Human Resources Division - Downloadable Forms

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COBRA

COBRA Rates July 1, 2012 – June 30, 2013

COBRA Rates July 1, 2011 - June 30, 2012

COBRA Rates July 1, 2010 - June 30, 2011 

COBRA Initial Notice
This explains the eligibility requirements to be enrolled in COBRA.
 
Important Notice About Your Health Care Benefits Upon Separation

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Dental/Vision

Delta Dental of Ohio Claim Form
NOTE: If you seek treatment from a participating dentist, you do not need to print a claim form; the dentist will have a form and will submit it for you.

Benefit Enrollment and Change Form (ADM 4717) (exempts) (For use until July 1, 2013.)
When you and your dependents become eligible for dental or vision coverage, complete this form and return it to your payroll office. See the Dental and Vision pages for more information.

Benefit Enrollment and Change Form (ADM 4717) (exempts) (For use July 1, 2013.)
When you and your dependents become eligible for dental or vision coverage, complete this form and return it to your payroll office.  See the Dental and Vision pages for more information. 

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Disability Forms

Application for Disability Leave Benefits-Employee Statement (ADM 4310)
This form is used only for an initial filing of benefits. 

Application for Disability Leave Benefits-Employer Statement (ADM 4312)
This is the employer's information and is to be attached to ADM 4310. This form is also used when the employee is requesting an extension of benefits.  

Disability Agreement (ADM 4313)
This form is used when filing for disability as an advancement of Workers' Compensation.

Disability - Agency Disability Questionnaire
This form is to be completed by the employer and should accompany all initial mental health-related disability claims being filed with DAS-Benefits Administrative Services-Disability.

Disability - Request for Appeal

Statement of Psychiatric Disability (ADM 4316)
This form is to be used when filing for disability benefits for mental/behavioral health disability. This should be used in addition to ADM 4310.

Supplemental Report for Disability Leave -Employee Statement (ADM 4311)
This form is to be used by the employee to request an extension of disability benefits.

Supplemental Report for Disability Leave-Employer Statement
This form is to be completed by the agency and accompany the employee's Supplement Report for disability leave benefits being submitted to BAS.

Work Capacity Form (ADM 4317)
This form is to be completed by the attending physician for use in transitional return to work. This may be used for either Worker's Compensation or Disability.

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Eligibility

Affidavit of House Bill 1 Child Status

Definitions and Required Documents Checklist
Use this checklist to see documents required to enroll a dependent for the 2011 Benefits Open Enrollment.

Required Documents for Dropping Dependents Checklist
Use this checklist to see documents required to disenroll a dependent.

Verification Form (for union dental/vision benefits only)

Affidavit of Common Law Marriage (ADM 4731)
This affidavit should be used to enroll a common law spouse for benefits.

Affidavit of Student Status (ADM 4729)
This affidavit is to be completed when an enrolled dependent turns 19, a dependent is being enrolled in coverage, or the document is requested during the course of an audit.

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Medical Mutual

Medical Mutual of Ohio(Ohio Med) Handicap Child Member Form
Medical Mutual of Ohio (Ohio Med) enrollees who have a handicapped dependent child who is 1.) between the ages of 19 and 23 and not a student, or 2.) over the age of 23 must complete this form and send it to Medical Mutual of Ohio (Ohio Med) per instructions on the form.

United Health Care

United Healthcare Handicap Child Member Form
United Healthcare enrollees who have a handicapped dependent child who is 1.) between the ages of 19 and 23 and not a student, or 2.) over the age of 23 must complete this form and send it to United Healthcare per instructions on the form.

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 Life Insurance

Life Insurance (Basic) Beneficiary Designation/Change Form (SI 11210-645571)
The Standard Insurance Company's fillable beneficiary form for exempt employees. Can be completed online, printed, signed and then mailed to The Standard Insurance Company at the address on the form.

Life Insurance (Basic) Continuation Form (ADM 4302) (for laid-off employees)

Life Insurance (Supplemental) Conversion Privilege Form (for exempts)
Exempt employees may use this form to convert their supplemental (employee-paid) term insurance to whole life insurance upon leaving active state employment.

Life Insurance (Supplemental) Enrollment and Beneficiary Designation Form (for exempts)
Union-represented employees should consult the Union Benefits Trust at 800-228-5088 for information. Click here for detailed information about using this form.

Life Insurance, The Standard Insurance Claim Form (for exempts)
This form should be used by beneficiaries to apply for benefits upon the death of a covered exempt State employee.

