
2720 PLASTIC WITH METAL CROWN
2721 CROWN-PLASTIC TO NON-PRECIOUS METAL
2722 CROWN-PLASTIC TO SEMI-PRECIOUS METAL
2740 PORCELAIN CROWN
2750 PORCELAIN WITH METAL CROWN
2751 CROWN-PORCELAIN TO NON-PRECIOUS METAL
2752 CROWN PORCELAIN - SEMI PRECIOUS METAL
2780 CROWN PORCELAIN - SEMI PRECIOUS METAL
2790 GOLD FULL CAST CROWN
2791 NON-PRECIOUS METAL (FULL CAST)
2792 SEMI-PRECIOUS METAL (FULL CAST)
2910 RECEMENT INLAYS-PER TOOTH
2920 RECEMENT CROWNS-PER TOOTH
2930 PREFABRICATED STAINLESS STEEL CROWN - PRIMARY
2950 CORE BUILDUP INCLUDING ANY PINS
2951 PIN RETENTION-PER TOOTH, IN ADD TO RESTORATION
2952 CAST POST AND CORE IN ADDITION TO CROWN
2954 PREFABRICATED POST AND CORE IN ADD CROWN
3220 THERAPEUTIC PULPOTOMY (EXC FINAL RESTOR)
Root Canal Therapy (includes treatment plan, clinical
CLASS
2
2
2
2
$67.64
$67.64
$87.00
$96.63
2
2
2
$67.64
$87.00
$96.63
2
2
2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
2
$144.95
$193.26
$96.63
$125.62
$360.75
$360.75
$360.75
$360.75
$360.75
$360.75
$360.75
$360.75
$289.89
$360.75
$360.75
$67.64
$67.64
$116.00
$106.29
$29.00
$96.63
$183.60
$96.63
2
2
2
2
2
2
$338.21
$434.84
$531.47
$338.21
$434.84
$531.47
2
2
2
2
2
2
$270.57
$270.57
$270.57
$96.63
$473.49
$96.63
2
2
2
2
2
2
2
$260.90
$164.27
$483.15
$483.15
$483.15
$483.15
$483.15
procedures and follow-up care but excludes final restoration)
3310 ONE CANAL TRADITIONAL
3320 TWO CANALS TRADITIONAL
3330 THREE CANALS-TRADITIONAL
3346 RETREATMENT - ANTERIOR
3347 RETREATMENT - BICUSPID
3348 RETREATMENT - MOLAR
Periapical Services
3410 APICOECTOMY - SEPARATE PROCEDURE
3421 APICOECTOMY - BICUSPID 1ST ROOT
3425 APICOECTOMY - MOLAR 1ST ROOT
3426 APIOECTOMY/PERIRADICULAR SURGERY EA ADD
3450 ROOT RESECTION-PER ROOT
3920 HEMISECTION
PERIODONTICS
Surgical Services (including usual post-operative services;
only one of the following services is covered per quadrant)
4210
4220
4240
4250
4260
4263
4264
GINGIVECTOMY GINGIVOPLASTY PER QUAD
GINGIVAL CURETTAGE PER QUAD
GINGIVAL FLAP PROCEDURE
MUCOGINGIVAL SURG PER QUAD
OSS SURG FLAP PER QUAD
OSSEOUS SURGERY W/FLAP & CLOSURES EXTANT
OSSEOUS SURGERY W/FLAP & CLOSURE TOOTH
Page 101
CODE
DENTAL PROCEDURE
4270 PEDICLE, SOFT TISSUE GRAFTS
4271 FREE, SOFT TISSUE GRAFTS
4341 PERIO SCALING/ROOT PLANING-PER QUADRANT
4910 PERIODONTAL MAIN PROCED (FOLLOW ACTIVE)
PROSTHODONTICS - REMOVABLE
CLASS
2
2
2
2
$483.15
$483.15
$77.30
$135.28
3
3
3
3
$386.52
$386.52
$241.58
$241.58
3
3
3
3
3
$277.01
$277.01
$409.07
$409.07
$309.22
3
3
3
3
3
3
3
3
$87.00
$96.63
$87.00
$54.76
$144.95
$96.63
$96.63
$135.28
3
3
3
3
3
3
3
3
3
3
3
3
$309.22
$309.22
$309.22
$309.22
$145.00
$145.00
$145.00
$145.00
$193.26
$193.26
$193.26
$193.26
3
3
3
$386.52
$386.52
$386.52
3
3
3
3
3
3
3
3
3
$174.00
$174.00
$193.26
$193.26
$193.26
$193.26
$193.26
$193.26
$193.26
3
$145.00
Benefits for dentures and partial dentures include adjustments
within 6 months after installation)
Complete Dentures - including six months postdelivery care
5110 COMPLETE UPPER DENTURE
5120 COMPLETE LOWER
5130 IMMEDIATE UPPER
5140 IMMEDIATE UPPER
Partial Dentures - includeing six months postdelivery care
5211 DENTURE-PART UPPER W/OUT CLASPS, ACRYLIC BASE
5212 DENTURE-PART LOWER W/OUT CLASPS, ACRYLIC BASE
5213 UPPER PARTIAL-CAST METAL BASE W/RESIN BASE
5214 LOWER PARTIAL-CAST METAL BASE W/RESIN BASE
5281 REMOV. UNILAT PART DENTURE-1 PIECE CAST METAL
Repairs to Dentures
5510 REPAIR BROKEN COMPLETE DENTURE BASE
5520 REPLACE MISSING OR BROKEN TEETH (COMPLETE)
5610 REPAIR PART DENTURE-NO TEETH DAMAGE
5620 REPAIR DENT REPLACE 1 BROKEN TOOTH
5630 REPAIR OR REPLACE BROKEN CLASP
5640 REPL BKN TEETH ON PARTIAL DENT PER TOOTH
5650 ADD TOOTH/PAR REPL EXT TOOTH NO CLASP
5660 ADD TOOTH/PAR REPL EXT TOOTH WITH CLASP
Denture Relining
5710 REBASE COMPLETE MAXILLARY DENTURE
5711 REBASE COMPLETE LOWER DENTURE
5720 DENTURE-DUP UP/LOW PARTIAL /JUMP CASE
5721 REBASE LOWER PARTIAL DENTURE
5730 DENTURE RELINE, COMPLETE 'OFFICE'
5731 RELINE COMPLETE LOWER DENTURE (CHAIRSIDE)
5740 DENTURE RELINE, PARTIAL 'OFFICE'
5741 RELINE LOWER PARTIAL DENTURE (CHAIRSIDE)
5750 DENTURE RELINE, COMPLETE 'LAB'
