Office of Human Resources - Forms

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Form Name	Purpose / Description	Format
A-C
A-4 (Employee’s Arizona Withholding Percentage Election)	Arizona State Income Tax Withholding	PDF
Aetna Evidence of Insurability	Use to provide evidence of insurability when enrolling or increasing the amount of life insurance.	PDF
Academic Bi-Weekly Pay Calendar	Bi-Weekly Pay Calendar for Academics	PDF
Announcement of Vacancy- Faculty/Academic Professional	Use this form to open a vacancy announcement for an open Faculty/Academic Professional position.	PDF & Glossary
Applicant List- for resumes sent directly to departments	Use this form to track resumes received from applicants replying to a posted position.	PDF
Arizona Foundation Out-of-Network Claim	Use to claim medical expenses.	External PDF
Arizona State Retirement System	Enrollment Form Beneficiary Form Change of Address or Name	PDF PDF PDF
ASU ID Number Change Request	Employees Only - Use this form to request a change to an ASU ID number that is not a Social Security Number.	Word
Background Verification	Use these forms to perform a background verification for a new employee.	HR web page
Benefit Declaration For Change/Enrollment Form	Use to request changes to your benefit elections.	PDF

Certification of Health Care Provider (FMLA)	Form used to certify medical condition for FMLA leave.	PDF
COBRA Enrollment Form	Use to continue or decline insurance after loss of coverage.	PDF
Compassionate Transfer of Leave	To Request Hours To Donate Hours Supervisor Memo	PDF PDF Word
Compensation/ Classification Action Request	Use this form to re-classify filled positions.	PDF or Word
D-H
Delta Dental Claim	Use to submit a claim to Delta Dental.	PDF
Direct Deposit	Form used to establish or change direct deposit of pay.	ASU Interactive
Emergency Hire	Use this form to fill an open position that needs an immediate hire.	PDF or Word
Equal Employment Opportunity Survey	Voluntary form for new employees used by ASU to collect EEO data	PDF
Faculty and Academic Professional Search Plan	Use when beginning a search for a faculty member or academic professional	PDF
Family Leave Brochure	Information on Family Leaves	PDF
FICA Refund Request	Use this form when an employee requests a prior year refund on FICA OASDI and MEDICARE.	PDF or Word
Flexible Employment Conversion Application	Use this form to volunteer to reduce your time worked by one to six pay periods a year.	Word
Flexible Spending Accounts	Enrollment Form Change Form Claim Form Direct Deposit/Email Notification	PDF PDF External PDF External PDF
Focused Recruitment Form	This form replaced Waiver of Recruitment	PDF
Glacier Nonresident Alien Tax Compliance System Information Form	Form to comply with regulations regarding the taxation and reporting of payments made to individuals who are not residents for tax purposes.	PDF or Word
Hiring Process Report	Use this form to request approval to hire from EOAA and then submit to HR for processing of new hires.	PDF Word Glossary
I-O
I -9	Form for Employment Eligibility Verification	PDF
Independent Contractor Checklist	Use this form for review and approval of Independent Contractors before performance of services begins.	PDF Word Glossary
Leave of Absence and Hold Request	Use to request a leave (e.g. Military, FMLA, Extended)	PDF
Leave of Absence Status Change Form	For Supervisor Use Only	PDF
MetLife Dental Claim	Use to submit a claim to MetLife Dental.	External PDF
Military Leave Letter	Form sent to employees to acknowledge request for Military leave.	PDF
New Employee Payroll Packet	Payroll and other HR forms needed from new hires.	PDF
Non-Exempt Employee Calendar	Alternate record for reporting time worked. Click on the tabs at the bottom of the spreadsheet for the pay period in which you are recording time worked.	Excel
Overdraft Reimbursement		PDF
Owner Automobile Mileage Report	Report of miles driven for dealer owned automobiles.	Word
P
Pay Correction	Form to correct employee's pay. Online (Manual) Check and Pay Correction (Direct Deposit)	Word
Pay Option	Form used to select payment options for faculty on academic year appointments.	PDF or Word
Payroll Redistribution and Instructions	Request a payroll expense transfer.	PDF Excel Instructions
Personal Data Change	Form used for existing employees to report changes of personal information.	ASU Interactive
Position Change Request	Use this form to change the position attributes of any Faculty/Academic Professional positions or any vacant Classified/Service Professional/Administrative positions.	Word
Post Offer of Employment Physical Exam Sheet	Use this form when requiring an employee to have a physical examination.	PDF or Word
Prescription Fax Order	Use to have your physician fax a 90-day prescription to Walgreens Health Initiatives.	External PDF
