Contents

• Leave Forms
  • Vacation/Leave
• Benefit Forms
  • Adoption
  • Benefit Continuation
  • Disability Insurance
  • Domestic Partnership
  • Family and Medical Leave (FML)
  • Flexible Spending Accounts (FSA)
  • GlobalCare
  • Graduate Associates
  • HIPAA Privacy Practices
  • Life Insurance
  • Medical Benefits
  • Retirement
  • Returning Retirees
  • Sponsored Dependents
  • Tuition Assistance
  • Workers' Compensation
• Employment Forms
  • Applications
  • Background Check
  • Hiring
  • Other
• Payroll/HRIS Forms
  • Change of Personal Information
  • Direct Deposit
  • HR System Adjustments
  • Payroll Processing
  • Savings Programs
  • Taxes
• Training and Development Forms
  • Enrollment
  • Performance Management
• Other Forms
  • Classification and Compensation
  • Immigration
  • Mediation
  • Sexual Harassment & Discrimination
  • Special Events
  • Veterans Affairs
  • Whistleblower
  • Workplace Violence

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Forms

The following are many of the forms required by the Office of Human Resources for different programs and services available to Ohio State University employees. For more information about the forms and their use, contact the Office of Human Resources Customer Service Center.

Leave Forms

Vacation/Leave

• Application for Leave  
• Vacation Donation Donor Form  
• Vacation Donation Recipient Form

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Benefit Forms

Adoption

• Adoption Assistance Reimbursement Request Form

Benefit Continuation

• Continued Health Plan Eligibility for Over Age Dependents
• COBRA Election Form (includes survivor continuation)
• Benefit Continuation Due to Unpaid Leave of Absence
• Benefit Continuation During Military Leave Election Form
• Long-Term Disability (LTD) Conversion Form

Disability Insurance

• Short-Term Disability (STD) Enrollment Form
• Short-Term Disability (STD) Evidence of Insurability (EOI)
• Short-Term Disability (STD) Claim, Authorization – UnumProvident
• Short-Term Disability (STD) Claim, Authorization – University
• Short-Term Disability (STD) Claim, Authorization – Hartford
• Long-Term Disability (LTD) Conversion Form
• Fitness for Duty Request Form
• Employee Accident Report

Domestic Partnership

• Affidavit of Same-Sex Domestic Partnership for Health and Life Insurance
• Affidavit of Domestic Partnership (for sick leave and FML)
• Affidavit of Termination of Same-Sex Domestic Partnership and/or Sponsored Dependency Status (includes opposite-sex domestic partners)

Family and Medical Leave (FML)

• FML Medical Certification of Health Care Provider for Employee’s Serious Health Condition
• FML Medical Certification of Health Care Provider for Family Member’s Serious Health Condition
• FML Notice of Eligibility and Rights & Responsibilities
• FML Designation Notice
• FML
• FML Certification of Qualifying Exigency for Military
• Family and Medical Leave Act Poster

Flexible Spending Accounts (FSA)

• FSA Dependent Care Request for Reimbursement
• FSA Health Care Request for Reimbursement
• FSA Election Form

GlobalCare

• GlobalCare Employee Enrollment Form for University-Sponsored Business Travel
• GlobalCare Dependent Enrollment Form for University-Sponsored Business Travel

Graduate Associates

• Prime Care Advantage Health Plan Enrollment Form
• University Insurance Premium Contribution Waiver

Student Retirement

• Student Retirement Election Form (includes GAAs, GRAs, and GTAs)
• Request for Optional Exemption as a Student (OPERS)
• Form SSA-1945: Statement Concerning Your Employment in a Job Not Covered by Social Security
• Payroll Deduction of Other Fees for Graduate Associates

HIPAA Privacy Practices

• Member Request to Restrict Uses and Disclosures of Personal Health Information
• Privacy Complaint Form
• Confidential Communication Request Form
• Authorization To Release Medical Records
• Amendment Request Form
• Access Request Form
• Accounting Request Form

Life Insurance

Group Term Life Insurance

• Group Term Life Insurance Beneficiary Designation
• Group Term Life Insurance Change of Name
• Group Term Life Insurance Change of Beneficiary
• Group Term Life Insurance Waiver of Entitlement

Dependent Group Life Insurance

• Dependent Group Life Insurance (DGLI) Enrollment form
• Dependent Group Life Insurance (DGLI) Evidence of Insurability

Voluntary Group Term Life Insurance

• Voluntary Group Term Life Insurance (VGTLI) Application

Retiree Life Insurance Information

• Post-Retirement Life Insurance Change of Beneficiary
• Retiree Group Term Life Insurance Change of Beneficiary
• Retiree Group Term Life Insurance Waiver of Entitlement

Medical Benefits

• Health Plan Election Form
• Prescription Drug Reimbursement Form
• Prescription Drug Home Delivery Form
• NGS Health Insurance Claim Form
• NGS Claim Form for Weight Watchers
• NGS Claim Form for Hospital Based/Physician Directed Weight Loss
• NGS Request for Additional Coverage Information
• NGS Request for Dependent Verification
• Temporary Out-of-Area Election Form