5751 RELINE COMPLETE LOWER DENTURE (LAB)
5760 DENTURE RELINE, PARTIAL 'LAB'
5761 RELINE LOWER PARTIAL DENTURE (LAB)
PROSTHODONTICS - FIXED (each abutment and each pontic
constitutes a unit in a bridge)
5931 OBTURATOR PROSTHESIS, SURGICAL
5932 OBTURATOR PROSTHESIS, DEFINITIVE
5933 OBTURATOR PROSTHESIS, MODIFICATION
Bridge Pontics
6210 PONTIC-CAST GOLD
6211 PONTIC-CAST PREDOMINANTLY BASE METAL
6212 PONTIC - CAST NOBLE METAL
6240 PONTIC-PORCELAIN FUSED TO METAL
6241 PONTIC-PORCELAIN FUSED TO PREDOM BASE METAL
6242 PONTIC-PORCELAIN FUSED TO NOBLE METAL
6250 PONTIC-RESIN WITH HIGH NOBLE METAL
6251 PONTIC-RESIN WITH PREDOMINANTLY BASE METAL
6252 PONTIC-PLASTIC RESIN WITH NOBLE METAL
Retainers
6520 INLAY- METALLIC-TWO SURFACES
Page 102
CODE
DENTAL PROCEDURE
6530 INLAY-METALLIC-THREE OR MORE SURFACES
6543 ONLAY-METALLIC-THREE SURFACES
6545 RETAINER-CAST METAL FOR ACID ETCH FIXED
Crowns
6720 CROWN - RESIN W/HIGH NOBLE METAL
6721 CROWN - RESIN W/PREDOMINANTLY BASE METAL
6722 CROWN - RESIN W/NOBLE METAL
6750 CROWN - PROCELAIN FUSED TO HIGH NOBLE METAL
6751 CROWN - PORCELAIN FUSED TO PREDOM BASE METAL
6752 CROWN-PORCELAIN FUSED TO NOBLE METAL
6780 CROWN - 3/4 CAST HIGH NOBLE METAL
6790 CROWN - FULL CAST HIGH NOBLE METAL
6791 CROWN FULL CAST PREDOMINANTLY BASE METAL
6792 CROWN FULL CAST NOBLE METAL
Other Prosthetic Services
6930 RECEMENT BRIDGE
6950 PRECISION ATTACHMENT
ORAL SURGERY
Simple extractions (includes local anesthesia and routine
CLASS
3
3
3
$193.26
$116.00
$116.00
3
3
3
3
3
3
3
3
3
3
$318.88
$289.89
$289.89
$367.20
$289.89
$289.89
$212.59
$289.89
$289.89
$289.89
3
3
$58.00
$193.26
2
2
2
2
2
2
2
2
2
$58.00
$58.00
$96.63
$193.26
$241.58
$289.89
$328.54
$96.63
$386.52
2
2
2
2
$96.63
$96.63
$96.63
$96.63
2
2
2
$96.63
$193.26
$193.26
2
2
2
2
2
2
2
2
2
2
2
2
2
2
$145.00
$145.00
$67.64
$48.32
$145.00
$869.68
$579.78
$869.68
$676.41
$579.78
$193.26
$289.89
$145.00
$77.30
1
1
$29.00
$67.64
postoperative care)
7110 SINGLE TOOTH
7120 EXTRACTION SIMPLE EACH ADDITIONAL
7210 SURGICAL REMOVAL ERUPTED TOOTH
7220 REMOVAL OF IMPACTED TOOTH - SOFT TISSUE
7230 REMOVAL IMPACTED TOOTH PARTIALLY BONY
7240 REMOVAL OF IMPACTED TOOTH - COMPLETELY BONY
7241 REMOVAL OF IMPACTED TOOTH COMPLETELY BONY
7250 SURGICAL REMOVAL OF RESIDUAL TOOTH ROOTS
7260 ORAL ANTRAL FISTULA CLOS &/OR ROOT REC
Other Surgical Procdures
7270 TOOTH REPLANTATION
7280 SURG EXPOS IMPACT TOOTH ORTHO RESONS
7285 BIOPSY OF ORAL TISSUE-HARD
7286 BIOPSY-ORAL TISSUE-SOFT
Alevoplasty (surgical preparation of ridge for dentures)
7310 ALVEOLOPLASTY IN CONJUNCTION W/EXTRACTION
7320 ALVEOLOPLASTY NOT IN CONJUNCTION W/EXTRACTION
7340 VESTIBULOPLASTY-RIDGE EXTENSION
OTHER SERVICES
7450 RMVL OF ODONT CYST/TUMOR UP TO 1/ INCH
7460 RMVL OF NONODONT CYST/TUMOR UP TO 1/2"
7510 INCISION & DRAINAGE ABSCESS EXTRAORAL
7520 I & D ABSCESS EXTRAORAL
7560 MAXIL SINUSOTOMY FOR RMVL TOOTH FRAG/ FB
7610 MAXILLA - OPEN REDUCTION
7620 MAXILLA - CLOSED REDUCTION
7630 MANDIBLE - OPEN REDUCTION
7640 MANDIBLE CLOSED REDUCTION
7650 FRACT SMPL MALAR OR ZYG ARCH OPRED
7660 FRACT SMPL MALAR OR ZYG ARCH CLRED
7810 OPEN REDUCTION OF DISLOCATION
7820 CLOSED REDUCTION OF DISLOCATION
7960 FRENULECTOMY-SEP PROC
Emergency Treatment
9110 PALLIATIVE TREATMENT-MINOR
9310 CONSULTATION - PER SESSION
Anesthesia
Page 103
CODE
DENTAL PROCEDURE
9220 ANESTHESIA-GENERAL FIRST 30 MINUTES
Miscellaneous Procedures
9410 VISIT-HOUSE CALL
9420 HOSPITAL CALL
CLASS
2
$193.26
1
2
$38.65
$38.65
Page 104
Select your Plan
TRANSACTION AND PREDETERMINATION INFORMATION
13. Type of Transaction (Mark all Applicable Boxes)
SUBSCRIBER INFORMATION
1. Policyholder / Subscriber Name (Last, First, Middle Initial, Suffix), Address, City, State, ZIP Code
Statement of Actual Services
Request for Predetermination/Pre-treatment Estimate
EPSDT/ Title XIX
Encounter
14. Predetermination/
Pre-treatment
Estimate Number
TREATMENT INFORMATION
15. Treatment Resulting From
Occupational Illness/injury
Auto accident
Other accident
16. Date of Accident (MMDDCCYY)
2. Date of Birth
(MMDDCCYY)
3. Gender
Hospital
ECF
Radiograph(s)
