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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

Retiree Enrollment Form - Over 65 (pdf)
Retiree Enrollment Form - Under 65 (pdf)

EMERGENCY LOAN APPLICATION

Emergency Loan Application (pdf)

FLEXIBLE SPENDING

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

HEALTH CARE 

Waiver Forms/Retiree Enrollment:

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)

 

LIFE INSURANCE

The Hartford Evidence of Insurability Form (pdf)
The Hartford Beneficiary Designation Form (pdf)

NEW HIRE FORMS

Benefits:

Social Security Number Exception Request Form (pdf)
MyCafeteria Plan Direct Deposit Form (pdf)
TIAA New Hire Flyer (pdf)

Employment:

Background Check Verification Process
Direct Deposit Form (pdf)
Employee Data Sheet Packet - Staff (pdf)
Employee Data Sheet Packet - Faculty (pdf)
Federal Withholding Instructions (W-4) (pdf)
Instructions for Completing the Electronic I-9 (Employment Eligibility Verification) (pdf)
**To schedule an appointment to complete an I-9, you may use the following online calendar tools or call our office at 937-229-2541 for an appointment.
Online I-9 Google Calendar Link - Instructions to create I-9 appointment (pdf)
I-9 Appointment Request Form (for those without a google account)
State of Ohio Withholding Certificate (IT4) (pdf) - Employees working outside of Ohio, visit your state's revenue site to download and complete the appropriate State Withholding form.

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

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

NON-EMPLOYEE FORMS

Background Verification 
Non-Employee Agreement & Information Sheet
Visitor Personnel Action Form (PAF) (xls)
Visitor Technology Access Request (pdf) - applicable to UDRI non-employees only

OUTSIDE EMPLOYMENT & ADDITIONAL SERVICES

Outside Employment & Additional Services Approval Form (pdf)

PERSONAL DATA CHANGE

Request for Change of Personal Data Form (pdf)

POSITION CLASSIFICATION JUSTIFICATION

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

PROMOTION REVIEW

Promotion Review Form (pdf)

SEPARATION FORMS

Employee Separation Checklist (pdf)
Fifth Third HSA Post-Separation Fee Structure (pdf)
Separation Q&A (pdf)
Supervisor Separation Checklist (pdf)
Voluntary Resignation Form (tdx)

 

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)

CONTACT

Human Resources

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