Office of Human Resources - Forms

A-C | D-H | I-O | P | R | S | 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

University Services Building | 1551 S. Rural Rd. (map)
Mail: PO Box 875612, Tempe, AZ 85287-5612
Phone: 480.965.2701 | Fax: 480.965.1971 | ASKHR
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Office of Human Resources - Forms

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