Other
20. Is Treatment for Orthodontics?
No (Skip 21-22)
Dependent Child
Other
Oral Image(s)
Model(s)
21. Date Appliance Placed (MMDDCCYY)
Yes (Complete 21-22)
22. Months of
Treatment
Remaining
7. Relationship to Policyholder/Subscriber in #1 Above
Spouse
19. Number of Enclosures (00 to 99)
Provider's Office
6. Employer
Name
PATIENT INFORMATION
Self
17. Auto Accident State
18. Place of Treatment
F
M
5. Plan or Group
Number
4. Policyholder / Subscriber ID (SSN or ID#)
23. Replacement of Prosthesis?
No
24. Date of Prior Placement (MMDDCCYY)
Yes (Complete 44)
OTHER INSURANCE COVERAGE
8. Patient Name (Last, First, Middle Initial, Suffix), Address, City, State, ZIP Code
25. Other Coverage?
Dental (Complete 26-32)
None
Medical (Complete 26-32)
26. Name of Other Coverage Policyholder / Subscriber (Last, First, Middle Initial, Suffix)
27. Date of Birth (MMDDCCYY)
9. Date of Birth (MMDDCCYY)
10. Gender
11. Patient ID/Account # (Assigned by Dentist)
12. Remarks
33. Diagnosis Codes
29. Policyholder / Subscriber ID (SSN or ID#)
F
31. Patient's Relationship to Person Named in #26
30. Plan or
Group
Number
F
M
28. Gender
M
Self
Spouse
Dependent
Other
32. Other Insurance Company / Dental Benefit Plan Name, Address, City, State, ZIP Code
A.
B.
D.
C.
RECORD OF SERVICES PROVIDED
34. Procedure Date
(MMDDCCYY)
38. Quantity
35. Area of
36. Tooth Number(s) 37. Tooth
Oral Cavity
Surface
or Letter(s)
40. Diagnosis
Pointer
(A, B, etc.)
39. Procedure
Code
41. Description
42. Fee
1
2
3
4
5
6
7
8
Permanent
MISSING TEETH INFORMATION
44. (Place an 'X' on each missing tooth)
Primary
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
A
B
C
D
E
F
G
H
I
J
32
31
30
29
28
27
26
25
24
23
22
21
20
19
18
17
T
S
R
Q
P
O
N
M
L
K
AUTHORIZATION - RELEASE OF INFORMATION
0.00
AUTHORIZATION - ASSIGNMENT OF BENEFITS
45. I have been informed of the treatment plan and associated fees. I agree to be responsible for all
charges for dental services and materials not paid by my dental benefit plan, unless prohibited by law, or
the treating dentist or dental practice has a contractual agreement with my plan prohibiting all or a portion of
such charges. To the extent permitted by law, I consent to your use and disclosure of my protected health
information to carry out payment activities in connection with this claim.
X
43. Total
Fee
46. I hereby authorize and direct payment of the dental benefits otherwise payable to me, directly to the below named
dentist or dental entity
X
Subscriber signature
Date
TREATING DENTIST AND TREATMENT LOCATION INFORMATION
Patient/Guardian signature
Date
53. I hereby certify that the procedures as indicated by date are in progress (for procedures that require multiple
visits) or have been completed
BILLING DENTIST OR DENTAL ENTITY
47. Dentist or Entity Name, Address, City, State, ZIP Code
X
Signed (Treating Dentist)
Date
54. Treatment Location Address, City, State, ZIP Code - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
48. NPI
55. NPI
49. License
Number
50. SSN
or
TIN
56. License
Number
57. Provider
Specialty
Code
51. Phone
Number
52. Additional
Provider ID
58. Phone
Number
59. Additional
Provider ID
Delta Dental Enterprise Claim Form
Version 1, Rev 0
10/12/2011
Page 105
Claim Form Disclosure
You may be subject to civil and criminal penalties for knowingly providing false or misleading information.
Alabama: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information
in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof.