Life Insurance, The Standard Insurance Dismemberment Claim Form (for exempts)
This form should be used by exempt employees to file a work-related claim for loss of a limb, hearing or sight.

Life Insurance, The Standard Accelerated Benefit Application (for exempts)
This form may be used by exempt employees to apply for an advancement of benefits if diagnosed with a terminal illness.

Life Insurance, The Standard Insurance Application for Portability (for exempts)
This form should be used by exempt employees to apply for a continuation of their life insurance after leaving State employment.

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Medical Benefits

Benefit Enrollment and Change Form (ADM 4717)  (For use until July 1, 2013.)
Needed to initially enroll yourself and your dependents in the Ohio Med PPO. Also used to make changes throughout the year such as the addition of a newborn or adopted child, the removal of a dependent, changing from family to single coverage, etc. For more information, see the Pathways to myBenefits spring publication.

Benefit Enrollment and Change Form (ADM 4717)  (For use July 1, 2013.)
Needed to initially enroll yourself and your dependents in the Ohio Med PPO. Also used to make changes throughout the year such as the addition of a newborn or adopted child, the removal of a dependent, changing from family to single coverage, etc. For more information, see the Pathways to myBenefits spring publication.

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Prescription Drug

Catamaran Mail Order Registration & Prescription Order Form
Use this form to register to use the Catamaran mail order program provided by Catamaran Home Delivery.

Catamaran Direct Member Reimbursement Form
Use this form to request reimbursement from Catamaran for unpaid prescription drug claims.

Catamaran Prescription Fax Form
The Prescription Fax Form is a form that you can take to your physician's office during an office visit to have your physician fax your prescription to our mail service provider Catamaran Home Delivery. This form must be faxed directly from your physician's office in order to be valid. 

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 Supplemental Benefits

Child Care Voucher Application

2013 Flexible Spending Account Enrollment Form
Use this form to enroll in the Health Care Spending Account and/or Dependent Care Spending Account program. NOTE: check the FSA Reference Guide for eligibility information.

2012 Flexible Spending Account Enrollment Form
Use this form to enroll in the Health Care Spending Account and/or Dependent Care Spending Account program. NOTE: check the FSA Reference Guide for eligibility information.

Flexible Spending Account Health Care Claim Form
Use this form to request funds from your Health Care Spending Account.

Flexible Spending Account Dependent Care Claim Form
Use this form to request funds from your Dependent Care Spending Account.

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Workers' Compensation

Accident or Illness Report (ADM 4303)
This report should be completed if you are injured at work. For more details, see the Workers' Compensation Web page.

Salary Continuation or Occupational Injury Leave Extension Request Form (ADM 4726)

Calendar of Wages Paid (ADM 4741)
This form is for agency use only. This form is used by the agency to report wages for lost time Workers' Compensation claims.

SC or OIL Reactivation Request Form (ADM 4722)

SC/OIL Hourly Payment Request Form
This form is to be used by an employee when requesting the use of SC/OIL on an hourly basis.  This form is to be used only if the employee is in a transitional work program.

SC and OIL Appeal Form

Part-time Employment Calculation Report (ADM 4728)
  

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Position Description Processing

Position Description Authorization Form - Revised 1-2011 

Position Description Form - Revised 1-2011 

Position Description Change Form - Revised 1-2011 

List of Major Worker Characteristics 

Table of Organization Guidelines

Position Specific Minimum Qualifications

PSMQ Submission Checklist

MQ Conversion Table

Job Analysis Questionnaire

SME Instruction Form

Job Analysis Spreadsheet - Long Version 

Job Analysis Spreadsheet Instructions - Long Version 

Job Analysis Spreadsheet - Short Version

Job Analysis Spreadsheet Instructions - Short Version

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Performance Management

Bargaining Unit Performance Review Forms

Clerical

Direct Care

Labor

Professional/Paraprofessional

Protective Services

Trades/Technical

Teachers 

Exempt Alternative

Exempt Performance Review Forms

Support Staff

Manager/Supervisor and Professional/Paraprofessional 

Other Needed Forms

Goals and Objectives Attachment Form 
 

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Action/Reason Code Matrix

Certificate of Records Disposal (ADM 3504)
This form is used to certify the destruction or transfer of records according to an approved records retention schedule.

Certification Eligible List (ADM 4267)
This form is used to prepare a list of persons whose average standing on civil service exams make them eligible for a position in a specific grade or classification.

