Aerial photograph of the Immaculate Conception Chapel

HR Forms

Adoption Reimbursement
Banner Forms
Bombeck Family Learning Center Discount
Continuing Education
Dental Care
Emergency Loan Application
Flexible Spending
Health Care
Leave/Sabbatical Forms
Life Insurance
Long Term Care
New Hire Forms
Non-Employee Forms
Outside Employment & Additional Services
Payroll Forms
Performance Appraisal Forms
Personal Data Change Form
Personnel Action Form (PAF)
Position Classification Justification Forms
Retirement Forms
Separation Forms
Tax Forms
Tuition Exchange 
Tuition Remission/Assistance
Vision Plan
Wellness Forms
Worker's Compensation Claim Forms


ADOPTION REIMBURSEMENT

Adoption Reimbursement Form (doc) 

BANNER FORMS

Paper Leave Report for Exempt Employees (xls)
Paper Time Sheet for Benefit Eligible Nonexempt Employees (xls) 
Paper Time Sheet for Part Time Nonbenefit Eligible Employees and Student Employees (xls)
Unpaid Personal Leave Form for Exempt Employees (doc)

BOMBECK FAMILY LEARNING CENTER

Bombeck Family Learning Center Discount Form (pdf)

CONTINUING EDUCATION

Continuing Education Funds - General Form (pdf)
Continuing Education Funds - Center for Leadership Executive Program (pdf)
Continuing Education Funds - Center for Leadership Emerging Leader Program (pdf)
Continuing Education Funds - Supervisory Leadership Certificate Program (pdf)

DENTAL CARE

Active Employee & GA Benefits Enrollment Form (pdf) - Replaces Superior Dental Enrollment form & Dental Waiver form.
Retiree Benefits Enrollment Form (pdf) - Replaces Superior Dental Enrollment form & Dental Waiver form.

EMERGENCY LOAN APPLICATION

Emergency Loan Application (pdf)

FLEXIBLE SPENDING

Benefits Enrollment Form (pdf) - Replaces FSA Enrollment form 
Change 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) - Replaces Anthem Healthcare Enrollment/Change form, Pretax Treatment of Health & Dental Premiums form, Employee Healthcare Waiver form, & Graduate Assistant Healthcare Waiver form.
Retiree Benefits Enrollment Form (pdf) - Replaces Anthem Healthcare Enrollment/Change form & Retiree Healthcare Waiver form.

Claim Forms

Anthem Medical Claim (pdf)
Medical Claim Form for Claims Incurred Internationally (pdf)
Express Scripts Prescription Claim (pdf)

Prescription Forms 

Express Scripts Mail Order Form (PDF) - for Active Employees, GA's, and Under 65 Retirees 1-866-216-5449
Express Scripts Mail Order Form (PDF) - for Medicare Eligible Retirees

LEAVE/SABBATICAL FORMS

FMLA/Leave/Sabbatical Form (doc)
Military Leave Form (pdf)

LIFE INSURANCE

The Hartford Life Insurance Form (pdf) - COMING SOON
The Hartford Evidence of Insurability Form (pdf) - COMING SOON
The Hartford Beneficiary Designation Form (pdf)
The Hartford Accidental Death & Dismemberment Form (pdf) - COMING SOON
Waiver of Entitlement to Group Term Life Insurance (in Excess of $50,000) (doc) 

LONG TERM CARE 

Long Term Care Short Enrollment Form (pdf)
Long Term Care Long Enrollment Form (pdf)

NEW HIRE FORMS

Benefits:

Forms Checklist (pdf)
Benefit Eligibility Form (pdf)
Unum Life Insurance Enrollment Form (pdf)
Unum Accidental Death & Dismemberment Form (pdf) 
Waiver of Entitlement to Group Life Insurance in Excess of $50k (doc)
Unum Long Term Disability Form (pdf)
Benefits Enrollment form (pdf) - Replaces Anthem Healthcare Enrollment Application, Healthcare Waiver Form, Pre-tax Treatment of Health & Dental Premiums Form, Superior Dental Care Enrollment form, Dental Waiver Form & MyCafeteria Plan Flexible Spending Accounts Enrollment Form
Social Security Number Exception Request Form (pdf)
MyCafeteria Plan Direct Deposit Form (pdf)
CNA Long Term Care Long Enrollment Form (pdf)
Retirement Plan Salary Reduction Agreement (pdf)
New Employee Information Form (pdf)

Employment:

Background Check Release (pdf)
Direct Deposit Form (doc)
Employee Data Sheet - Staff (doc)
Employee Data Sheet - Faculty (doc)
Federal Withholding Certificate (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)

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

New Hire Forms Checklist & Instructions (pdf)
Office of Federal Procurement Policy Act (pdf)
Computer Usage Policy (pdf)
Intellectual Property Rights Agreement (pdf)
Conflict of Interest Policy (pdf)
Conflict of Interest Disclosure Form (pdf)
Determination and Resolution Form (pdf)
Procedure for Implementing UDRI's Business Ethics & Integrity Code (pdf)
Business Ethics & Integrity Code Addendum (pdf)
Employment Agreement (pdf)

NON-EMPLOYEE FORMS

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

OUTSIDE EMPLOYMENT & ADDITIONAL SERVICES

Outside Employment & Additional Services Approval Form (pdf)

PAYROLL FORMS

Direct Deposit Form (doc)
Paper Leave Report for Exempt Employees (xls)
Paper Time Sheet for Benefit Eligible Nonexempt Employees (xls) 
Paper Time Sheet for Part Time Nonbenefit Eligible Employees and 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 (doc)

PERSONNEL ACTION FORM

Personnel Action Form (PAF) (xls)

POSITION CLASSIFICATION JUSTIFICATION

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

RETIREMENT

Retirement Plan Salary Reduction Agreement (pdf)
Fidelity Investments 403(b) Beneficiary Designation Form (pdf)
TIAA CREF Beneficiary Designation Form (pdf)

SEPARATION FORMS

Employee Separation Checklist (doc)
Exit Interview Questionnaire (doc)

TAX FORMS

Federal Withholding Certificate (W-4) (pdf)
State of Ohio Withholding Certificate (IT-4) (pdf)

TUITION EXCHANGE

Tuition Exchange Application (doc)

TUITION REMISSION/ASSISTANCE

Tuition Remission Application for Employee (doc)
Tuition Assistance Application for Child or Spouse (doc)

VISION PLAN

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

WELLNESS FORMS

Weight Watchers Agreement & Application (pdf)

WORKERS COMPENSATION

Workers Compensation Claim Form (pdf)