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: EZ Claim Form for Incentive PPO and Purdue 500 PHCS Provider Referral Letter   Anthem Claim Form Anthem Mail Order Form Medco Mail order form Flexible Spending Account (FSA) Forms: Dependent Care FSA Claim Form (PDF) Dependent Care FSA Claim Form (Excel) Health Care FSA Claim Form (PDF) Health Care FSA Claim Form (Excel) FSA Direct Deposit Authorization Auto Reimbursement Waiver/Election Form Retirement Forms: Salary Reduction Agreement Form - 403(b) Plan and 457(b) Plan Request for Estimate of Benefits Application for Waiver of TIAA/CREF Three-Year Waiting Period Other Benefit Forms: Change in Family Status Form (medical) This effects core benefits only and does not effect voluntary benefits such as dental. Change in Family Status Form (dental) Coverage will start on the first of the month following the effective date of the change.   Prudential Short Form Health Statement Worker's Compensation First Report of Injury Form  Worker's Compensation Witness Report Form Disabled Child Physician's Form VSP Out-of-Network Claim Form Performance Management Forms (Word documents) Performance Planning Worksheet  Performance Coaching and Feedback Worksheet  Performance Summary  Development and Career Planning Worksheet  Feedback for My Supervisor Worksheet

Employee Information Forms (Form 13) About the Employee Information Forms Form 13S Short Form for New Employees with ESS Form 13L Long Form for New Employees without ESS and Updates without ESS Employment and Compensation Forms  Staff Position Posting Form only Temporary Position Request Employment Eligibility Verification I-9 Flex Schedule Form Request for Exception to Nonexempt Pay Scales OnePurdue Forms effective dates: June 11 - 15 Release 2 HR Data Validation Corrections Worksheet 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 Personnel Action Forms: Personnel Action (PA) Form Fellowship Action (FA) Form Personnel Change (PC) Form Required documents for Payroll processing Student Hiring Form - optional Contract Form 19 Contract Form 19L Non Renewal of Contract Notice Form 19E Additional Pay Request Form Cost Override form Family and Medical Leave Act (FMLA) Forms FMLA Request and Notice FMLA Medical Certification Form Employee Checklist HRS Form 33FMLA FMLA Procedures for Supervisors, Business Offices, and Human Resource Services OnePurdue Leaves Reference Grid Other Leave Forms Form 33ABSENCE (PDF) Form 33ABSENCE (Excel) Form 33F (PDF) Form 33F (Excel) Leave Action Form (Excel) OnePurdue Leaves Reference Grid