Alaska: A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim containing false, incomplete or
For your protection Arizona law requires the following
statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for
payment of a loss is subject to criminal and civil penalties. Arkansas: Any person who knowingly presents a false or
misleading information may be prosecuted under this title. Arizona:
fraudulent claim for payment for a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to fines and confinement in prison. California: For your protection, California law requires the following to appear on this form: Any person
who knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state
prison. Colorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of
defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance
company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant
for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance
proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies. Delaware: Any person who knowingly,
and with intent to injure, defraud or deceive any insurer, files a statement of claim containing any false, incomplete or misleading information is guilty of
a felony. District of Columbia: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the
insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information
materially related to a claim was provided by the applicant. Florida: Any person who knowingly and with intent to injure, defraud or deceive any
insurance company files a statement of claim containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
Hawaii: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime
punishable by fines or imprisonment, or both. Idaho: Any person who knowingly, and with intent to defraud or deceive any insurance company, files a
statement containing any false, incomplete, or misleading information is guilty of a felony. Indiana: Any person who knowingly, and with intent to
defraud an insurer, files a statement of claim containing false, incomplete or misleading information commits a felony. Kansas: Any person who
knowingly files a statement of claim containing any misrepresentation or any false, incomplete or misleading information may be guilty of a criminal act
punishable under law and may be subject to civil penalties. Kentucky: Any person who knowingly and with intent to defraud any insurance company
or other person files a statement of claim containing any materially false information or conceals, for the purpose of misleading, information any fact
material thereto commits a fraudulent insurance act, which is a crime. Louisiana: Any person who knowingly presents a false or fraudulent claim for
payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and
confinement in prison. Maine: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the
purposes of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits. Maryland: Any person who
knowingly and willfully presents a false or fraudulent claim for payment for a loss or benefit or who knowingly and willfully presents false information in
an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Minnesota: A person who files a claim with
intent to defraud or helps commit a fraud against an insurer is guilty of a crime. New Hampshire: Any person who, with a purpose to injure, defraud
or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information is subject to prosecution and
punishment for insurance fraud as provided in R.S.A. 638.20. New Jersey: Any person who knowingly files a statement of claim containing any false
or misleading information is subject to civil and criminal penalties. New Mexico: Any person who knowingly presents a false or fraudulent claim for
payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines
and criminal penalties. New York: Any person who knowingly and with intent to defraud any insurance company or other person files an application
for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any
fact material thereto, commits a fraudulent insurance act, which is a crime shall also be subject to a civil penalty not to exceed five thousand dollars and
the stated value of the claim for each such violation. Ohio: Any person who, with the intent to defraud or knowing that he is facilitating a fraud
against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. Oklahoma: WARNING:
Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing
any false, incomplete or misleading information is guilty of a felony. Pennsylvania: Any person who knowingly and with intent to defraud any
insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for
the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such
person to criminal and civil penalties. Puerto Rico: Any person who knowingly and with the intention to defraud presents false information in an
insurance application or, who presents helps or has a fraudulent claim presented for the payment of a loss or other benefit, or presents more than one
claim for the same loss or damage, will incur in a felony and if convicted, will be sanctioned for each violation with a fine of no less than five thousand
($5,000) dollars or no more than ten thousand ($10,000) dollars or imprisonment by the fixed term of three years, or both punishments. With
aggravating circumstances the fixed term of the punishment could go up to five (5) years; with mitigating circumstances the punishment could be
reduced to a minimum of two (2) years. Rhode Island: Any person who knowingly presents a false or fraudulent claim for payment of a loss or
benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
Tennessee: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purposes of defrauding the
company. Penalties may include imprisonment, fines or a denial of insurance benefits. Utah: Any person who knowingly presents false or fraudulent
underwriting information, files or causes to be filed a false or fraudulent claim for disability compensation or medical benefits, or submits a false or
fraudulent report or billing for health care fees or other professional services is guilty of a crime and may be subject to fines and confinement in state
prison. Virginia: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding
the company. Penalties include imprisonment, fines and denial of insurance benefits. Washington: It is a crime to knowingly provide false,
incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and
denial of insurance benefits. West Virginia: Any person who knowingly presents a false or fraudulent claim for payment of a loss or
benefit
Page
106 or
knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
Long Term Disability
Eligibility for Long Term Disability [LTD] is subject to collective bargaining agreement. If you have any
questions on your coverage, contact the Office of Human Resources.
The College’s long term disability program provides disability income and waiver of annuity premium
benefits only. It does not provide basic hospital, basic medical or major medical insurance as defined by
the NYS Insurance Department.
Amount of Benefits
• 60% (benefit percentage) of the first $2,000 of basic monthly earnings, plus 40% of the excess
not to exceed the maximum benefit, less other income benefits.
• The maximum monthly benefit is $2,500
• The minimum monthly benefit is $50
Maximum Benefit Period
Benefits begin on the first of the month following six (6) consecutive months of Total Disability, and
continues as follows:
• For a period of continuous Total Disability which commences prior to or on your 60th birthday,
benefits will be paid until the first day of the month in which you reach age 65 or until the first
day of the month in which Total Disability terminates, whichever occurs first.
• For a period of continuous Total Disability which commences after your 60th birthday, benefits
will be paid until the first day of the month in which you reach age 70 or until the first day of the
month in which you have been in a period of Total Disability for five years, whichever occurs
first. In no event, however, will any benefits be paid beyond the first day of the month in which
Total Disability terminates.
Examples:
♦ If you become totally and continuously disabled on March 15, 1984 at age 40 and you
remain so disabled, your benefit payments will begin on October 1, 1984 (1st of the month
next following six (6) months of disability) and will continue until the 1st of the month in
which your each your 65th birthday.
♦ If you become totally and continuously disabled on March 11, 1984, at age 61 and you
remain so disabled your benefit payments will begin on October 1, 1984 (1st of the month
next following six (6) months of disability) and will continue until March 1, 1989 (1st of the
month in which you have been disabled for a period of five years).
♦ If you become totally and continuously disabled on March 15, 1984 at age 66 and you
remain so disabled, your benefit payments will begin on October 1, 1984 (1st of the month
next following six (6) months of disability) and will continue until the 1st of the month in
which you reach your 70th birthday.
♦ Regardless of your age, benefit payments sill cease on the first day of the month in which
Total Disability ends.
Elimination Period: Six (6) Months
Page 107
Monthly Waiver Benefit
The Monthly Waiver Benefit will be equal to 12% of that portion of your monthly salary base at the
commencement of the period of continuous Total Disability which is subject to Social Security [FICA]
taxes on such date, plus 15% of the remainder of such monthly salary base.
