Office of Human Resources - Forms

FORMATS
There are several downloadable formats used on for HR forms. You can download a viewer for any of these formats from the ASU online plug in center. Plug-in viewers are free to download.

E-FAX NUMBERS
HR Data Management | 480.993.0005
HR Background Checks | 480.993.0006
HR Benefits & Leaves | 480.993.0007
HR Retirement | 480.993.0008

A-C | D-H  | I-O  | P |   | | T-U  | V-Z

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 HR Web page
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
Application for Change of Name
Form for employees to use to request a name change
INSTRUCTIONS

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
BENEFITS
COBRA Application

COBRA allows an employee who has lost healthcare coverage to continue the group medical, dental and vision insurances that s/he had while a benefits-eligible employee.
Employees can get application forms on the Benefits Options website.
There are two forms: with premium assistance or without premium asssistance.

Forms Online
BENEFITS
2009-2010 ENROLLMENT PACKETS
FOR BENEFITS BEGINNING OCT. 1, 2009

Standard Benefits Enrollment Packet
Declaration For Change

Benefits Enrollment--Domestic Partner
Benefits Enrollment--Domestic Partner Child
Benefits Enrollment--Older Child

HSA Payroll Deduction Authorization

PDF
PDF

PDF
PDF
PDF

PDF

Consent and Disclosure Form
Use this form to get a job applicant's OK to do a background check or fingerprinting PDF

D-H

Data Management Exception
Use this form for PeopleSoft actions that cannot be entered via PeopleSoft Manager Self-service by the required deadline(s), or because of limitation of program options or hard system errors. Word
Data Management EFax Cover Sheet
Use when you are efaxing documents to Data Management PDF
Department Code Change Request Form
Departments should use this form to request new department codes or modifications to existing codes. Fill out at least two weeks before the effective date of the change. Online Form
Delta Dental Claim
Use to submit a claim to Delta Dental. PDF
Dependent/Beneficiary
Personal Data Update Form
Use this form to request a change of incorrect information for a dependent and/or beneficiary. 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
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
Paper forms are no longer accepted. Please use eHire (accessed through My ASU). Access eHire
through My ASU

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
LEAVES MANAGEMENT
EMPLOYEE    
Compassionate Transfer of Leave
To Request Hours
To Donate Hours
PDF
Word
Family Leave Brochure
Information on Family Leaves PDF
Health Information Release
  PDF
Leave of Absence Request
UPDATED 10.09

Submit to request long-term, paid or unpaid leaves of absence

PDF

Paid Time Off
Hourly employees should use this form to request vacation and sick time Word
Return to Work Release
  PDF
SUPERVISOR USE ONLY    
Compassionate Transfer of Leave
Supervisor Memo Word
Leave of Absence Request
--Business Reasons
  PDF
ASU LEAVES REPRESENTATIVE USE ONLY NEW 10.09!  
Birth/Adoption/Foster Care
Includes Notice of Eligibility, Employee and Family Health Certifications, Health Information Release, Designation Notice, Return to Work and LOA Status Change Forms FMLA Packet PDF

Employee Medical

Includes Notice of Eligibility, Employee Health Certification, Health Information Release, Designation Notice, Return to Work and LOA Status Change Forms

FMLA Packet PDF
Leave (Non-FMLA) Packet PDF

Employee Military
Form sent to employees to acknowledge request for Military leave PDF
Employee Personal
   
Family Health

Includes Notice of Eligibility, Family Health Certification, Health Information Release, Designation Notice and LOA Status Change Forms

FMLA Packet PDF

Leave of Absence Status Change Form

To update status or return employee from leaves of absence

PDF
Military Family Business
   
Military Family Health
   
 
MetLife Dental Claim
Use to submit a claim to MetLife Dental. External PDF
Name Change
Form for employees to use to request a name change
INSTRUCTIONS

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. HRIS web page
Owner Automobile Mileage Report
Report of miles driven for dealer owned automobiles. Word

OUT-OF-STATE EMPLOYEE

Approval of Out-of-state Employee (New Hire or Relocation)
Report Days Worked in Arizona by Out-of-State Employee

PDF
PDF

P

Pay Option:
Faculty/Academic Professionals (AP)

Form used to select payment options for faculty on academic year appointments. PDF
Payroll Redistribution
and Instructions
Request a payroll expense transfer.

PDF
Excel
Instructions

Performance Management Forms

Performance Evaluation--Management
Performance Evaluation--Staff
Performance Improvement Plan

Word
Word
Word

Personal Data Change
Form used for existing employees to report changes of personal information. ASU Interactive
Post Offer of Employment
Physical Exam Sheet
Use this form when requiring an employee to have a physical examination. PDF or Word
Pre-Employment Inquiry Form
To be filled out by job candidates before a background check or fingerprinting is done PDF
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 MedImpact 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
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
RETIREMENT
ADOA Retiree Health Insurance
Enrollment Form
Use to enroll in ADOA health insurance PDF
Benefit Enrollment/
Change Form
Use to continue or decline insurance benefits at retirement. External PDF
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

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
Timesheet
For non-exempt employees to manually record work time Word
Timesheet Enhancement
Documentation

Technical info about enhancements made to the online timesheet for
hourly non-exempt and student employees paid from project sponsored accounts

PDF
Transition of Care
Use this form to request continuation of medical care with a provider who is not in your chosen network. PDF
TUITION WAIVERS
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,
• Employee 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
 
Request for Domestic Partner Tuition Benefit
  PDF
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
Verification of Employment
Use this form to request a verification of employment. PDF
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 or 1042S PDF
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