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Human Resource Forms


ADOPTION REIMBURSEMENT

Adoption Reimbursement Form (doc) 

CONTINUING EDUCATION FUNDS - Center for Leadership

Center for Leadership Programs
Executive Program Form (pdf)

DENTAL CARE

Active Employee & GA Enrollment Form (pdf)
Retiree Enrollment Form - Over 65 (pdf)
Retiree Enrollment Form - Under 65 (pdf)

EMERGENCY LOAN APPLICATION

Emergency Loan Application (pdf)

FLEXIBLE SPENDING

Benefits Enrollment Form (pdf)
Direct Deposit Enrollment Form (pdf) 
Medical & Dependent Care Claim Form (pdf) 
Orthodontic Claim Form (pdf) 

HEALTH CARE 

Enrollment Forms/Waiver Forms:

Active Employee & GA Benefits Enrollment Form (pdf)
Affidavit of Spousal Eligibility for Health Care (pdf)
Affidavit of Non-Tobacco Use (pdf)
Retiree Enrollment Form - Over 65 (pdf)
Retiree Enrollment Form - Under 65 (pdf)

Claim Forms:

Anthem Medical Claim (pdf)
Medical Claim Form for Claims Incurred Internationally (pdf)

LEAVE/SABBATICAL FORMS

FMLA/Leave/Sabbatical Form (doc)
Leave and Workers Compensation Process (pdf)

LIFE INSURANCE

The Hartford Life Insurance Form (pdf)
The Hartford Evidence of Insurability Form (pdf)
The Hartford Beneficiary Designation Form (pdf)
Waiver of Entitlement to Group Term Life Insurance (in Excess of $50,000) (doc)

NEW HIRE FORMS

Benefits:

Benefit Eligibility Form (pdf)
Waiver of Entitlement to Group Term Life Insurance (in Excess of $50,000) (doc)
Benefits Enrollment Form (pdf)
Social Security Number Exception Request Form (pdf)
The Hartford Life Insurance Form (pdf)
MyCafeteria Plan Direct Deposit Form (pdf)
TIAA New Hire Flyer (pdf)

Employment:

Background Check Verification Process (pdf)
Direct Deposit Form (doc)
Employee Data Sheet - Staff (doc)
Employee Data Sheet - Faculty (doc)
Federal Withholding Instructions (W-4) (pdf)
Instructions for Completing the Electronic I-9 (Employment Eligibility Verification) (pdf)
State of Ohio Withholding Certificate (IT4) (pdf)
Voluntary Self-Identification of Disability (Post Hire) (pdf)
Voluntary Self-Identification of Protected Veteran Status (Post Hire) (pdf) 
W-2 Electronic Consent (pdf)

* In addition to the above forms, Research Institute employees must also complete the following:

New Hire Forms (pdf) Return completed form to HR
Conflict of Interest Disclosure Form (pdf) Return completed form to supervisor

NON-EMPLOYEE FORMS

Non-Employee Agreement (pdf)
Non-Employee Information Sheet (pdf)
Background Verification (pdf)
Visitor Personal Action Form (PAF) (xls)

OUTSIDE EMPLOYMENT & ADDITIONAL SERVICES

Outside Employment & Additional Services Approval Form (pdf)

PAYROLL FORMS

Direct Deposit Form (doc)
Faculty & Staff Giving Form
Paper Leave Report for Exempt Employees (xls)
Paper Time Sheet for Nonexempt Benefit Eligible Employees (xls) 
Paper Time Sheet for Nonexempt Nonbenefit Eligible Employees & Student Employees (xls)
Unpaid Personal Leave Form for Exempt Employees (doc)

PERFORMANCE APPRAISAL FORMS

General Competency Option (doc)
Goals Based Option - Version 1 (doc)
Goals Based Option - Version 2 (doc)
Mission Based Competency Option (doc)
Narrative Option (doc)

PERSONAL DATA CHANGE

Request for Change of Personal Data Form (pdf)

PERSONNEL ACTION FORM

Personnel Action Form (Post 7/1/19 PAF) (xlsx)

POSITION CLASSIFICATION JUSTIFICATION

Position Classification Justification Form (doc)
Position Description Guidelines (pdf)

PROMOTION REVIEW

Promotion Review Form (pdf)

SEPARATION FORMS

Employee Separation Checklist (doc)
Separation Q&A (pdf)
Fifth Third HSA Post-Separation Fee Structure (pdf)

TAX FORMS

Federal Withholding Instructions (W-4) (pdf)
State of Ohio Withholding Certificate (IT-4) (pdf)
    Employees working outside of Ohio, visit your state's revenue site to download and complete the appropriate State Withholding form.

TUITION EXCHANGE

Tuition Exchange Application (pdf)

TUITION REMISSION

Tuition Assistance Application for Child or Spouse (pdf)

VISION PLAN

EyeMed Out-of-Network Claim Form (pdf)
EyeMed Provider Nomination Form (pdf)

WORKERS COMPENSATION

Leave and Workers Compensation Process (pdf)
Workers Compensation Form Instructions(pdf)
Workers Compensation Form Browser Help (pdf)
UD Employee Injury and Illness Report (pdf)
UD Employee Injury and Illness Supervisor Report (pdf)
UD Incident Witness Report (pdf)

CONTACT

Human Resources

St. Mary's Hall
300 College Park
Dayton, Ohio 45469 - 1649
937-229-2541
Email