Retirement

• Retirement Program Election Form
• Form SSA-1945: Statement Concerning Your Employment in a Job Not Covered by Social Security
• ARP Vendor Change Form
• OPERS Traditional Pension Plan Refund Application (notarization required)
• Supplemental Retirement Account Salary Reduction Agreement
• Request for Prior Service Credit Certification
• Student Retirement Election Form (includes GAAs, GRAs, and GTAs)
• Request for Optional Exemption as a Student (OPERS)
• STRS New Hire Notification for University and College Employers

Returning Retirees

• Retirement Program Election Form for Reemployed Retirees
• Notice of Re-employment of a OPERS Retiree
• STRS Notice of Reemployment as a Teacher of a Retiree

Sponsored Dependents

• Health Election Form (includes sponsored dependents and opposite-sex domestic partners)
• Affidavit of Sponsored Dependency For Health Care Coverage (includes opposite-sex domestic partners)
• Affidavit of Termination of Same-Sex Domestic Partnership and/or Sponsored Dependency (includes opposite-sex domestic partners)

Tuition Assistance

• Dependent Tuition Assistance Application
• Request for Course Enrollment During Regularly Scheduled Work Hours
• Program Exception Request
• Graduate Education Program Assistance Waiver

Workers' Compensation

• Employee Accident Report

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Employment Forms

Applications

• Online Application
• Equal Employment Identification Form

Background Check

• Disclosure, Authorization, and Release Form
• Sample Letters to Final Candidate of Negative Information on Background Check
• Sample Letters to Final Candidate of Negative Information on Background Check
• Summary of Your Rights Under the Fair Credit Reporting Act

Hiring

• Offer Letter Samples Downloadable, customizable letters for use in the hiring process
• Employment Eligibility Verification (I-9) Form [ I-9 Handbook for Employers]
• Ohio Ethics Law Acknowledgement Form [ Ohio Ethics Law and Related Statutes ]
• DMA Form [ Terrorist Exclusion List (TEL) | DMA Guidelines | DMA Frequently Asked Questions | DMA Letter to Affected Employees ]

Other

• DMA Letter to Affected Employees (Sample letter to be given to employees hired after April 14, 2006 who have not yet completed a DMA form)
• Employment Verification
• Request for Reduction in Workforce
• Employment Dispute Form
• Student Employment Form (departments may have their own versions of this form)
• Staff Extramural Activity Reporting Form
• Editable Full Time Equivalency (FTE) Change Letters (for department HR contacts to use with their customers)

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Payroll/HRIS Forms

Change of Personal Information

• Change of Record
  For corrections or changes to Social Security Number, Name, or Date of Birth

Direct Deposit 

• Direct Deposit Enrollment Form
  For direct deposit of student financial aid, contact Fees and Deposits.

HR System Adjustments

• Request for Retroactive Change in Job Data
• Hire Data Worksheet
• Request for Off-Cycle Check NOW ONLINE!
• Exception User Request

Payroll Processing

• Timesheet (departments may have their own versions of this form)
• Application for Duplicate Payroll Check
• Part-Time Exempt Employee Time Record
• Internal Supplemental Compensation Approval Form
• Relocation Check Request Form
• Relocation Request Form
• Payroll Processing Biweekly Checklist
• Payroll Processing Monthly Checklist

Savings Programs

• Credit Union of Ohio Authorization for Payroll Deduction
• Credit Union of Ohio Membership Card application
• Savings Bond Authorization for Enrollment/Payroll Deduction
• College Advantage Savings Program Payroll Deduction Authorization Form
• College Advantage Savings Program Application

Taxes

• W-4 Employee's Withholding Allowance Certificate
• W-5 Earned Income Credit (EIC) Advance Payment Certificate
• Form IT 4 NR Employee Statement of Reciprocity
• Form W-9 Request for Taxpayer Identification Number and Certification
• Form 1040NR US Income Tax Return for Nonresident Aliens with dependents
• Form 1040NR-EZ US Income Tax Return for Nonresident Aliens without dependents

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Training and Development Forms

Enrollment

• STEP Workshop Enrollment Form

Performance Management

• Planning Worksheet
• Coaching Worksheet
• Self Evaluation
• Performance Review

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Other Forms

Classification and Compensation

• Salary Adjustment and Reclassification

Immigration

• Alien's Change of Address Card (Form AR-11)
• Employment Verification Information Sheet/Form

Mediation

• Agreement to Mediate
• Settlement Agreement

Sexual Harassment & Discrimination

• Discrimination/Harassment Complaint Form

Special Events

• Staff Career Development Grant Application

Veterans Affairs

• Veteran Self-Identification Form
• Skurow Student Veteran Award Application Form
• Benefit Continuation During Military Leave of Absence

Whistleblower

• Whistleblower Report Form

Workplace Violence

• Incident Report Form for Workplace Violence

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