The Monthly Waiver Benefit will be credited as monthly premiums to a TIAA retirement annuity contract
[Form 1000.18] and if you so elect a College Retirement Equities Fund retirement annuity certificate
[Form C1000.7] issued on your life. The allocation of a portion of the Monthly Waiver Benefit to CREDF
will be in accordance with the options then available. In no event will the Monthly Waiver Benefit be
credited to such contract or certificate earlier than the date a satisfactorily completed application for
such TIAA contract or CREF certificate is received by TIAA. The portion of the Monthly Waiver Benefit
allocated to a TIAA contract of CREFD certificate will terminate at any time premiums are no longer
payable on such contract of certificate.
Terms you should know
Many terms in your certificate of coverage have special meanings. A list of these terms and meanings
follows:
Total Disability – the term total disability will mean you inability, by reason of sickness or bodily injury,
to engage in any occupation for which you are reasonably fitted by education, training, or experience.
Monthly Salary Base – the term Monthly Salary Base as of any given date will mean 1/12 of your basic
annual salary rate (exclusive of overtime, bonuses, and other forms of additional compensation)
receivable from your employer.
Reduction Amount – the term Reduction Amount will include and benefits
1. Payable on your wage record under the Social Security Act of the United States including any
benefits for dependents, or under any governmental program in Canada, as in effect at the
commencement of benefit payments, hereunder, without regard to any deductions from such
benefits which may be made for work or for your refusal to accept rehabilitation
2. Paid under any Workmen’s Compensation Law or similar statute except for any such benefits to
which you were entitled prior to the occurrence of the accident or sickness resulting in the
period of continuous Total Disability for which benefits are payable hereunder and
3. Any disability benefits payable under any insurance or retirement plan for which contributions
or payroll deductions are made by your employer. Any such benefits under (1) will be deemed
to be payable for the purpose of the group policy unless, after submitting the required
application for such benefits together with all proofs required, such benefits have been declined
by the Social Security Administration. The term Reduction Amount will also include any
payments receivable by you under your employer’s sick leave or salary continuation program.
General Exclusions
Benefits will not be payable if Total Disability results from
Injury or sickness as a result of war, declared or undeclared
Injuries sustained in an accident which occurred or sickness which commenced prior to the date
you became covered under the group plan, but this exclusion will not apply to a period of Total
Disability commencing after a period of at least nine months during which you are continuously
covered under the group plan
Intentional self-inflicted injury or sickness
Pregnancy, except that this exclusion will to apply to a period of Total Disability commencing
after termination of pregnancy
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Termination of Insurance
Your coverage will terminate up on the occurrence of the first of the following events:
• Termination of the group plan
• Modification of the group plan to terminate coverage for the class of employees to which you
belong
• The last day of the month which is seven (7) months prior to the month in which you attain your
70th birthday
• Termination of you employment, or cessation of your active service, in the classes of employees
eligible for coverage. If you cease active work, without actual termination of employment ask
your employer when cessation of active service will be deemed to occur under the group plan.
• Termination of you required contribution, if any, toward payment of premiums.
Termination of your coverage will not affect your benefits for a Total Disability existing on the date such
termination is effective.
General Provisions
Notice and Proof of Claim: On receipt of written notice of claim by the College, the College will furnish
forms for filing proof of claim.
Initial written proof of Total Disability must be furnished to the College on an approved claim form
within twelve (12) months after the commencement of the period of continuance of Total Disability.
Subsequent written proofs of the continuance of Total Disability must similarly be furnished to the
College at such intervals as the College may reasonably require. Failure to furnish such proof within
such time will not invalidate or reduce your claim if it was not reasonably possible for you to furnish
proof within such time and if proof was given as soon as was reasonably possible. The College will have
the right and opportunity to examine you whenever it may reasonably required during the period of
continuous Total Disability.
The College may require as part of the proof of claim, statements of attending physicians or surgeons,
copies of laboratory reports or examinations, x-rays, or extracts of hospital records, and in addition,
satisfactory evidence that you have made application for all benefits included in the Reduction Amount
and furnished all required proofs for such benefits.
Payment of Benefits: Monthly Income Benefits will be paid to you, and Monthly Waiver Benefits will be
paid or credited in accordance with the provision entitled Monthly Waiver Benefit, on the first day of
each calendar month subject to due proof on the continuance of Total Disability. The College may, in its
discretion, pay any Monthly Income Benefit to any person or institution by whom or in which you are
being maintained, as trustee for you, if it is shown to the satisfaction of the College that you are
physically or mentally incapable of personally receipting for such payment, and such payment will
discharge the College’s obligation with respect to payment so made.
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Employee Assistance Program [EAP]
Hudson Valley Community College subscribes to the Capital Employee Assistance Program, a
confidential assistance program designed to allow an employee experiencing a problem to selfrefer for two (2) counseling visits designed to provide problem resolution or guidance to an
appropriate agent for further assistance. This program is entirely confidential.
Professional counseling services offered include but are not limited to marriage or relationship
problems, difficulties with children or elder relatives, depression, grief and loss, stress-related
concerns, substance abuse, fear and anxiety, anger management, or legal and financial issues.
Capital EAP also provides training workshops at different locations throughout the area.
Schedules are distributed quarterly (usually with your paycheck) and are also available on the
EAP website; www.capitaleap.org.
To make an appointment contact Capital EAP at (518) 465-3813 or 1-800-777-6531.
Counseling appointments are typically made within three to five business days. There are no
co-pays or costs for this initial contact.
There are affiliate locations throughout the region, NYS and the U.S. and several office locations
in our area:
650 Warren Street, Albany, NY 12208
632 Plank Road, Clifton Park, NY 12065
15 Maple Dell, Saratoga Springs, NY 12866
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Retirement
The SUNY Optional Retirement Program (ORP) TIAA-CREF membership is open to full time
unclassified staff members.
New York State Employees’ Retirement System membership is open to all employees.
New York State Teachers’ Retirement System membership is open to employees in the
unclassified service employed in a select group of titles: faculty, librarian or coach title,
chancellor, president, vice-president, dean, associate dean or assistant dean.
If you are a full-time employee, you must elect to participate in one of these programs within
thirty (30) days of the effective date of your appointment. If you do not make a timely election,
and are in a position eligible for TRS membership, you will then be required to join TRS. All
other full-time employees who do not make a timely election will be required to join ERS. Parttime employees are not required to join a retirement system.
