Form Op-175 - Application For Per Session Employment And Claim For Retention Rights - 2016-2017
ADVERTISEMENT
1
2Chancellor’s Regulation C-175
2016-17 APPLICATION FOR PER SESSION EMPLOYMENT AND CLAIM FOR RETENTION RIGHTS (OP-175)
Directions: This form must be completed and submitted to the per session supervisor prior to commencement of
employment in a per session activity. A copy of this form must be retained by the per session supervisor. An applicant
who wishes to claim retention rights must assert such a claim on this form. Retention rights may be claimed ONLY in one
per session activity. No person may work more than 400 hours in one or a combination of per session activities (with a
maximum of 270 hours in a school psychologist and/or school social worker position) without prior written approval of the
Division of Human Resources in accordance with Chancellor’s Regulation C-175.
Last Name: _______________________________
First Name: ______________________ MI: _____________
Home Address: ________________________________________________________
Zip Code: ______________
Home Phone: (____) ______________
File No.: ______________
Email Address: ________________________
1. Are you a full-time employee of the NYC Department of Education?
Yes ____
No _____
If yes, indicate current work location: CFN ____________
District _______
School/Office _________________
License or Title ______________________ Hours of Employment from ________________ to ______________
2. Per Session Position for which you are Applying: Program Name: ______________________________________
CFN ____ District _____ Approximate Start Date __________ Do you claim retention rights? Yes ____ No ____
School/Office __________________________
Approximate Total No. of Hours in Activity __________________
Work Hours Monday – Friday ___________ to _____________
Saturday – Sunday __________ to __________
3. Between July 1, 2016 and June 30, 2017, have you worked or do you plan to work in any other per session
activity? Yes _____ No _____. If yes, indicate all positions below. Use additional sheets if necessary.
a. Program Name: __________________________________________________________________________
CFN _____ District _____ Approximate Start Date _____ Do you claim retention rights? Yes ____ No ___
School/Office __________________________
Approximate Total No. of Hours in Activity ______________
Work Hours Monday – Friday _________ to ___________
Saturday – Sunday __________ to __________
b. Program Name: __________________________________________________________________________
CFN _____ District _____ Approximate Start Date _____ Do you claim retention rights? Yes ____ No ___
School/Office __________________________ Approximate Total No. of Hours in Activity _______________
Work Hours Monday – Friday ___________ to ____________
Saturday – Sunday _________ to ________
4. Will your total per session hours for this year, including the hours for the position for which you are applying, exceed
400? Yes _____ No _____
5. If yes, have you submitted a waiver request to exceed the 400 hour maximum? Yes _____ No _____
6. Declaration: I have read and understand the requirements in Chancellor’s Regulation C-175. I understand that I am
bound by this regulation. I affirm that the information given above is, to my knowledge, accurate and complete, and I
understand that a willfully false answer to any question contained herein is a Class E felony which shall render this
application null and void and may result in loss of retention rights, cancellation of per session employment, loss of
pay, recoupment of compensation already paid, and/or disciplinary action.
___________________________________________ ______________________________________________
Signature of Applicant
Date
7. Approval by Per Session Supervisor: I certify that this applicant possesses the qualifications established for the
position and that the selection was made after following advertising procedures set forth in Chancellor’s Regulation C-
175.
_______________________________________________ __________________________________________
Signature of Per Session Program Supervisor
Date
OP-175 – 2016-2017
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Op-1 - Application For Motor Property Carrier And Broker Authority - U.s. Department Of Transportation
Legal
Form Op-305 - Application For Tax Amnesty - Connecticut Department Of Revenue Services, 2002
Financial
Related Categories
Parent category: Legal