I. Bonus Guideline Extension
A. Sign-on Bonus Agency choose one H73 - Department of Vocational Rehabilitation J02 - Department of Health and Human Services J04 - Department of Health and Environmental Control J12 - Department of Mental Health J16 - Department of Disabilities and Special Needs N04 - Department of Corrections N12 - Department of Juvenile Justice Employee Name First Last Social Security Number -- Class / Slot Amount of Bonus Date Awarded month/day/year Source of Funds B. Referral Bonus Agency choose one H73 - Department of Vocational Rehabilitation J02 - Department of Health and Human Services J04 - Department of Health and Environmental Control J12 - Department of Mental Health J16 - Department of Disabilities and Special Needs N04 - Department of Corrections N12 - Department of Juvenile Justice Employee Name First Last Social Security Number -- Class / Slot Amount of Bonus Date Awarded month/day/year Source of Funds C. Retention Bonus Agency choose one H73 - Department of Vocational Rehabilitation J02 - Department of Health and Human Services J04 - Department of Health and Environmental Control J12 - Department of Mental Health J16 - Department of Disabilities and Special Needs N04 - Department of Corrections N12 - Department of Juvenile Justice Employee Name First Last Social Security Number -- Class / Slot Amount of Bonus Date Awarded month/day/year Source of Funds
A. Sign-on Bonus
B. Referral Bonus
C. Retention Bonus
II. Education Initiatives
A. Leave for Class Agency choose one H73 - Department of Vocational Rehabilitation J02 - Department of Health and Human Services J04 - Department of Health and Environmental Control J12 - Department of Mental Health J16 - Department of Disabilities and Special Needs N04 - Department of Corrections N12 - Department of Juvenile Justice Employee Name First Last Social Security Number -- Class / Slot # of Leave Hours Received Cost of Leave Healthcare Degree Pursuing B. Paid Practicum Agency choose one H73 - Department of Vocational Rehabilitation J02 - Department of Health and Human Services J04 - Department of Health and Environmental Control J12 - Department of Mental Health J16 - Department of Disabilities and Special Needs N04 - Department of Corrections N12 - Department of Juvenile Justice Employee Name First Last Social Security Number -- Class / Slot Location of Field Placement (name of agency) # of Hours in Field Placement Amount Paid to Employee for Practicum Healthcare Degree Pursuing C. Loan Repayment Agency choose one H73 - Department of Vocational Rehabilitation J02 - Department of Health and Human Services J04 - Department of Health and Environmental Control J12 - Department of Mental Health J16 - Department of Disabilities and Special Needs N04 - Department of Corrections N12 - Department of Juvenile Justice Employee Name First Last Social Security Number -- Class / Slot Critical Need (rural area, high turnover, recruiting difficulty, other explain) Amount to be Paid to Employee over Five-Year Period Healthcare Degree Approved for Loan Repayment D. Tuition Assistance Agency choose one H73 - Department of Vocational Rehabilitation J02 - Department of Health and Human Services J04 - Department of Health and Environmental Control J12 - Department of Mental Health J16 - Department of Disabilities and Special Needs N04 - Department of Corrections N12 - Department of Juvenile Justice Employee Name First Last Social Security Number -- Is Employee Probationary? Yes No Class / Slot # of Credit Hours / Semester Amount Paid During Fiscal Year Healthcare Degree Approved for Tuition Assistance Reimbursement or Prepayment? Which is Employee Receiving, Reimbursement or Pre-Payment? choose one Reimbursement Pre-Payment
A. Leave for Class
B. Paid Practicum
C. Loan Repayment
D. Tuition Assistance
Your form will be submitted to the SC Office of Human Resources