Prescription Mail Order	Use to mail a 90-day prescription to Walgreens Health Initiatives.	External PDF
Prescription Reimbursement	Use to request a reimbursement from Walgreens Health Initiatives when you have paid out-of-pocket for a prescription.	PDF
R
RAN+AMN Claim	Use to claim out-of-area Urgent Care & Emergency expenses.	External PDF
Recruitment Handbook	Use for guidance in recruiting faculty and academic professsionals	PDF
Reinstatement for Spring 2008	Form for active spring Faculty, Graduates and Academic Professionals continuing in the same department	Word
Release to Return to Work/Certificate of Illness	Used when returning to work after a medical leave of absence.	PDF
ReliaStar Life Insurace	Application Form Beneficiary Form Change Form	PDF External PDF External PDF
Request for Paid Time Off		Word
Request to Pay OT in Lieu of Comp Time	Pay overtime in lieu of compensatory time	Excel
Retiree Benefit Enrollment/ Change Form	Use to continue or decline insurance benefits at retirement.	External PDF
Retirement Certificate Request	Form to request certificate to honor ASU employees who retire with five or more years of continuous service	PDF
RIF Analysis	Use this form to perform a departmental analysis in the determination of a RIF.	PDF or Excel
S
Salary Reduction Agreement Authorization for Deductions	Authorize/discontinue salary deductions for a Tax Sheltered Annuity Program.	PDF
Sample Offer Letter	Use these sample templates to confirm Classified or Service Professional employment offers.	HR Advisor
Sample Regret Letter (Budget)	Use this form as a template to notify applicants that the position will not be filled at this time.	PDF or Word
Sample Non-select Letter (Applicant)	Use this form as a template to notify applicants that they were not selected.	Word
Sample Non-select Letter (Interviewee)	Use this form to notify applicants that have been interviewed, that they were not selected.	Word
Savings Bonds	Authorize a deduction from your pay to purchase U. S. Savings Bonds; or to change beneficiary.	PDF
Schaller Anderson Claim	Use to claim out-of-area Urgent Care & Emergency expenses.	External PDF
Sick Leave Accrual Verification	To verify the sick leave balance of an employee retiring, or moving to a different Arizona State agency.	PDF or Word
Summer Address	Use this form to provide HR with your summer address information.	Word
T-U
Temporary Employment Request (External)	Use this form when completing a Temporary Employment Request with an external temporary agency.	Word
Temporary Employment Request (Internal)	Use this form when completing a Temporary Employment Request with Staffing Services.	Word
Time Adjustment	Use this form to adjust an employees time.	Word
Time Sheet	For non-exempt employees to manually record work time	Word
Tuition Waiver (1)	Classes at any ASU campus: • Employee • Employee's spouse • Employee's dependent(s)	Word
Tuition Waiver (2)	Classes at UA or NAU: • Employee, • Emplopyee spouse • Employee dependent(s) Classes at ASU, UA or NAU: • Retiree, their spouse and their dependent(s) • Eligible LTD participant, their spouse and their dependent(s) • Affiliate, their spouse and their dependent(s)	Word
2008 Tuition Waiver Dependent Questionnaire		Word
UnitedHealthcare Claim	Use to claim medical expenses.	External PDF
V-Z
Vacation/Compensatory Time Termination Worksheet	Form used to calculate Vacation/Compensatory time for terminating employees.	PDF or Word
Verification of Employment	Use this form to request a verification of employment.	PDF or Word
Vision Plan Out-of-Network Claim	Use to claim out-of-network vision benefits.	External PDF
W-2 Request	Use this form to request a duplicate copy of a W-2	Word
W-4	Employee's Federal Income Tax Withholding Allowance Certificate	2007 PDF 2008 PDF
W-5 (Earned Income Credit)	Use IRS Form W-5 if you are eligible to get part of the Earned Income Credit (EIC) in advance with your pay and choose to do so.	PDF
Waiver of Right to Pre-termination Hearing	Form to be used if you have been notified to attend a pre-termination hearing and you will not attend.	Word
Waiver of Recruitment	This form has been replaced by Focused Recruitment Form
Walgreens Health Initiatives Mail Order Fax	Use for physician to order 90-day prescription.	External PDF and Instructions
Walgreens Health Initiatives Mail Order	Use for employee to order 90-day prescription.	External PDF
Walgreens Health Initiatives Prescription Reimbursement	Use to request a reimbursement from Walgreens Health Initiatives when you have paid out-of-pocket for a prescription.	PDF
Workers' Compensation	Flow Chart Employer's Report of Injury Supervisor's Incident Report Authorization for Payment Release To Return to Work	PDF External PDF Word PDF PDF

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Mail: PO Box 875612 , Tempe, AZ 85287-5612
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