Once you become a participant in one of these programs, either through election or by failure
to make a timely election, you will not be able to change from one to another during
employment at Hudson Valley Community College.
Exception: if you are not now eligible for a particular retirement program, and later become eligible for that
program, you will be permitted to change to that program at that time. Example: you are a classified staff member
and become a full time faculty member; you would then be eligible to elect either TIAA or TRS since you were not
eligible for either as a classified staff member. NTPs that change status to full time faculty need to contact the
Office of Human Resources on the ability to change systems when changing positions as several other caveats may
apply.
The public retirement systems (TRS and ERS) are both “defined benefit” retirement programs.
The benefits you receive at retirement will be determined based on a formula, using specific
formula factor, your final average salary, age and years of service. The Optional Retirement
Program is a “defined contribution” program. The amount of benefits you receive at
retirement will be based on the amount of funds contributed to your account, the investment
earnings on those funds, your age when you take income and the benefit option you choose.
Detailed information on each plan is available on the systems’ websites. You should review
these prior to making your decision. The site addresses are:
www.tiaa-cref.org
www.osc.state.ny.us
www.nystrs.org
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Tax Deferred Retirement Savings Program
As an employee of Hudson Valley Community College you are eligible to participate in the taxdeferred voluntary Retirement Savings Program. This Program provides a way for you to save
extra money for retirement through payroll deduction; there is no employer contribution.
We offer two (2) vehicles for deferred savings; NYS Deferred Compensation [IRS section 457]
and Tax Shelter Annuity [IRS section 403(b)]. You choose the amount to contribute, within
certain limits. You may change your contribution as frequently as you wish, but the rules for
withdrawal of funds and maximum contributions may vary by plan and should be reviewed
prior to selection. For the 403(b) plans, you choose the provider you wish to invest with. All
contributions to 403(b) and 457 are always 100% vested. Your contribution is subtracted from
your income before federal and state taxes are computed on your paycheck. You will be taxed
on your contributions plus earnings at the time you withdraw the funds.
NYS Deferred Compensation Plan [IRS 457]
Detailed information and enrollment forms are available on line at www.nysdcp.com or you
may contact them at 1-800-422-8463. This plan is administered directly by NYSDCP, therefore
all applications and changes are communicated to Hudson Valley Community College through
NYSDCP. The minimum bi-weekly deduction amount allowed is $10. The maximum allowances
are currently the same as the 403(b).
Tax Shelter Annuity [IRS 403(b)]
To participate in the program or change the amount of your contribution you and your
company representative must sign a Salary Reduction agreement.
Limit if under age 50 in 2010 – $16,500
Limit if age 50 or over (by 12/31) in 2010- $21,500
Employees who have at least 15 years of service with SUNY may be eligible to contribute an
extra $3,000 per year (lifetime maximum $15,000) in addition to the amounts listed above.
Contributions to the 457 (deferred compensation) plans do not affect contributions to 403(b).
Approved providers for 403(b) plans
TIAA-CREF 1-800-842-2776 or www.tiaa-cref.org
VALIC 1-888-569-7055 or www.AIGRetirement.com
ING 1-800-677-4636 or www.ingretirementplans.com
MetLife 716-634-2117 or www.metlife.com
Fidelity 1-800-343-0860 or www.fidelity.com
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HUDSON VALLEY COMMUNITY COLLEGE
SUNY 403(b) VOLUNTARY SAVINGS PLAN
SALARY REDUCTION AGREEMENT
By this AGREEMENT, made between _____________________________________________________________,
Employee Name-Please Print
Hudson Valley Community College and the State University of New York, the parties hereto agree as follows:
This Agreement represents a:
_____New Agreement _____Change to an existing Agreement _____Cancellation of existing Agreement
Effective with respect to amounts paid on or after ____________________________________________________,
Date
which is subsequent to the execution of this Agreement, the employee’s salary will be reduced by the amount
indicated below. At the same time, the College agrees to contribute that amount to the employee’s account with:
_____TIAA-CREF _____VALIC _____ING _____METLIFE _____FIDEITY
The amount of the salary reduction shall be $____________________ annually OR $____________________ per
pay period (total amount of annual reduction divided by 26 pay periods) which will produce a total contribution that
does not exceed the employee’s statutory exclusion allowance under IRS Code Section 403(b), Section 415, or
Section 402(g), whichever is least. Responsibility for assuring that total annual salary reduction contributions do not
exceed the maximum exclusion allowance defined in the IRS Code rests solely with the employee.
This Agreement shall be legally binding and irrevocable as to each of parties hereto while employment continues
and shall replace any existing Agreement currently in effect. Either party may terminate or modify this Agreement
as of the end of any payroll period by giving at lease thirty (30) days written notice, so that this Agreement will not
apply to salary subsequently paid.
Date __________________________
____________________________________________________________
Employee Signature
Date __________________________
____________________________________________________________
Company Representative Signature
Administration Use Only
___________________________________________________
Office of Human Resources
____________________________
Date
Annual Contribution $___________ Date Deductions Begin ___________ Catch-up 50+__________ 15 Year ____________
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Standard Work Day
The College has a standard work day with two options for most Classified and NTP employees
working 37.5 hours per week: 8:00 a.m. to 4:30 p.m. or 8:30 a.m. to 5:00 p.m., both with a one
hour lunch period. It is not permissible to take lunch at the end of the day and leave early, nor
is it permissible to take only a ½ hour lunch to shorten the work day. A student, employee or
member of the public should always be able to contract a College office until at least 4:30 p.m.
Where work demands are better served by a non-standard schedule, different arrangements
may be made through consultation with Human Resources.
Time and Attendance Forms As a public institution, the College must be able to demonstrate that
employees are paid for services rendered. While completion of timesheets my seem
unnecessary, records of attendance and leave use meet a basic audit standard and must be
kept up to date. Timely completion is expected of all employees. Failure to submit time sheets
may result in withholding of pay.
