Forms by Type

Pay-Related

The AD Pay Forms (West Lafayette, Fort Wayne and Northwest campuses) are accessible via DocuSign in the Overload and AD Pay Forms folder and are used to process awards, extra duty, bravo and other recurring or nonrecurring payments. Follow the DocuSign - Sending a Template quick reference guide to learn how to access the appropriate template, route for approval and monitor status of the form.

• Multiple Awards Upload Form (when 5 or more employees are receiving an award)

The Overload Payment Forms (West Lafayette, Fort Wayne and Northwest campuses) are linked in processes for extra compensation. The following are DocuSign forms that will route for approval.

• Overload and AD Pay Forms folder

Overpayment Repayment Agreement Form

The agreement form is initiated by the WL Payroll Center or PNW/PFW Payroll area (Human Resources) and routed to employee for signature. The form is uploaded to the OverPayment Process SharePoint site for payroll to process. The form acknowledges the repayment agreement. Payroll Centers will utilize the email template to notify employee of the overpayment and acknowledge they will receive an email via DocuSign to sign the form. Employees can follow the Employee Overpayment Repayment Agreement Quick Reference to review and sign form. 

Please access DocuSign, search the Shared Folders for Overpayment under Templates, in order to initiate the Agreement Form. Follow the DocuSign - Sending a Template quick reference guide to learn how to access the appropriate template, route for approval and monitor status of the form.

Off-Cycle Payment Request

An Off-cycle Payroll will generate payments for employees who did not receive payments to which they were entitled during the regular payroll run and the employee cannot be reasonably expected to wait until the next regular payroll run.  Payroll or Employment Centers use this paper form.

Off-Cycle Payment Request Form with Instructions

Tech Allowance

Form is linked in the process for requesting, editing or deleting tech allowances. The DocuSign form routes for supervisor and fiscal approval.

• Tech Allowance Request Form for ITaP Staff
• Tech Allowance Request Form for Non-ITaP Staff

Cost Override

The DocuSign form routes for supervisor and fiscal approval.

• Cost Override Form

Contract Extension or Non Renewal

These forms are used to extend contracts or notice of non-renewal.  Initiate the Form 19, 19L or 19E through DocuSign by following the DocuSign - Sending a Template quick reference guide to learn how to access the appropriate template, route for approval and monitor status of the form.

The forms are located in DocuSign within a shared folder called Contract Extension or Non Renewal.

• Form 19 – Faculty Extension
• Form 19L – Lecturer Appointment or Form 19L – Lecturer New Appointment (regional campuses only)
• Form 19E – Notice of Non-Renewal of Contract

Change in Location of Duty

A Change in Duty form is required for completion when an employee’s normal work duties will be performed for more than 22 days away from their hiring campus. The change in location is not required to complete the work but rather the same work can be completed from a different location. The  departmental business office, payroll center or administrator initiates the form in DocuSign. Follow the Quick Reference Guide or Process to learn how to complete the form.

Additional information is provided on the Global Support website, Change in Duty Station Request.

Please initiate the Change in Location of Duty Form through DocuSign by following the DocuSign - Sending a Template quick reference guide to learn how to access the appropriate template, route for approval and monitor status of the form.

The form is located in DocuSign within a shared folder called Change of Duty.

Non-Paid Employees that need SAP/SF Access

The Non-Employment Appointment form is used for non-paid, usually short-term positions, that need access to SuccessFactors or SAP systems. If access is not needed, the Request for Privileges may be the best option.

• West Lafayette -  Non-Employment Appointment Form
• Fort Wayne -  Non-Employment Appointment Hire Form 
• Northwest -  Non-Employment Appointment Form

Social Security Number Request

Employment or Payroll center can initiate the Social Security Number Request form for F-1/J-I student workers hired for their area(s). The student’s last and first name, date of birth, start date, job information, hours per week, and PUID are needed. The form routes to International Students and Scholars (ISS).

• F-1/J-1 Social Security Number Request

Benefit-Related

Dental

• Delta Dental Claim Form

Medical and Prescription

• Anthem Medical Claim Form
• Anthem Continuation of Care Form  
• Anthem Continuation of Insurance for Disabled Children Form
• CVS Caremark Prescription Claim Form
• CVS Caremark Prescription Mail Order Form
• Tobacco User Certification Form (For those who become 12-months tobacco-free midyear)

Working Spouse Premium

• Working Spouse Premium Waiver Form (Note: For spouses who are self-employed and need to provide a waiver form, the form can be signed by a representative of their company (i.e. HR) or the spouse can sign himself or herself. The employee still signs to certify.) More information is available on the Working Spouse Premium website.

  Information on spousal coverage for 2021 can be found on the dedicated open enrollment website.

Healthcare Spending and Savings Accounts

HSA Bank

• (FSA/HRA) HSA Bank Reimbursement Account Claim Form 
• Dependent Care FSA Recurring Claim Form
• (FSA/HRA) Letter of Medical Necessity Form
• (HSA) Beneficiary Designation Form
• (HSA) Excess Contribution Removal Form
• (HSA) Trustee Transfer Form

Payflex (2018)

Those who chose to set up an online account with PayFlex in 2018 can access the following resources:

• HSA Bank Customer Service at 800-357-6246 or askus@hsabank.com,
• HSA website is http://www.hsabank.com/hsabank/homepage.
• HSA Bank Member Website Guide

Family and Medical Leave Act (FMLA)

• Request and Notice
• Medical Certification Form
• Certification Of Qualifying Exigency For Military Family Leave
• Certification for Serious Injury or Illness of Covered Service member

Retirement

• Application for Waiver of Three-Year Waiting Period 403(b) Defined Contribution Base Retirement Plan Form
• Voluntary Partial Retirement:  VPR DocuSign Request Form and Completing VPR Request Form-QRG

Vision

• VSP Out-of-Network Claim Form

Worker's Compensation

• Worker's Compensation Reporting Form
• Worker's Compensation Witness Report Form

Employment-Related

Employment-Related Forms

• Flex Schedule Form
• Exception to Nonexempt Pay Scales Request Form
• Reasonable Accommodation Request (ADA) Form
  • Fitness for Duty Employee Guidance.
• Alternative Dispute Resolution (ADR) Form

Data/Access-Related

HR Data

• HR Data Team Request Form (Mass email lists, HR Data requests)
• My HR Data Team Requests (Your current list of HR Data requests)

Request for Privileges

• Visit Secure Purdue for all identity and access information.
• Request for Privileges Web Application
• Guidelines for a Request for Privileges
• Requestor Instructions
• Approver Instructions
• Auditor Instructions
• How to add or delete an approver
• Frequently Asked Questions

Purdue Person Search (PPS)

• PPS Application
• PPS SSN Exception Form
• Purdue Person Search Access Form

Position Descriptions

• The Organizational Structures and Positions web page links to Position Description information (templates), Position Title Standards, How to Create Positions and more.

Approval Process for Promotion within Job

• HR Promotion Review Template
• Staff Promotion Guidelines