Civil Service Application (GEN 4268)
Application for job positions within the State of Ohio

Civil Service Status Change Checklist - Revised 2-2011
Process of changing the Civil Service status from classified to unclassified or unclassified to Classified.

Declaration Regarding Material Assistance/Nonassistance to a Terrorist Organization
This form serves as a declaration of the provision of material assistance to a terrorist organization or organization that supports terrorism as identified by the US Department of State Terrorist Exclusion List, and must be completed for each individual hired for employment.

Electronic Compliance Review Form
This form is used to conduct the annual Personnel Action compliance review for those agencies participating in the PA Decentralization program. 

Electronic Records Release Form
This form should be completed when an agency rehires an employee or receives an employee who has transferred from a different agency. It is used to "release" the employee's electronic records to the new agency.

Employment Eligibility Verification Form (Form I-9)
All U.S. employers are responsible for completion and retention of Form I-9 for each individual they hire for employment in the United States.

Layoff/Displacement Form (ADM 4138)
This form must be included with an employer's written notification to an employee of the employee's layoff or displacement.

Notice of Proposed Intent to Layoff
Agencies should complete and submit this memo to DAS when they are considering a staff reduction resulting from a layoff or abolishment of personnel.

Ohio National Guard Prior Service
Application to claim annual leave accrual credit for prior service in the Ohio National Guard.

Order of Removal, Reduction, Suspension, Fine, Involuntary Disability Separation (ADM 4055)
This form is still on NCR paper and still contains a distribution list. You may view this form on the Internet, however, you must order this form from State Printing.

Personnel Action Cover Sheet
During the Temporary Hiring Control, agencies are required to complete the PA Cover Sheet for all PAs submitted to the Governor's Office. To ensure proper routing, please return PAs for positions subject to the hiring controls to DAS State Services, and return PAs for positions exempt from the hiring controls to the initiating agency.

Personnel Action Form (ADM 4100)
A Personnel Action (PA) form is required to initiate and document any activity significantly affecting an employee in state service.                                           

Position Description (ADM 4107)
The position description (PD) is the key document in determining the appropriate classification and status of a position. It serves as a descriptive of the major goals and worker activities of the position. The PD is to be filled out by an appointing authority or his/her designee.

Position Description Authorization (ADM 4136)
This form may be used by an appointing authority to authorize certain changes to a position description.

Pre-hire Review (ADM 4174)
This form provides a checklist of items that must be verified prior to submission of a personnel action form for a new hire, promotion or transfer.

Prior Service Certification (pdf)

Prior Service Certification (Word)

Records Inventory Worksheet (ADM 3516)
This form should be completed for each records series and includes information on record title and description, type of record, location of record, beginning and ending date of record, method of retention and suggested period of retention.

Records Retention Schedule (ADM 3500)
This form is completed for each record series and provides instructions for the disposal of the record series.

Records Transfer List (ADM 3502)
This form is completed for each record series and provides instructions for the transfer of the record series.

Signature Authorization
This form may be used by a Director to authorize certain employees in the agency to sign personnel action forms on his/her behalf.

Supplemental Employment Agreement (ADM 4288)
This form states that the newly highly employee will pay any child support payments required of him/her, and must be filled out as part of the new hire process.

Supplemental Nepotism Statement (ADM 4173)
This form states that the newly hired employee has no known or undisclosed relatives or business associates employed by the State of Ohio or any business interests which are involved with state business. This form must be filled out as a part of the new hire process.

 Unclassifed Background Check Form A (Background Information)

Unclassified Background Check Form B (Disclosure Questionnaire)

Unclassified Background Check - Limited Tax Waiver Form

Unclassified Background Check Form - Instructions

Unclassifed Service Explanation and Acknowledgment Form
This form should be used by appointing authorities to provide unclassified employees with written information describing the nature of employment in the unclassified civil service. 

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Change of Address (ADM 4058)
This form is to be completed by an employee who has had a change of address. Upon receipt of this form, personnel officers should pull the employee's old address form and replace it with the updated form.

Disability Checklist

Disability Cover Letter

Disability Retirement Supplement Worksheet
This worksheet may be used to calculate the amount of supplemental payments for which a disability retired employee may be eligible.

Disability Pay Worksheet
Use this form to calculate disability pay.

ePay Notification Form
This form should be completed when an employee changes their decision to accept/decline electronic receipt of their paystub.

Overpayment Form
This form should be completed when an employee receveives an overpayment of any kind.

Family Medical Leave Act (FMLA) Physician Certification Forms:
Depending on the need for leave, these forms should be completed by the physician that treat the employee applying for FMLA leave benefits.