Leave Accruals
Leave which is accrued on a pay period basis (for NTP and Classified staff), is not actually
‘earned’ until the end of the pay period. One cannot use the accrued hours in advance of the
end of the period. In other words, one earns the bi-weekly accrual by working all the days in
the pay period, or by covering those days with leave already on the books at the beginning of
the period. The only exceptions to this are in the areas of half-pay and termination payouts.
Sick Leave
All bargaining units have Sick Leave in the event of personal or family illness, but amount and
conditions for use are function of contract.
In general sick leave may not be utilized in conjunction with holidays or vacations unless
validated by a physician’s statement or unless a known condition exists. Sick leave is not a
payout item at point of resignation, and may not be “liquidated” immediately prior to
termination. The College always has the right to require validation of sick leave use, but will
almost always do so when sick leave is being used at a rate which exceeds accrual, or when sick
leave is used to extend a break in schedule.
Any planned medical leave, such as for surgery or childbirth, needs to be arranged with the
supervisor and the Office of Human Resources in advance and be documented by physician’s
certification of need and projected dates of absence. See FMLA.
Sick leave at ½ pay is a form of short-term disability insurance available upon exhaustion of sick
leave for NTP and Classified staff.
An additional sick leave benefit which is becoming more recognized and important is the use of
accrued sick leave to fund health insurance coverage in retirement. While contractual
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provisions differ with respect to options and contribution, the basic principle for all employees
is that the college converts sick leave time on the books at point of retirement to a dollar
amount based on salary at that time. An employee then decides how much to leave for health
insurance payment of take in cash depending up on the contractual options available. For
certain long-servicing employees who are leaving employment but not retiring there are also
cash payments for unused sick leave. These are increasingly important benefits which should
encourage maintenance of the largest possible sick leave balance.
Personal Leave is available to all categories of employee but amount and conditions of use are a
function of contract. In general personal leave may not be utilized in blocks of days unless the
employee is prepared to document that its use was actually for personal business which could
not be otherwise accomplished. As with sick leave, it is not to be used to extend holiday or
vacation periods. Personal leave is not a payout item at point of termination.
Vacation Leave or Annual Leave is accorded to both NTP and Classified staffs and the amount of
accrual differs with bargaining unit and longevity.
Sabbatical Leave is available to both Faculty and NTP employees. Request forms may be found
on the Office of Human Resources website.
Bereavement Leave is available to NTP and Classified staff in the event of a death in the
immediate family. Employees with faculty rank utilize Personal Leave for this purpose.
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Leave for Breast Cancer and/or Prostate Cancer Screening
Employees are eligible to take up to four (4) hours of paid leave, without charge to leave credits
for breast cancer screening and/or prostate cancer screening per year.
Cancer screening includes physical exams and mammograms for the detection of breast cancer,
and physical exams and blood work for the detection of prostate cancer. Travel time is
included in the four (4) hour cap. Absence beyond the four (4) hour cap must be charged to
leave credits.
Employees who undergo screenings outside of their regular work schedule do so on their own
time.
A Hudson Valley Community College Cancer Screening Leave form must be completed by the
Physician’s office to authorize this leave.
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Hudson Valley Community College
Cancer Screening Leave
Employee Name
Prostate Cancer Screening
Breast Cancer Screening
Date
Time In
Time Out
Physician’s Office Signature
Please send completed form with your timesheet to the Office of Human Resources.
Pursuant to Civil Service Law [Chapter 362 (as amended)] Community College employees are entitled to
take up to four (4) hours of paid leave, without charge to leave credits for breast cancer and/or prostate
cancer screening.
Cancer screening includes physical exams and mammograms for the detection of breast cancer, and
physical exams and blood work for the detection of prostate cancer. Travel time is included in the four
(4) hour cap. Absence beyond the four (4) hour cap must be charged to leave credits.
Leave for breast and/or prostate cancer screening is not cumulative and expires at the close of business
on the last day of the calendar year.
This form is to document that the employee’s absence was for the purpose of screening for breast
and/or prostate cancer. The completed form will be retained by the Campus Health Office.
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Jury Duty
Although different contracts address the topic differently, if at all, the college policy has certain
common expectations of all employees:
♦ Upon receipt of a jury duty summons, an employee should notify the immediate supervisor
and notify the Office of Human Resources
♦ A copy of the jury duty summons must be provided to the Office of Human Resources prior
to jury duty service to validate the jury duty leave.
♦ When actually on jury duty, the employee must obtain validation from the court clerk of
hours served and provide that validation to the Office of Human Resources.
♦ If jury service does not take up an employee’s entire normal workday, the employee must
return to work for the balance of the day. In addition, any time taken for jury duty service
should be noted on the employee’s timesheet for that period. (Note: Special arrangements
are made for employees who work late shifts. Contact the Office of Human Resources for
advice.)
♦ Public employees are not supposed to receive pay from the court (since you are being paid
anyway). Do not sign any form provided by the court that would produce pay for service.
Federal jury service is an exception to this rule.
Compliance with this procedure is expected. Failure to comply may result in a charge to accrued
leave or loss of pay.
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To:
Classified and Non-Teaching Professional Staff
From:
John R. Tibbetts, Director of Human Resources
Subject:
Summer Hours
Summer hours are in effect beginning Monday next following Memorial Day for a period of ten (10) weeks in accordance
with the administrative calendar. Most importantly, the College and all of its offices will remain open until 4:00 p.m.,
and certain offices which provide direct student services may remain open later. No exceptions will be made for offices
wishing to close at 3:30p.m. Staff of all offices must be assigned flexibly to ensure that the 4:00 p.m. or later closing
time is observed.
Please note that unit-covered NTPs will observe summer hours this year in the same manner as do Classified staff i.e. a
one-half hour lunch and a seven-hour workday resulting in departure from campus one hour earlier than is normal
during the regular academic year. This should not result in any conflict between NTP and Classified staff as to who leaves
early and who stays later. Supervisors in each office should consult with Human Resources where the potential for any
such problem exists.
Please remember; all offices must remain open until 4:00 p.m. The choice of schedule is 8:00 a.m. to 3:30 p.m. or 8:30
a.m. to 4: 00 p.m. unless otherwise specified by the responsible Vice President.
