Vice President for Human Resources

Forms

Some of the forms listed below were created using Microsoft Word or Microsoft Excel.

See the Business Services Forms Web page for more forms.

Benefit Forms

Medical Forms:

• Tobacco User Certification Form (PDF)
• CIGNA Medical Claim Form
• CIGNA Mail Order Form (Choice Fund Plan Only)
• CIGNA Rx Claim Form (Choice Fund Plan Only)
• Medco Mail Order Form (Co-pay and Incentive Plan)
• Medco Rx Claim Form (Co-pay and Incentive Plan)

Flexible Spending Account (FSA) Forms:

• PayFlex FSA Claim Form
• CIGNA Dependent Care FSA Claim Form
• CIGNA Health Care FSA Claim Form
• CIGNA FSA Debit Card Validation Form

Health Savings Account (HSA) Forms:

• CIGNA HSA deposit slip

Retirement Forms:

• Application for Waiver of Three-Year Waiting Period 403(b) Defined Contribution Base Retirement Plan Form
• Appendix B Supplemental Release Agreement

Other Benefit Forms:

• Change in Family Status Form (Grad Staff Medical) This form is for Graduate Staff Medical only
• Dependent Eligibility Verification Matrix
• Disabled Child Physician's Form
• Group Life and AD&D Insurance Enrollment
• Life Insurance Beneficiary Designation and Change Request
• VSP Out-of-Network Claim Form
• Vision Requirements Questionnaire
• Worker's Compensation Reporting Form
• Worker's Compensation Witness Report Form

Performance Management Forms

Currently under development. Please check back after April 1, 2012.

Employment and Compensation Forms

• Staff Position Posting Form only
• Temporary Position Request
• Employment Eligibility Verification I-9
• Flex Schedule Form
• Exception to Nonexempt Pay Scales Request Form

Org Management Forms:

• Business Processes and all Forms
• Interdepartmental Position Guidelines
• Forms only
  • Continuing Lecturer Position Request
  • Faculty Position Request
  • Fellowship Position Request
  • Grouped Position Request
  • Staff Position Description
  • Supervision Roster
  • HR Organizational Unit Creation/Maintenance

Family and Medical Leave Act (FMLA) Forms

• Family Medical Leave Act Request and Notice
• FMLA Employee Checklist
• FMLA Medical Certification Form
• FMLA Certification Of Qualifying Exigency For Military Family Leave
• FMLA Certification for Serious Injury or Illness of Covered Servicemember
• Record of FMLA Leave for Monthly-Paid Employees, Form 33FMLA
• OnePurdue Leaves Reference Grid

Other Leave Forms

• Form 33ABSENCE (Excel)
• Form 33ABSENCE (PDF)
• Form 33Other (Excel)
• Request and Leave Action form (RLA) for Sabbatical, Research/Instructional/Engagement Travel, Outside Activity Leave or Change in Duty Station (PDF)
• Request and Leave Action form (RLA) for Sabbatical, Research/Instructional/Engagement Travel, Outside Activity Leave or Change in Duty Station (Excel)
• Leave Action Form (Excel)
• OnePurdue Leaves Reference Grid