Employee's Serious Health Condition

Family Member's Serious Health Condition

Serious Injury or Illness of Covered Servicemember

Qualifying Exigency for Military Family Leave   

Fine Calculation Worksheet
This form should be used to calculate the amount of fine to be deducted from an employee's payroll record.

Leave Balance Adjustment Worksheet

Leave Donation Donor Application Form (ADM 4256)
This form should be completed by the employee seeking to donate his/her leave to a fellow employee who is eligible to receive donated leave.

Leave Conversion/Restoration Form
This form may be used by any eligible separated employee seeking to have his/her accumulated leave balances paid out or retained for future restoration.

Military Differential Worksheet
This form may be used by an agency to determine a military employee's total monthly military pay differential.

Military Leave Request 
This form should be used in conjunction with military orders to indicate leave time and insurance while on military duty.

Organ Donor Physician Certification (ADM 4261)
This form should be completed by the physician that treated the employee applying for organ donor leave.

Overnight Hospitalization or Outpatient Surgery Certification
This form should be completed by the physician that treated the employee who was hospitalized overnight or had outpatient surgery.

Payroll Refund/Adjustment Form
Use for any adjusment or refund processed through payroll

Poll Worker Leave Verification Form
This form must be submitted to your supervisor on the first day you return after service as a judge of elections.

Payroll Deduction Card (ADM 6307)
This form should be used by an employee to authorize his/her payroll officer to make certain deductions from the employee's earnings.

Request for Leave (ADM 4258)
This form may be used to request sick leave, vacation leave, leave without pay, bereavement leave, jury duty, personal leave, compensatory time off, witness duty leave, military leave, adoption childbirth leave, pending disability leave and pending workers' compensation leave.

Request for Off-Cycle Manual Paycheck
This form should be used to process a request for a manual paycheck for unpaid wages, disability leave benefits or disability leave supplements.

Manual Paycheck Request page 2
This form is used in conjunction with Off-Cycle Manual Paycheck Request form.  It must  be filled out as the second part of ordering a manual check for an employee.

Request for a W-2 C

Reversal or Return of Direct Deposit
This form should be used by agencies to prevent or reverse the direct deposit of an employee's compensation.

Special Retirement Breakdown:

Pre-2006 Retirement Breakdown
2007 - 2008 Retirement Breakdown
2009 - 2010 Retirement Breakdown
2011 - 2012 Retirement Breakdown

If there is a problem with an employee's retirement contributions, this form may be necessary to effectuate a make-up of retirement benefits.

Statement of Residency in a Reciprocity State
Employers are required to have a copy of this form on file for each employee who is a resident of Indiana, Kentucky, West Virginia, Michigan or Pennsylvania receiving compensation paid in Ohio and who claims exemption from withholding of Ohio income tax.

W4

Withholding Exemption Certification
Employees should use this certificate if the number of natural dependency exemptions increases or decreases.

Forms for Agency Use Only

Benefits Make-Up Form

Benefits Refund Form

Direct Payment Instructions

Direct Payment Form
Benefits Direct Pay Form is to be completed and sent in with payments for Board and Commission Members, Military Leave payments, etc. 

Part-time Employment Calculation Report
This form is used by the agency to report wages for lost time Workers' Compensation claims for Part-time employees. 

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Online Registration Brochure
Download a brochure with step-by-step instructions on how to electronically access the training registration system.

Training & Development Training Application
This form should be used by employees who are interested in applying for a training and development program, including Ohio Certified Public Manager Program (OCPM), PASS, Project Management, etc.

Exempt Professional Development Program Forms
This form may be used to request reimbursement for certain tuition expenses and costs associated with certain professional development events. This form must be submitted 14 days prior to the beginning of the course/event.

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ELM Security/Functional Request Form
This form is used to request security and functional profile access to ELM 9.0.

ELM Security/Functional Instructions

ELM Categories Request Form
This form is used to request for a category to be added to ELM 9.0

ELM Categories Instructions

ELM Learning Resources Request Form
This form is used to request for additional Learning Resources to be added to ELM 9.0
(examples of learning resources are facilities, equipment, and materials).

ELM Learning Resources Instructions

ELM Catalog Items/Delivery Methods Request Form
This for is used to request the creation of catalog items and delivery methods to be added to ELM 9.0.

ELM Catalog Items/Delivery Method Instructions

ELM Learner Group Request Form

This form is used to request the creation of a learner group to be added to ELM 9.0.

ELM Learner Group Instructions 

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