Physical Plant, Central Receiving and Public Safety staff will be granted two (2) work days off during this period and may
use these days up until November 30. These days should be arranged in advance with supervisory personnel and are to
be denoted as “summer leave day.”
The following is provided to remind you of the record keeping requirements and procedures which were implemented in
association with this employee benefit:
•
•
•
•
•
•
Eligible Classified and Non-Teaching Professional employees currently scheduled for a 5-day, 37 ½ hour work
week will be required to work 35 hours per week and will reduce their lunch period from one hour to one-half
hour. Bear in mind that the actual schedule for classified staff will be subject to coordination with the schedules
of NTP office staff.
Timesheets should reflect actual hours worked. During the time of “Summer Hours”, employees will continue to
accrue sick leave and vacation leave as though they were working 37 ½ hours. Therefore, charges to these leave
accrual categories must be made on the basis of a normal 37 ½ hour work week and employees must make
charges to such above categories to account for a full 7 ½ hour workday. For example, if an employee works for
3 ½ hours and covers the balance of the day with leave, 4 hours must be charged.
Charges to personal leave, flex time and compensatory time may be made to reflect the 7 hour work day in
effect during the period of “Summer Hours.”
Excess time for eligible classified employees will be paid at overtime rate for work performed beyond 35 hours.
Excess time for eligible NTP employees will be paid at special assignment rate for work performed beyond 35
hours per week, and eligible NTP employees will be paid at overtime rate for work performed in excess of 40
hours.
Employees working less than 37 ½ hours per week (part-time) or who have been appointed to temporary
positions on a non-benefitted basis will continue to be paid only for hours worked.
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Professional Development Opportunities and Funding
Hudson Valley Community College offers employees a multitude of ways to increase
professional development and incentives for furthering your education. Some of these are
negotiated in your employee contract and guidelines can be found in all employee contracts.
Listed below are some of the opportunities that are available to you, since these opportunities
do change periodically a complete and current list of funding resources can always be located
on our website.
Tuition Waivers You could be eligible for a tuition waiver! Eligible employees may request a waiver of up to
eight evening credit hours and up to four credit hours during the normal workday. Consult with
your employee contract for specific guidelines.
Personnel Resources Committee:
Hudson Valley Community College allocates monies to the Personnel Resources Committee
each year to support faculty and staff professional development requests. For more
information on the guidelines for funding, please consult the Personnel Resources web page.
SUNY Tuition Waiver, funded by SUNY
SUNY sponsors a $4,383 tuition waiver fund that grants faculty and NTPs 50% of tuition, up to
six credit hours per semester, at any SUNY Institution. Funds are allocated on a first come-first
served basis. Fees are not reimbursable. Contact Suzanne Kalkbrenner in the President’s Office
at 629-4530 or [email protected] for more information.
SUNY Tuition Reimbursement funded by Hudson Valley Community College
Hudson Valley Community College sponsors a $47,500 tuition reimbursement fund that grants
faculty, NTP and Classified staff 50% of tuition, up to six credit hours per semester, at any SUNY
institution. Funds are allocated on a first come-first served basis. Fees are not reimbursable.
Contact Suzanne Kalkbrenner in the President’s office at 629-4530 or [email protected]
for more information.
President’s Innovation Fund
Grants are offered each year by President Andrew J. Matonak to fund innovative projects that
explore teaching and learning processes and assessment thereof. The president seeks novel
approaches and creative activities at Hudson Valley Community College to enrich the college’s
teaching and learning environment and/or the assessment of student outcomes. Additional
information may be found on the College’s website or by contacting the President’s Office at
629-4530.
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Personnel Resources Committee:
Hudson Valley Community College allocates funding to the Personnel Resources Committee
each year to support faculty and staff professional development requests. For more
information on the guidelines for funding, please consult the Personnel Resources web page.
Faculty Workshop Day
The College budgets each year to support professional development opportunities for Faculty
Workshop Day in February.
Staff Development Day
The College budgets each year to support professional development opportunities for Staff
Development Day in May.
Training
The College is required by a variety of statutes at the state and federal level to provide training
to its employees. Where such training is mandated, the college will comply with the law. This
may require an employee to attend training sessions and sign certification forms. Failure to
comply with such mandates may result in disciplinary action.
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College Services Available to Employees
Dental Hygiene Clinic
Located in Fitzgibbons Hall, the clinic provides preventative dental services while providing our
students with an excellent learning experience. Dentists and/or licensed dental hygienists are
always present during clinic sessions and many treatments are free to Hudson Valley
Community College faculty and staff. Appointments are required and clinic hours are posted on
the Clinic’s website. Please contact extension 7400 for an appointment.
Food Service
Chartwells Dining Services is the Hudson Valley Community College food service provider. They
offer several food service locations on campus as well as catering services for special meetings.
The daily menu items are available on the website at www.diningoncampus.com/hvcc . To
arrange catering for a meeting you may contact Chartwells on campus at extension 7173.
Fitness Room/Racquetball Courts/Ice Skating
The McDonough Sports Complex, Fitness room, and Racquetball courts are all available to
Hudson Valley Community College employees. All have a mandatory registration procedure
that needs to be completed prior to utilization of these facilities. A valid employee ID must be
presented for access to all recreational facilities. For the current recreation schedule please
check the website at https://www.hvcc.edu/facilities/schedule.html or contact the Office of
Institutional Events at campus extension 4829.
Employee Discounts
Occasionally businesses will offer discounts to our employees. Currently, we are offered
discounts through a program entitled SUNY Perks, which you may sign up for this using your
Hudson Valley Community College email address. Computer Services also maintains a list on
their website of any discounts available to our employees for software or hardware (MircoUB,
Verizon, etc).
Auto Lab
Automotive service and repair for employee’s personal vehicles is available through the senior
automotive lab for a low cost (parts and lab fee). Appointments are necessary and prior
registration is required. For information on vehicle repair and criteria please contact the
Automotive Department at campus extension 7189.
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