Human Resources Forms

Forms listed below are grouped by department and listed in alphabetical order by title. Some forms require Adobe Acrobat Reader for viewing. Acrobat Reader is available free of charge from Adobe Systems.

Benefits | Payroll | Employment | Compensation Management | Employee Relations | Immunization

Benefits

• Accidental Death & Dismemberment Enrollment
• Additional Benefits Enrollment
• Authorization for Release of Protected Health Information
• Beneficiary Change Form - Life Insurance and AD&D
• Benefit Cancellation Request
• Benefits Enrollment Information
• BlueCross BlueShield Advantage Plan
• BlueCross BlueShield Comprehensive Plan
• BlueCross BlueShield Medical Claim
• Certification of Dual Coverage for Coordination of Prescription Benefits
• Certification of Hardship Withdrawal from Elective 403(b) Contributions
• Certification of Hardship Withdrawal from Elective 457(b) Contributions
• Coordination of Prescription Benefits Claim
• Dental Coverage Summary Plan Description
• Employer's First Report of Injury or Illness - E1 Form 122
• FMLA - Certification of Health Care Provider for Employee
• FMLA - Certification of Health Care Provider for Dependent
• FMLA - Frequently Asked Questions
• FMLA - Hospital FMLA
• FMLA - Intermittent Tracking
• FMLA - Release of Information (Family Member)
• FMLA - Release of Information (Self)
• FMLA - Request for Family and Medical Leave of Absence
• FSA Change
• FSA Enrollment
• FSA Reenrollment
• FSA Reimbursement Request Form (ASI Flex)
• Health Care and Dental Coverage Enrollment - Campus
• Health Care and Dental Coverage Enrollment - UUHC and HPP Benefit Program
• Health Care Coverage Change
• Health Care Student Verification
• Health Plan Request for Reimbursement - Blue Cross Blue Shield/ValueCare
• Health Plan Request for Reimbursement - University Health Care Plus
• Health Savings Account Enroll or Change Form
• High Deductible Health Plan (HDHP) and HSA Enrollment Form - Full Time Employees
• High Deductible Health Plan (HDHP) and HSA Enrollment Form - Part Time Employees
• Hyatt Legal Plans Certificate of Coverage
• Hyatt Legal Plan Covered Legal Services
• Hyatt Legal Plan - New Hires
• Life Insurance - Personal Health Application
• Life Insurance Enrollment
• Long Term Disability - Hospitals/Clinics Physician Option Booklet
• Long Term Disability - Late Enrollment (paper form)
• Long Term Disability - Late Enrollment (online form)
• LTC - CNA Employee/Spouse Enrollment - Short Form
• LTC - CNA Enrollment
• LTC - CNA Retiree/Parent/Grandparent Enrollment - Long Form
• Prescription Drug Coverage Information/Forms
• Long Term and Short Term Disability (New Hires) - Campus
• Long Term and Short Term Disability (New Hires) - Hospital Clinical Faculty/Optometrists
• Long Term and Short Term Disability (New Hires) - SOM
• Long Term and Short Term Disability (New Hires) - UUHC
• Opt Out Notice
• Medicare D
• Military Leave of Absence
• Extended Sick Leave Benefits
• Request for Non-Health Related Leave of Absence
• Reinstatement of Prior Service
• 401(a) Retirement Plan Investment Provider Change
• Salary Reduction Agreement - 403(b) Supplemental Retirement Plan
• Salary Reduction Agreement - 457(b) Supplemental Retirement Plan
• Separating from the University
• Summary Comparison of Health Plan Medical and Dental Options
• Summary Comparison of Health Plan Medical and Dental Options - UUHC
• Travel Assistance Brochure - AD&D
• Travel Assistance Brochure - Life Insurance
• Tuition Reduction, Application for
• U Health Care Plus Advantage Plan
• U Health Care Plus Comprehensive Plan
• Vacation Donation

Payroll

• Academic Contract Worksheet
• Accruals Adjustments, Vacation
• Cell Phone Cancellation
• Cell Phone - Policy (Hospital)
• Cell Phone Reimbursement
• Charge Nurse Kronos Access Request
• Direct Deposit Authorization
  Due By 3:00 PM, 2 business days before Pay Period End.
• Direct Deposit Cancellation
• Early Retirement Incentive
• ERIP Auxiliary Earnings
• Kronos Supervisor Access Request
• Kronos Late Sign off
• Missed Punch/Exception
• Paper Timesheet(Campus Hourly)
• Paper Timesheet for Special Check Request
• Paystub Copy Request or Self Service Online
• Premium Holiday Hours and OT Compensation (Hospital)
• Retroactive Adjustment (Hospital)
• Reallocations
• Special Check (Hospital)
Stale Date Request
• Stop Payment

Additional Earnings

• Additional Compensation
• Additional Compensation for Teaching
• Bonus Pay
• Clinical Income Payment
• Payment of Exempt Clinical Shift
• Prize and Awards

Employment

• Affiliate/Non-Employee
• Company Consulting Services Agreement
• Drug Screening - Schedule a pre-employment drug screening
• EduCAT Reporter Request
• Employment Verification Request (Past and Present employee use only)
• Evaluation (sample process)
• Evaluation (sample short process)
• Evaluation (SOM Employees)
• Exit Survey Checklist
• Exit Survey Packet
• Hiring Process & Forms/Open Position Information
• I-9 Employment Eligibility Verification
• IRS Forms and Instructions
• Offer Letter, Benefited Staff
• Offer Letter, Non-Benefited Staff
• Non-selection Letter
• Non-Staff and Volunteer Photo ID Authorization
• Non-Staff Workforce & Volunteer ID Badge Information Data Sheet
• Patient Care Acknowledgment
• Reference Check, Sample Document
• Veterans' Preference Addendum

Compensation Management

• Compensatory Time Agreement
• Complete list of Information Technology jobs and descriptions
• Job Analysis Questionnaire
• Job Analysis Questionnaire-Supervisor Review
• Leadworker Employee Questionnaire
• Market Value Report Guidelines 2007
• New Position Classification Instructions
• Reclassification Instructions

Employee Relations

• Acceptance of Resignation
• Request to Examine/Copy Data From Personnel File
• Staff Appeal

Immunization

• University Hospital and School of Medicine Patient Care Staff Only.